Easy dental starts here

Dental made simple.

Benefits Administration Manual

:)

Delta Dental of Tennessee

Mission Statement

The mission of Delta Dental of Tennessee is to improve oral health by being the leading dental carrier providing programs of demonstrated value that balance the needs of the customers.

Customers

Because we believe that you, our customer, are one of our most valued stakeholders, we provide you the highest level of service available. You are the catalyst that inspires us to become more innovative and progressive.

Enrollees

We treat enrollees with respect in a friendly, courteous manner. We endeavor to assist them in receiving the full value of their benefits by accurately describing their program. We address their questions and concerns promptly and thoroughly.

i

Table of Contents

Welcome ................................................................................................. 1 Web-based Services

Benefit Manager Toolkit ................................................................ 1 e-Billing ......................................................................................... 1 Online Bill-pay ............................................................................... 2 Dentist Search .............................................................................. 2 Employer Resources ..................................................................... 2

EyeMed Vision Care ............................................................................... 3 Dental Benefits: Eligibility and Enrollment

Who Can Enroll? .......................................................................... 3 When Coverage Begins ................................................................ 3 Qualifying Events ......................................................................... 4 Rejoining the Plan ........................................................................ 4 When Coverage Ends ................................................................... 4 Member Retroactivity ................................................................... 4 Verifying Eligibility Information ..................................................... 4 Filling out the Enrollment/Change Forms ..................................... 5 ID Cards ...................................................................................... 5 Coordination of Benefits ................................................................ 5 COBRA ........................................................................................ 5

Billing e-Billing ....................................................................................... 6 Online Bill-pay .............................................................................. 8

Claims Claim Filing ................................................................................... 9 For Services performed by a participating dentist......................... 9 For services rendered by non-participating dentist ....................... 9 Explanation of Benefits ............................................................... 10 Pre-treatment Estimates ............................................................. 10 Appealing a Claim ....................................................................... 10

Health and Wellness ............................................................................. 11 Administrative and Employee Contact Information ........................... 11 Forms and Documents

Enrollment Form ......................................................................... 12 Change Form .............................................................................. 13 Claim Form ............................................................................14-15 Sample Invoice ......................................................................16-17 e-Billing Registration Form .......................................................... 18 Online Bill-pay Instructions .......................................................... 19 Coordination of Benefits .............................................................. 20 Sample ID Card .......................................................................... 21 Understanding your Explanation of Benefits ...........................22-25

ii

Welcome Employers! We are pleased to provide your dental benefits and we look forward to serving you and your employees.

Client satisfaction comes first at Delta Dental of Tennessee. So, we have several resources available to assist you in managing your dental program and for helping your employees to make the most of their dental benefits.

Benefit Manager Toolkit With the Benefit Manager Toolkit (BMT), benefit managers can:

• Get real-time benefit and eligibility information 24/7 • Take control of your group’s eligibility • Enter, edit and terminate enrollee eligibility • Download dentist directories in a printable format • Streamline your benefits management process • Access Client Knowledge, our web-based reporting service

e-Billing e-Billing is a fast and easy way to receive your bill and stay organized. With e-Billing you can:

• Receive an email with your monthly invoice attached • View complete subscriber listings online with quick, secure access • Automatically archive bills so they’re always available • Download a list of active subscribers in an Excel format • Receive a higher level of security to maintain Protected Health

Information (PHI) • Combine with ACH or bank draft for the most convenient processing • Reduce unnecessary paper clutter

The Benefit Manager Toolkit and e-Billing give you more control of your benefits. To sign up for e-Billing, complete the form on page 18 and return it to your Account Manager.

1

Online Bill-pay This new feature allows you to pay your monthly invoice quickly and securely through our bank’s online portal. There is a $3.00 processing fee per transaction, but there is no sign-up process and all you need to make a payment is your group number and a Visa, MasterCard, or checking account.

Dentist Search With nearly 3 out of 4 providers nationwide in our networks, you and your employees have a wide selection of dentists from which to choose.

To locate a dentist, just access the Dentist Search by visiting our website at www.DeltaDentalTN.com and clicking on the link titled Find a Dentist.

Here are a few tips to help you select the right dentist:

• Put in a City and a Zip Code to get more accurate results.• Search for locations near both your home and work to

find more options.• If you are unsure about your plan type, you should be

able to find it on the Declaration Page of your group dental contract. You may also contact your AccountManager for assistance.

Employer ResourcesAdministrative materials, like the ones listed below, may be downloaded from our website at www.deltadentaltn.com/Groups/Employer-Resources.

Administrative Manual As a plan administrator, you are the primary contact between Delta Dental and your employees. To assist you, we have created this handbook to serve as a valuable resource to answer your how to or what if questions.

Claim Form Download a hard copy of the commonly-used claim form.

Quick Reference Guide to DASI Get assistance with DASI, Delta Dental's automated inquiry system.

Newsletters Miss one of our newsletters? View our archived editions.

Online Bill-pay Pay your monthly invoice quickly and securely.

2

EyeMed Vision Care The choice is clear. More Choices. Better Quality. The EyeMed Vision CareSM discount plan provides significant savings on eye care and eyewear simply by showing a Delta Dental ID card to any EyeMed provider. Choose from a nationwide network of optometrists, ophthalmologists and opticians, as well as the nation’s leading optical retailers such as LensCrafters®, Sears Optical®, Target Optical® and most Pearle Vision® locations.

This is not insurance, so there are no claims to file. Discounts should be given in the office at the time of the appointment. For more information, visit the website at www.eyemedvisioncare.com/deltadental or call toll free at 1-866-246-9041.

Dental Benefits: Eligibility and Enrollment As the Plan Administrator, you may already be familiar with some of our guidelines for enrolling your company or group in Delta Dental. However, there are some additional guidelines, such as ongoing group participation requirements, that you may want to refer to from time to time. This section highlights a few of these key underwriting areas for participation, member eligibility, and retroactivity. Participation Requirements refer to the number of employees who enroll in the plan compared to the number of employees who are eligible to enroll, excluding those employees with other coverage (e.g. spouse’s plan, other employer group). The group’s eligibility requirements and enrollment may be reviewed and audited at least once each year— typically prior to the renewal date—to ensure compliance with these requirements.

Please note: If an employee has dental coverage elsewhere (e.g. through a spouse), that employee may be eliminated from the calculation of the total eligible population.

Who Can Enroll? Active Employees: All active employees who are eligible for your group’s benefits program and for whom the company contributes all, some, or none of the premium charge are eligible for membership in your group’s dental benefits plan. Active employees—including owners, partners, and corporate officers—must regularly work 30 or more hours per week and be on the company’s payroll. Only employees (and their family members, if your company has family coverage) are eligible for coverage. Dependents: Your plan’s family coverage includes the following dependent categories:

• The employee’s legal spouse • Children by birth, step-children, or legally adopted children to age 26 • Children over 26 who are mentally or physically incapable of earning their own living

(proof of which must be on the file with Delta Dental of Tennessee). • Divorced spouses in accordance with applicable federal and state law. In the case of remarriage,

the ex-spouse can no longer be covered under the family plan.

When Coverage Begins Please review the Certificate of Coverage for your group’s eligibility period (this is in accordance with the

3

If any employees or eligible dependents do not enroll when they are first eligible, they must wait to apply until the next open enrollment period scheduled for your company or when a qualifying event occurs.

Qualifying Events

The monthly premium rates have been developed assuming all members have committed to a 12-month enrollment period. For a new enrollee to join the program or make a status change, the member must meet an industry-accepted qualifying event.

Qualifying Events include: • New Hire• Marriage or Divorce• Birth, Adoption, Change of Custody• Workers’ Compensation• Family Medical or Disability Leave• Spouse’s Loss of Coverage• Full Time/Part Time Status Change• Death of a Member

Rejoining the Plan

An enrolled member who voluntarily cancels membership in the group may not re-enroll in that group until the first open enrollment following 12 months without coverage. The re-enrollment must occur on the group’s anniversary or open enrollment unless a qualifying event occurs.

When Coverage Ends

Coverage ends on the last day of the month in which the group notifies us that coverage is cancelled by completing the applicable form or online transaction.

Please review your contract for detailed participation, enrollment and re-enrollment requirements.

Member Retroactivity

Retroactivity occurs when we are notified of an addition, change or termination after the requested effective date has occurred.

Additions: Member additions are made on the first day of the month or as your contract allows.

Terminations: Member terminations take effect on the first day of the month following the last date of coverage or as your contract allows. The maximum credit that can be given is 90 days, provided there are no claim(s) paid on the member during this period. If a claim(s) has been paid, the termination will take effect on the last day of the month in which the claim(s) was paid.

Example: On July 8th, you request a retroactive termination effective July 1st. However, the member went to the dentist on July 6th and a claim was submitted and paid. As a result, the member’s coverage will be cancelled effective August 1st.

Verifying Eligibility Information

With our streamlined administration, the same eligibility records are used for both claims processing and monthly billings. This means there is no discrepancy between the two functions and that corrections and

4

updates need only be made once. In addition, a complete Subscriber List (there is a list for each of your sub-groups) is available online through e-Billing. You can also request this listing by fax.

The Subscriber List displays all employees who are eligible to receive dental benefits and the type of coverage. Review these lists carefully to ensure that the information is correct.

Filling out the Enrollment/Change Form

Enrollment forms need to be completed for new hires. Please see page 12 for a sample of an enrollment form.

When adding a dependent, terminating a dependent, changing an address or terminating the subscriber, please complete a change form. Please see page 13 for a sample of a change form.

ID Cards

Delta Dental automatically issues identification cards (ID cards) for all employees covered under your plan. ID cards are mailed to each enrolled employee’s home address and should be received within 7 to 14 days after their enrollment is completed.

The front of each ID card contains your Company’s name, your Delta Dental group number, and the Subscriber’s name. The back of the card indicates how to contact Delta Dental and outlines claim filing instructions. Please see page 21 for a sample of an ID Card. Your employees should always present their ID card when they visit a dentist outside of the state of Tennessee.

Employees may replace a lost ID card by printing a paper copy from the Consumer Toolkit at www.DeltaDentalTN.com/consumertoolkit. Or, they may contact Customer Service at (800) 223-3104 to request that a new card be mailed to them.

Coordination of Benefits

To enhance benefits and prevent duplication of coverage, Delta Dental coordinates benefits for members covered under a second insurance policy (e.g. through a spouse’s plan). This process is known as Coordination of Benefits (COB).

A document with additional information about Coordination of Benefits is included on page 11 of this manual. Please check your contract to see if your company allows COB.

Delta Dental’s rigorous performance of dental benefits coordination during claims processing is designed to help your company and its employees control dental care costs. Delta Dental handles COB in accordance with industry standards. We use the “Birthday Rule” when dependent children are covered by both parents’ dental plans. The Birthday Rule means covered dependent children are generally covered first (primary) by the plan of the parent whose birthday occurs earlier in the year.

COBRA

How is COBRA processed?

Delta Dental does not administer COBRA. The group must pay all premiums. Delta Dental does not accept personal checks from the COBRA participant.

5

Billing Your coverage with Delta Dental of Tennessee is a prepaid benefits plan with premiums due on the first of the month. You can choose to receive your monthly invoice (no billing detail) by mail or email. To view a complete statement including billing details like subscriber listings, you can sign up for e-fax or log in to e-Billing. A sample invoice is included on pages 16-17 of this manual.

For assistance with your billing statement, e-Billing, or Online Bill-pay please contact Billing at (615) 255-3175 x.6585.

e-Billing

Signing up for e-Billing gets you faster, more secure access to your monthly invoice and billing detail. If you do not currently have e-Billing access, but are interested in enrolling, complete the included e-Billing form on page 18 and send it to your Account Manager. Complete PART I of the form to receive an emailed invoice only. Complete PART I and PART II to receive an emailed invoice and be able to log in to view complete billing information.

The monthly billing process starts around the 17th of each month. Once the statement is created and available for online access, an email will be sent to the user who has enrolled in e-Billing. The email will include a PDF of the invoice and a link to log in to e-Billing to view complete billing information.

At the e-Billing login page, the user will enter the chosen User ID and the Password provided by Finance.

The login information is typically created at the initial group implementation or when the e-Billing access is requested. If you are unsure of the User ID or Password, contact your Account Manager.

6

Login – After you have successfully logged in, the Account Selection page will be displayed. Here you will click on the link with your group name, where SAMPLE GROUP 2012 is indicated below.

Access Options – The following screen will allow you three separate access options. To view your billing statement, you will click the option titled E-Billing.

SAMPLE GROUP 2012

Sample Group 2012 ExtraNet

Welcome Sample Group 2012, Group Number TN057100001

7

Document Format Options – Billing statements are typically available in both .xls spreadsheet and PDF document formats. However, the PDF version is the most frequently used format.

On the final screen, as shown below, you have the option to choose the format that you prefer. Simply click on the appropriate document link to open the document.

Online Bill-pay

Online Bill-pay is a new feature that allows you to pay your monthly invoice quickly and securely through our bank’s online portal. There is a $3.00 processing fee per transaction, but there is no sign-up process and all you need to make a payment is your group number and a Visa, MasterCard, or checking account.

To make an online payment, go to www.DeltaDentalTN.com/OnlineBillPay. Go to page 19 of this manual for step-by-step instructions.

Welcome Sample Group 2012, Group Number TN057100001

20120517-1523-0000000-0000000-Extract.XLS

20120517-1523-0000000-0000000-E-Billing.pdf

8

Claims One of the most significant benefits to Delta Dental of Tennessee members is that they do not have to file claims when using participating dentists. Participating dentists file claims directly with Delta Dental. When seeing a non-participating dentist, members may need to submit a claim form to Delta Dental. Claim Filing You can find a claim form on our website at www.DeltaDentalTN.com under the Employer Resources Section. For services performed by a participating dentist As a member of Delta Dental, your employees enjoy distinct advantages when they visit a participating dentist. The dentist agrees to accept our payment as payment in full—minus any applicable deductibles or coinsurance—and your employees are protected against being billed for any remaining balance. A participating dentist will also file your employees’ claims directly with us and handle all of the paperwork.

How it works: 1. The member presents his or her ID card at the

dentist’s office. 2. The dentist contacts Delta Dental to verify eligibility

and benefits. 3. Once treatment is rendered, the dentist files a claim

directly with Delta Dental. For services rendered by non-participating dentists Non-participating dentists may require the member to file their own claims. To file a claim, members will need to do the following:

1. Download a Claim Form from the Consumer Toolkit. 2. Follow the completion instructions on page 2 of the downloaded document. 3. Review the form to make sure that all required information is provided and that dentist and

member/patient signatures are included. 4. Mail the completed Claim Form and any other applicable attachments to:

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228

All claims must be submitted within 15 months of the date of service. Payment for claims submitted by participating providers will be paid directly to the dentist. Claim payment for claims submitted by a non-participating dentist will be issued to the subscriber. (The only exception is when state law mandates assignment of benefits or if the group contract specifies assignment of benefits).

9

When payment is issued to the member, it is the member’s responsibility to pay the dentist. If the dentist is non-participating, the member is responsible for the difference between the dentist’s full charge and the Delta Dental payment, plus any applicable coinsurance, deductibles, etc.

Members receive an Explanation of Benefits form for services rendered by both participating and non-participating dentists.

Explanation of Benefits

The Explanation of Benefits (EOB) is used to inform the subscriber when a claim is processed. The EOB also indicates the total charges for the services rendered by the dentist, as well as any amount payable by the employee for deductibles, coinsurance, and charges for non-covered services.

A Claim Payment Statement is also sent to the participating dentist who performed the treatment. The Claim Payment Statement includes the same information as the patient’s EOB.

A document with additional information about the Explanation of Benefits is included on pages 22-25 of this manual.

Pre-treatment Estimates

For certain services (e.g. crowns, bridges, Periodontics, orthodontics), participating dentists are encouraged to submit a pre-treatment estimate (aka predetermination) to Delta Dental. This provides members with an estimate of the total cost of services and the members’ out-of-pocket expenses before services are performed. It is important that your employees are aware of this. To help ensure that the process does not unnecessarily delay the delivery of services, Delta Dental quickly responds to pre-treatment estimates submitted by dentists. In

addition, Delta Dental encourages members to ask their dentist to file a pre-treatment estimate when the cost of the treatment is expected to exceed $250.

Once the estimate is reviewed, a Predetermination Notice (Pre-Treatment Estimate) form is sent to both the member and the dentist describing the procedures that are covered or not covered. It also estimates how much Delta Dental will pay the dentist and any cost sharing the member will incur. The Pre-Treatment Estimate is not a guarantee of payment. Payment determination is made at the time that the actual claim for services is processed. It is based upon eligibility and subject to the applicable coinsurance, deductible and calendar year maximum.

If the patient proceeds with the estimated treatment, the date of service should be added to the Predetermination Notice form and submitted as the claim for payment.

Appealing a Claim

If a payment for services was denied, the EOB will give the reason. If the subscriber disagrees with the denial, he or she may appeal the denial by submitting request in writing asking that the claim be reviewed. Such requests should include the reason why the subscriber believes the claim was wrongly denied. The request must be received by DDTN within 180 days of the subscriber’s receipt of the EOB. Upon receipt, DDTN will

10

review the appeal and may ask for more documents if needed. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after DDTN receives the request for review.

If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of Delta Dental. This second level review request must be in writing and received by Delta Dental within a reasonable time after the subscriber receives the first level review decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for second level review.

If the subscriber does not agree with the second level review decision, he or she may file civil action in court.

Health and Wellness

Why Dental Benefits?

A healthy smile is important—not only to oral health, but for overall health, too. Did you know a dentist can detect more than 120 symptoms of non-dental diseases—including cancer, diabetes, heart disease, kidney disease, and osteoporosis—during a routine oral exam? A dentist may be the first line of defense in diagnosing health problems that could be more costly in the long run.

Having dental coverage helps members get the care they need to stay healthy. It also can help keep overall health care costs down. After all, good health starts with a healthy smile!

We offer several health and wellness publications that will help your employees understand the need for dental benefits. You can find the downloadable documents on our website in the Wellness section.

Contact InformationWe have dedicated account service representatives available to assist you with all of your dental benefit needs, including billing inquiries. The name and contact information for your representative is included on your Welcome Letter.

Employees who need assistance may contact our Customer Service department at (800) 223-3104, Monday through Friday from 7:00 AM to 5:00 PM (CST).

Our website, www.DeltaDentalTN.com, also provides access to our Dentist Search, Consumer Toolkit, Benefit Manager Toolkit, Wellness information, and more.

11

DDTN SS 1 EF (Rev 9/08)

ENROLLMENT FORM

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 Telephone 615-255-3175

GROUP NUMBER

SUBLOCATION NUMBER

GROUP NAME

If enrolling spouse and/or dependents, please list them below

SEX FIRST NAME & M.I. (LAST NAME IF DIFFERENT) M F

BIRTH DATE

SPOUSE: CHILD: CHILD: CHILD: CHILD:

I agree to make the required contribution. I certify that the information contained in this form is true and correct to the best of my ability.

Signature: Date:

FIRST NAME M LAST NAME

STREET ADDRESS

CITY STATE ZIP

BIRTH DATE

EFFECTIVE DATE

SEX M F

DECLINE COVERAGE

I have been given the opportunity to apply for group dental insurance coverage through my employer and choose at this time to not take coverage. I understand that by signing this area I am declining this coverage because:

I have other dental coverage I do not want at this time Other: _____________________

Declination Signature: Date:

SOCIAL SECURITY NUMBER

_ _

12

DDTN SS 2 CF (Rev 6/09)

CHANGE FORM Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 Telephone 800-223-3104

GROUP NUMBER

SUBLOCATION NUMBER

GROUP NAME

If terminating or adding a dependent(s) ONLY, use ‘Drop (D)/Add (A)’ box below

D A FIRST NAME & M.I. (LAST NAME IF DIFFERENT)

SEX BIRTH DATE

REASON EFFECTIVE DATE M F

SPOUSE:

CHILD:

CHILD:

CHILD:

CHILD:

CHANGE NAME From: To:

CHANGE ADDRESS To:

CHANGE SUBLOCATIONS: From: To: Effective Date:

TO TERMINATE EMPLOYEE COVERAGE, PLACE EFFECTIVE DATE HERE:___________ _______

(Rehired Employees and COBRA enrollees should fill out a new enrollment form)

Signature: Date:

SOCIAL SECURITY NUMBER

FIRST NAME M LAST NAME

13

© 2008 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF TENNESSEE WITH PERMISSION –12/2009

REMARKS31.

AUTHORIZATIONS ADDITIONAL CLAIM INFORMATION32. AS PERMITTED UNDER LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTH

INFORMATION FOR PURPOSES OF PAYMENT OF THIS CLAIM.

PATIENT/GUARDIAN SIGNATURE DATE

34. PLACE OF TREATMENT DENTAL OFFICE HOSPITAL ECF OTHER

35. NUMBER OF ENCLOSURESRADIOGRAPHS _______ DIGITAL IMAGES _______ MODELS _______

36. IS TREATMENT RELATED TO ORTHODONTICS? NO YES DATE APPLIANCE PLACED _______________ MONTHS OF TREATMENT REMAINING _______33. IF PERMITTED, I HEREBY ASSIGN AND AUTHORIZE PAYMENT OF THE DENTAL BENEFITS OTHERWISE

PAYABLE TO ME TO THE TREATING DENTIST.

SUBSCRIBER SIGNATURE DATE

37. TREATMENT RESULTING FROM: OCCUPATIONAL ILLNESS/INJURY AUTO ACCIDENT OTHER ACCIDENT

38. REPLACEMENT OF PROSTHESIS? YES DATE PRIOR PLACEMENT _______________ NO

BILLING DENTIST/DENTAL ENTITY (#40 - #43: USE FOR GROUP PRACTICE/MULTIPLE LOCATIONS) TREATING DENTIST AND LOCATION39. NAME, ADDRESS, CITY, STATE, ZIP 44. I HEREBY CERTIFY THAT I HAVE PERFORMED THE PROCEDURES AS INDICATED BY DATE AND/OR WISH TO

PREDETERMINE THE PROCEDURES WHICH ARE NOT DATED. THE PROCEDURES WERE/ARE NECESSARY IN MY PROFESSIONAL JUDGEMENT.

XSIGNED (TREATING DENTIST) DATE

45. NPI 46. LICENSE NUMBER 47. TIN

48. ADDRESS, CITY, STATE, ZIP (IF DIFFERENT THAN #39)

40. NPI 41. LICENSE NUMBER 42. TIN

43. PHONE NUMBER( )

49. PHONE NUMBER( )

50. ADDITIONAL DENTIST ID 51. SPECIALTY CODE

TYPE OF TRANSACTION

1. STATEMENT OF ACTUAL SERVICES PREDETERMINATION REQUEST

DELTA DENTAL 240 VENTURE CIRCLENASHVILLE, TN 37228

SUBSCRIBER INFORMATION11. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP

OTHER COVERAGE2. OTHER DENTAL OR MEDICAL COVERAGE?

NO IF NO, SKIP TO #11 YES3. AMOUNT OF PRIMARY PAYMENT

$

4. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP 12. DATE OF BIRTH 13. GENDER M F

14. SUBSCRIBER ID (SSN OR ID#)

15. PLAN/GROUP NUMBER 16. EMPLOYER NAME

PATIENT INFORMATION5. DATE OF BIRTH 6. GENDER

M F7. SUBSCRIBER/POLICYHOLDER ID (SSN OR ID#) 17. PATIENT NAME (LAST, FIRST, MIDDLE INITIAL)

8. PLAN/GROUP NUMBER 9. RELATIONSHIP TO PATIENT SELF SPOUSE CHILD OTHER

18. RELATIONSHIP TO SUBSCRIBER SELF SPOUSE CHILD OTHER

19. DATE OF BIRTH 20. GENDER M F

10. OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME 21. IF PATIENT IS A DEPENDENT OVER AGE 19, PLEASE INDICATE STATUS FULL TIME STUDENT TOTALLY & PERM DISABLED IRS DEPENDENT SPONSORED DEPENDENT

DENTAL SERVICES22. DATE OF SERVICE

MM/DD/CCYY23. AREA OF ORAL

CAVITY24. TOOTH NO. OR

LETTER25. TOOTH

SURFACE26. CURRENT CDT

PROCEDURE CODE27. DESCRIPTION 28. FEE

1

2

3

4

5

6

7

8

9

10

MAIL CLAIMS TO

MISSING TEETH PERMANENT PRIMARY 29. TOTAL FEE CHARGED

30. PLACE x ON MISSING TOOTH NUMBERS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K

DENTAL CLAIM STATEMENT

© 2008 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF TENNESSEE WITH PERMISSION –12/2009

INSTRUCTIONS FOR COMPLETING THE SCANNABLE CLAIM Optical scanning of paper claims can decrease total processing time by two to three days over those claims that must be manually keyed.

FOR CLAIMS TO BE OPTICALLY SCANNED:Clearly type, hand write, or use a computer printer to enter information.

Use all upper-case (capital) letters, if possible.

Write, type, or print in black or blue pen/ink—do not use red or green ink or any color of highlighter.

Keep information within the correct fi eld.

Make sure the typewriter or printer ribbon is dark and the print can be easily read.

Cover mistakes with line tape and print or type over—do not use liquid correction fl uid.

Use paperclips to hold attachments whenever possible. Place stapled items only at the lower edge of the form.

FIELDS 2 THROUGH 21—PATIENT/SUBSCRIBER INFORMATION:If the patient has dental coverage through another carrier(s), complete the other coverage section, fi elds #2 through #10 (if not, leave them blank). Fill in the amount of primary payment (#3) ONLY when the claim is billing for secondary benefi ts. Do not enter $0 unless the primary carrier’s determination of payment was $0. DO NOT ATTACH the primary carrier’s voucher.

Enter the patient’s and subscriber’s names in this order: last, fi rst, middle initial. Do not use titles, such as Mrs. or Dr.

FIELDS 22 THROUGH 31—DENTAL SERVICES AND REMARKS:Hand or machine print

When machine printing, double-space lines and enter information in between the correct column guidelines. Dates may be entered withoutseparators (/).

Use current ADA CDT procedure codes.

Use the REMARKS section (#31) for information necessary to process the claim, such as non-standard COB, miscellaneous codes, codes for which Delta Dental requires a report, or supporting documentation that will assist in accurately processing the claim. Keep documentation within the designated fi eld. Unnecessary documentation delays processing.

FIELDS 39 THROUGH 51—BILLING DENTIST AND TREATING DENTIST:The dentist’s name or business name entered in fi eld #39 must match the name on fi le with Delta Dental.

Enter the license number and Tax Identifi cation number (TIN) of the treating dentist in fi elds #46 and #47. Enter his/her National Provider Identifi er (NPI) in fi eld #45.

Fields #40 through #43 are optional for group practices or practices with more than one location who have more than one NPI, license numberand/or TIN.

NOTICE TO ALL PARTIES COMPLETING THIS FORM:Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or fi les a claim containing a false or deceptive statement is guilty of insurance fraud.

MAIL CLAIMS TO: FAX CLAIMS TO: TELEPHONE FOR ELIGIBILITY AND BENEFIT INFO WEB SITE

Delta Dental240 Venture Circle

Nashville, TN 37228(615) 244-8108 (800) 223-3104

(615) 255-3175 www.deltadentaltn.com

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

15

BILLING STATEMENTInvoice Cover Sheet

Delta Dental of Tennessee240 Venture CircleNashville, TN 37228-1699(615) 255-3175 or (888) 281-9396

Group No. : 0000111Run Date : 04-17-2014

Billing Date : 04-17-2014Closing Date : 04-17-2014

Due Date : 05-01-2014

Billing Period : 05-01-2014 - 05-31-2014

SARAH SMITH Tn Company ABC PO Box 1234 Nashville, TN 37228-0100

Invoice No. : 05SPVLU

Net Update Adjustment Current Month Billing

$0.00$4,507.49

2001Sub GroupContract ID

Sub Group Amount Due $4,507.49

Group Number 0000111

Net Update Adjustment Current Month Billing

$0.00$53.30

3001Sub GroupContract ID

Sub Group Amount Due $53.30

Group Number 0000111

Net Update Adjustment Current Month Billing

$0.00$337.74

$79.95Current Month Cobra Billing

5001Sub GroupContract ID

Sub Group Amount Due $417.69

Group Number 0000111

Net Update Adjustment Current Month Billing

$169.13$542.75

7001Sub GroupContract ID

Sub Group Amount Due $711.88

Group Number 0000111

Monday, May 05, 2014 Page 1 of 2

Group Number: Due Date:

Detach and return with payment

0000111 05-01-2014

1858

Subgroup: 2001

Make checks payable to: Delta Dental of Tennessee and mail to the following address:

Delta Dental of TennesseeP.O. Box 305172Dept. 35Nashville, TN 37230-5172

Invoice Number: 05SPVLU$5,690.36Amount Due:

16

BILLING STATEMENTInvoice Cover Sheet

Delta Dental of Tennessee240 Venture CircleNashville, TN 37228-1699(615) 255-3175 or (888) 281-9396

TOTAL AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,690.36

* If the subscriber count falls below the minimum of 140 subscribers as stated in yourcontract, you will be billed to meet the minimum requirement.

Monday, May 05, 2014 Page 2 of 2

Group Number: Due Date:

Detach and return with payment

0000111 05-01-2014

1858

Subgroup: 2001

Make checks payable to: Delta Dental of Tennessee and mail to the following address:

Delta Dental of TennesseeP.O. Box 305172Dept. 35Nashville, TN 37230-5172

Invoice Number: 05SPVLU$5,690.36Amount Due:

17

E-Billing Registration Form

Group Name: ____________________________________________ Group Number: ________________

Effective Date: _____________________

Complete PART I below to receive an invoice only or to add, update, or delete current users. To receive an invoice AND access complete billing detail, complete PARTS I and II.

PART I: Invoice Only (no login needed)

USER 1 INFORMATION New User Update User Delete User

Name: __________________________________________________ Phone Number: ________________

Email: _________________________________

USER 2 INFORMATION New User Update User Delete User

Name: __________________________________________________ Phone Number: ________________

Email: _________________________________

PART II: Invoice with Billing Detail/Subscriber Listings (login required)

USER 1 Requested User ID (min. 6 characters; can match BMT): ____________________________________________ Password: For security purposes, the Billing Department will email a password to you.

Subgroup Access: All Subgroups

Listed Subgroups: ___________________________________________________

Billing File Formats (choose one):

PDF & Excel E-Fax Fax #: _______________________

USER 2 Requested User ID (min. 6 characters; can match BMT): ____________________________________________ Password: For security purposes, the Billing Department will email a password to you.

Subgroup Access: All Subgroups

Listed Subgroups: ___________________________________________________

Billing File Formats (choose one):

PDF & Excel E-Fax Fax #: _______________________

For questions or other billing changes, please contact the Billing Department at (615) 255-3175 x.6585.

Please scan and email, fax, or mail this form to your Account Manager.

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Fax: (615) 244-8108 18

Online Bill-pay Instructions

Go to www.DeltaDentalTN.com/OnlineBillPay and click on ‘Pay My Bill’

Make Payment Screen 1 Click ‘Next’ to approve the $3.00 fee.

Screen 2 Enter your Group Number (without leading zeros).

Screen 3 Choose ‘Make Payment’ in the upper left corner (see ‘View Payment’ instructions below). Click the check box next to the invoice you would like to pay. You can only pay the total invoice amount, not a partial amount.

Screen 4 Set up your payment method by clicking ‘Add Account.’ You can select ‘Credit Card’ or ‘Checking’ from the drop down list, and then add the information. The payment information will be saved for future use, so you won’t have to add it again.

Screen 5 With the correct payment method selected, click ‘Continue.’ You can also select ‘Add Account’ to add another payment method.

Screen 6 For a credit card, enter the CVV2 code, expiration date, and set the payment date (which can be up to 5 business days out). For a checking account, the payment date will default to the same day, although the payment won’t clear until the next business day.

Screen 7 Review the payment details and accept the terms and conditions by clicking on the check box. You can click ‘Cancel’ to end the transaction, or click ‘Pay Now’ to complete the payment.

Screen 8 You will see your payment confirmation and receive a confirmation number.

View Payment Screen 1 Choose ‘View Payment’ in the upper left corner. Choose your search criteria from the dropdown menu (‘Group Number/Payment Amount’ is best), and then search for a payment by the amount or the payment date. When a list of payments is generated, you can view the payment by clicking on the Confirmation Number.

Screen 2 You will see the complete payment information for that invoice, including the confirmation number. You can also download this information into Excel format.

19

Coordination of BenefitsWhat is...

Coordination of Benefits (COB) is a way of paying health care expenses when people are covered by more than one

plan. The goal of COB is to make sure the cost of a dental procedure is covered within the scope of the plans, without

exceeding the amount of the actual bill. If you are covered by two or more dental plans—usually because both you

and your spouse receive coverage through work—your coverage will be coordinated.

In Tennessee, if you have coverage through your employer, it will pay as primary. If you are also covered by your

spouse’s plan, it will pay as secondary. If you do not have your own coverage, but are covered under your spouse’s

plan, it will pay as primary.*

For children covered by both parents’ (or guardians’) dental plans, the primary carrier is

determined by the “birthday rule.” The plan that covers the parent or guardian whose birthday

comes first in the calendar year will be considered the primary carrier. The birthday rule may be

superseded by a divorce judgment or court ruling.

Review your coverage in our online Consumer Toolkit at

www.DeltaDentalTN.com/consumertoolkit.

Or, call Customer Service at (800) 223-3104.

*While this is the standard way COB is handled, it can vary by plan.Review your Certificate of Coverage to confirm how your plan works.

For example: Robert and Sara Johnson each have dental coverage through their employer.

Robert is also covered under Sara’s plan and vice versa. Last time Robert went to the dentist,

he had a cleaning. His dental plan will pay as primary, and Sara’s plan will pay as secondary.

For example: Robert and Sara have a daughter, Amy, who is covered under both Robert

and Sara’s dental plans. Sara’s birthday is in February. Robert’s birthday is in July.

Because Sara’s birthday comes first, Amy is covered under Sara’s plan as primary

and Robert’s plan as secondary.

Dental made simple.

271 1/14

Procedure

Cleaning

Estimated Bill

$100

Robert’s Plan Pays 80%

$80

Sara’s Plan Pays Remainder

$20

The Birthday Rule

Standard COB – How it Works

Questions?

20

Find a Dentist Choosing a dentist from the Delta Dental PPOSM or Delta Dental Premier® networks will help you save money and get the most from your benefi ts. You also have the option to visit any licensed dentist.Go to www.DeltaDentalTN.com and click on “Find a Dentist” or call (800) 223-3104.

Your Benefi ts, 24/7 Our secure, online Consumer Toolkit® allows you to:

• Check benefi t eligibility• Print ID cards• Find current benefi t information• Review claims• And more!

Go to www.DeltaDentalTN.com and log in under “Toolkits & Resources.” Click on “New User” to register the fi rst time.

Your ID Card Your new ID cards are below! You do not have to show your ID card to your dentist to receive treatment, however you may wish to carry it for reference. Our toll-free phone number, website, and mailing address are listed on the back.Your Subscriber ID may be either your Social Security Number (SSN) or an alternate ID number. If it is your SSN, it will not be listed on your ID card to help protect your privacy.

Benefi ts on the Go The Delta Dental Mobile App lets you securely access your benefi t information anytime, anywhere and includes:

• Dentist search• Mobile ID card• Toothrush timer

Download the app for free for Apple® or Android by searching for ‘Delta Dental.’

Customer Service Call (800) 223-3104 to reach representatives Monday – Friday, 7:00am to 5:00pm CST. You can also callanytime and use DASI, our automated system, to access information about your eligibility, benefi ts, claim status, and listings for nearby dentists.

Delta Dental of Tennessee240 Venture CircleNashville, TN 37228 -1604

NAME

CLIENT

SUBSCRIBER ID

CLIENT NO.

NAME

CLIENT

SUBSCRIBER ID

CLIENT NO.

21

Understanding your Explanation of Benefits

The Explanation of Benefits (EOB) form is your key to understanding dental claim payments. We produce this form when your claims are processed to give you a record of how your dental benefits were used. We send the EOB directly to you, and it will provide you withthe information you need, including:

• Dental services performed (procedure description)• Dentist fees• Delta Dental’s payment• Your payment• Coordination of benefits information, if applicable• Annual maximums used in the current benefit year

We have included two samples in this brochure to help you understand your EOB:

• Example A shows a complete and fairly simple claim payment.• Example B shows areas of the EOB that would apply to a coordination of benefits.

To access any information you may need about your dental coverage, visit ConsumerToolkit® at www.DeltaDentalTN.com/consumertoolkit. Consumer Toolkit provides enrollees and their dependents all the information they need to learn about their plan, review claims and claim payments, access a searchable dentist directory, and more.

If you have questions, please contact Customer Service at (800) 223-3104. Representatives are available Monday through Friday from 7:00 a.m. to 5:00 p.m. CST.

22

Area/Tooth Code/Surface

Date of Service

Procedure Description

Submitted Amount

Maximum Approved Fee

Par DentistSavings

AllowedAmount

Deductible / P atient Co-Pay / O �ce V isits Co-Pay % Payment

Patient Payment

Pay To

Total

Patient Name:Date of Birth:Relationship:Subscriber:

Pay To: C = Custodial ParentS = SubscriberP = Provider

EOB_Subscriber

Business/Dentist:License No.:Check No.:Issue Date:Receipt Date:Claim No.:

P a t i e n t C o p y

Explanation of Benef its(THIS IS NOT A BILL)

ANTI-FRAUD TOLL FREE NUMBER1-800-524-0147 (select option 7)Insurance fraud signi �cantly increases the cost of health care. If you are aware of any false information submitted to Delta Dental, you can help us lower these costs by contacting us at the number given above. You do not need to identify yourself.

FOR INQUIRIES: 1-800-223-3104

Your privacy is important to us. To access our HIPAA Notice of Privacy Practices, please visit our website.

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

Patient Acct:

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

GENERAL MAXIMUM USED TO DATE

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

CLIENT/ID: PLAN: :TCUDORP :TNEILCBUS

DELTA DENTAL OF TENNESSEE240 VENTURE CIRCLENASHVILLE, TN 37228-1604

.

Payment for these services is determined in accordance with the speci�c terms of your dental plan and/or Delta Dental’s agreements with its participating dentists. For inquiries regarding participating dentists, please call the number listed above. Delta Dental’s payment decisions do not qualify as dental or medical advice. You must make all decisions about the desirability or necessity of dental procedures and services with your dentist.If your claim was denied in whole or in part so that you must pay some amount of the claim, upon a written request and free of charge, we will provide you with a copy of any internal rule, guideline or protocol or, if applicable, an explanation of the scienti�c or clinical judgment relied upon in deciding your claim. If you still believe your claim should have been paid in full, you may ask to have the claim reviewed. Your written request for a formal �rst level review must be sent within 180 days of your receipt of this EOB to the address listed. You may submit any additional materials you believe support your claim. A decision will be made no later than 30 days from the date we receive your request. If we again deny the claim, you may request a second level review. The manner in which to seek a second level review will be included with the letter informing you of our �rst level review decision. The second level review decision will be made no later than 30 days from the date we receive your request. If your claim is denied in whole or in part after both stages, you have the right to seek to have your claim paid by �ling a civil action in court within one year from the �nal denial.

.

Page 1 of 1

JANET DOE FRIZ FLOSSMOOR, D.D.S.000-000000XXXXXXXXXXXX08-25-201308-25-201300000-0000

03213005LR

08/25/1308/25/1308/25/1308/25/1308/25/13

EXTRACTIONEXTRACTIONEXTRACTIONEXTRACTIONSURGERY

168.00168.00168.00168.00255.00

927.00- 651.00 276.00 651.00 .00 611.00 40.00

110.00110.00110.00110.00211.00

58.00 58.00 58.00 58.00 44.00

110.00110.00110.00110.00211.00

.00

.00

.00

.00

.00

100%100%100%100%100%

110.00110.00110.00110.00171.00

.00 .00 .00 .0040.00

PPPPP

02-29-1973SPOUSEJEFFERY DOE

1

5678

9

1211

10

14

13

15 16 17 18 19 20 21 22 23 24 25

26

27

23

4

Example A—EOB (Simple Claim)

23

Example A—EOB (Simple Claim)

1. Patient Name: The first and last name of the personwho received the dental treatment.

2. Relationship: Identifies the relationship of the patient tothe subscriber.

3. Subscriber: The person who has obtained the healthinsurance. In the case of employer-sponsored healthinsurance, this is the employee.

4. Business/Dentist: The treating business ordentist name.

5. Check No.: The check number issued by Delta Dental.

6. Issue Date: The date the EOB was issued. This is alsothe date the claim was paid.

7. Receipt Date: The date the claim was received byDelta Dental.

8. Claim No.: The number assigned to the claim thatcorresponds to the EOB. This number and yoursubscriber ID number are needed to locate claims andshould be used when making inquiries.

9. Pay to: This key is for the “Pay To” column in item #25.It lets you know where payment was sent.

10. Client/ID: The number assigned to the main groupunder which you have dental coverage. (This is usuallyyour employer.)

11. Subclient: The number assigned to the particularcategory, branch or location under which you havedental coverage.

12. Plan: The name of the plan under which you havedental coverage (e.g. Delta Dental of Tennessee)

13. Product: The benefit plan selected by your group.

14. Area/Tooth Code/Surface: The number or letter of thetooth or area of the mouth that was treated. For area ofthe mouth, 01 = Upper Arch; 02 = Lower Arch;10 = Upper Right; 20 = Upper Left; 30 = Lower Left;40 = Lower Right. (For orthodontic EOBs, seeinformation on following page.)

15. Date of Service: The date treatment was rendered.

16. Procedure Description: A brief description ofthe procedure.

17. Submitted Amount: Amount submitted by the dentist.

18. Maximum Approved Fee: The portion of the dentist’ssubmitted fee approved by Delta Dental for theprocedure performed. Your out-of-pocket expense isbased on this figure.

19. Par Dentist Savings: The difference between what thedentist submitted and what Delta Dental will allow. Thisis the benefit of seeing a network dentist.

20. Allowed Amount: The portion of the dentist’s submittedfee allowed by Delta Dental for the procedureperformed. Your copayment percentage is based on thisfigure.

21. Deductible/Patient Co-Pay/Office Visits: The dollaramount that was subtracted from the allowed amountbefore calculating your payment and Delta Dental’spayment. Within the column itself a deductible amountwill be preceded with a D, a patient copay with either aPC or a C, and an office visit with an O or OV.

22. Co-Pay %: The percentage, as stated in your group’scontract, used to calculate Delta Dental’s payment.

23. Payment: The amount paid by your dental plan.

24. Patient Payment: The amount you are responsible forpaying.

25. Pay To: Identifies whether Delta Dental sent payment toa custodial parent (C), you (S), or your dentist (P). Seeitem #9.

26. Total: Column totals.

27. ERISA Statement: Delta Dental’s claims appealprocedures as required by the federal law known as theEmployee Retirement Income Security Act of 1974.

24

Area/Tooth Code/Surface

Date of Service

Procedure Description

Submitted Amount

Maximum Approved Fee

Par DentistSavings

AllowedAmount

Deductible / P atient Co-Pay / O �ce V isits Co-Pay % Payment

Patient Payment

Pay To

Total

Patient Name:Date of Birth:Relationship:Subscriber:

Pay To: C = Custodial ParentS = SubscriberP = Provider

EOB_Subscriber

Business/Dentist:License No.:Check No.:Issue Date:Receipt Date:Claim No.:

P a t i e n t C o p y

Explanation of Benefits(THIS IS NOT A BILL)

ANTI-FRAUD TOLL FREE NUMBER1-800-524-0147 (select option 7)Insurance fraud signi �cantly increases the cost of healthcare. If you are aware of any false information submitted to Delta Dental, you can help us lower these costs by contacting us at the number given above. You do notneed to identify yourself.

FOR INQUIRIES: 1-800-223-3104

Your privacy is important to us. To access our HIPAA Notice of Privacy Practices, please visit our website.

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

Patient Acct:

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

GENERAL MAXIMUM USED TO DATE

www.DeltaDentalTn.comwww.DeltaDentalTn.comwww.DeltaDentalTn.com

CLIENT/ID: PLAN: :TCUDORP:TNEILCBUS

DELTA DENTAL OF TENNESSEE240 VENTURE CIRCLENASHVILLE, TN 37228-1604

.

Payment for these services is determined in accordance with the speci�c terms of your dental plan and/or Delta Dental’s agreements with its participating dentists. For inquiries regarding participating dentists, please call the number listed above. Delta Dental’s payment decisions do not qualify as dental or medical advice. You must make all decisions about the desirability or necessity of dental procedures and services with your dentist.If your claim was denied in whole or in part so that you must pay some amount of the claim, upon a written request and free of charge, we will provide you with a copy of any internal rule, guideline or protocol or, if applicable, an explanation of the scienti�c or clinical judgment relied upon in deciding your claim. If you still believe your claim should have been paid in full, you may ask to have the claim reviewed. Your written request for a formal �rst level review must be sent within 180 days of your receipt of this EOB to the address listed. You may submit any additional materials you believe support your claim. A decision will be made no later than 30 days from the date we receive your request. If we again deny the claim, you may request a second level review. The manner in which to seek a second level review will be included with the letter informing you of our �rst level review decision. The second level review decision will be made no later than 30 days from the date we receive your request. If your claim is denied in whole or in part after both stages, you have the right to seek to have your claim paid by �ling a civil action in court within one year from the �nal denial.

.

Page 1 of 1

Example B—EOB (Coordination of Benefits/Processing Policies)

NETWORK:

OTHER CARRIER: OTHER DENTAL PLAN

POLICY CODE: BB0010

ORIGINALLY SUBMITTED:

REPLACED BY:

BB0010. THE PROCEDURE CODE WAS CHANGED BASED ON THE INFORMATION SUBM

THE FOLLOWING POLICIES ARE APPLIED TO EXPLAIN BENEFITS PAYABLE AND ARE NOT INTENDED TO ALTER THE TREATMENT PLAN DETERMINED BY THE DENTIST AND PATIENT.

OTHER CARRIER PAYMENT AMOUNT:

08/25/13

08/25/13

50.00

50.00

.00

50.00

.00

50.00

CLEANING

CLEANING

1. Other Carrier: The name of the primarydental carrier. (That is, the carrier thatwill pay first when you have coverageunder more than one dental plan.)

2. Other Carrier Payment Amount: Theamount paid by the primary carrier for the services listed.

3. Originally Submitted: The procedure code the dentist originally submitted onthe claim form.

4. Replaced By: The procedure code bywhich Delta Dental based its paymentaccording to the group’s benefit planallowances.

5. Policy Code: This code number refersto a Delta Dental processing policy. Thepolicy code applies to the services listeddirectly above it.

6. Explanation of Policy Codes: Theexplanation of each policy code used.

Please note: When an adjustment is necessary for a previous claim payment, the EOB will show the original line information as well as the adjusted line information. The policy code(s) relating to the adjustment will be explained on your EOB.

15. Area/Tooth Code/Surface: For orthodontic EOBs, this column is used to identify the stage of orthodontic treatment:T = Total; total fee for orthodontic treatment planI = Initial; initial fee for banding or placement of orthodontic appliancesNumeric Value(s) (01-99) = The month of the treatment plan processed (for example: “01” would be the first month of treatment after banding, “02” would be the second month of treatment after banding, etc.)L = Last; completion or last payment by Delta Dental for the orthodontic treatment planO = Only; only or one-time payment for orthodontic treatment

Please note:• On this EOB, Delta Dental’s total liability and your total liability for orthodontic treatment are shown. (Please see the

information on the line with “T” in the tooth column.) Because this is merely a statement of liability for as long as the patient remains eligible and in treatment, these figures are not included in the column totals.

• Delta Dental will automatically make the monthly payments specified on the original orthodontic claim. If treatmentis discontinued for any reason, notify Delta Dental immediately.

• When an adjustment is necessary for a previous claim payment, the EOB will show the original line information aswell as the adjusted line information. The policy code(s) relating to the adjustment will be explained on your EOB.

1

5

6

2

3

4

Orthodontic EOBs

25