Dental Plan - bdgmd.com › CareFirst Benefit Descriptions...8210 Removable appliance therapy 455...

10455 Mill Run Circle, RRS# 293 • Owings Mills, MD 21117-4208

Telephone 410-847-9060 • Fax 410-339-5360

Toll Free 888-833-8464

www.carefirst.com

Dental PlanBenefit Information

Provider Choice - Plan PC-5

FORM DN4005 (R. 1/10)

PROVIDER CHOICE – Plan PC - 5

ADA Procedure Name Copayment BASIC DENTAL SERVICE Per Office Visit Copay $5

Includes the following services (ADA Codes): all examinations (120; 140; 150; 170, and 180), prophylaxis (1110 and 1120), x-rays (210; 220; 230; 240; 270; 272; 274; 277; 330; 340), pulp vitality test (460), diagnostic casts (470), oral hygiene instructions (1330), fluoride treatments (1203 and 1204), sealants (1351), pulp caps (3110 and 3120), amalgam and composite restorations (2140; 2150; 2160; 2161; 2330; 2331; 2332; 2335; 2391; 2392; 2393; and 2394), sedative fillings (2940), extractions (7111 and 7140), recementation of space maintainers, inlay(s), crown(s) or bridge (1550; 2910; 2920 and 6930), pin retention (2951), complete or partial denture adjustments (5410; 5411; 5421; and 5422), palliative treatment (9110), and follow-up visits for Major Dental Services (listed below).

SOFT TISSUE MANAGEMENT Per Office Visit Copay $60

Includes the following services (ADA Codes): all periodontal scaling and root planing (4341 and 4342), full mouth debridement (4355), and periodontal maintenance procedures following active therapy (4910).

MAJOR DENTAL SERVICES SPACE MAINTENANCE (PASSIVE APPLIANCES) 1510 Space Maintainer - Fixed Unilateral 80 1515 Space Maintainer - Fixed Bilateral 105 1520 Space Maintainer – Removable Unilateral 50 1525 Space Maintainer – Removable Bilateral 105 INLAY/ONLAY RESTORATIONS 2510 Inlay metallic - one surface 155 2520 Inlay - metallic - two surfaces 190 2530 Inlay - metallic - three or more surfaces 210 2543 Onlay - metallic - three surfaces 40 2544 Onlays - metallic - four or more surfaces 52 2610 Inlay - porcelain/ceramic - one surface 165 2620 Inlay - porcelain/ceramic - two surfaces 180 CROWNS - SINGLE RESTORATION ONLY 2710 Crown – Resin-based composite (Indirect) 90 2740 Crown - porcelain/ceramic substrate 315 2750 Crown - porcelain fused to high noble metal 320 2751 Crown - porcelain fused to predominantly base metal 300 2752 Crown - porcelain fused to noble metal 310 2790 Crown - full cast high noble metal 320 2791 Crown - full cast predominantly base metal 300 2792 Crown - full cast noble metal 310 2799 Provisional Crown - at least six months 60

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FORM DN4005 (R. 1/10)

ADA Procedure Name Copayment OTHER RESTORATIVE SERVICES 2930 Prefabricated stainless steel crown – primary tooth 70 2931 Prefabricated stainless steel crown – permanent tooth 70 2933 Prefabricated stainless steel crown with resin window 80 2950 Core buildup, including any pins 65 2952 Post and core in addition to crown, indirectly fabricated 72 2953 Each additional indirectly fabricated post — same tooth 36 2954 Prefabricated post and core in addition to crown 60 2957 Additional prefabricated post and core 30 2970 Temporary crown (fractured tooth) 60 PULPOTOMY 3220 Therapeutic Pulpotomy (excluding final restoration) 40 ENDODONTIC THERAPY ON PRIMARY TEETH 3230 Pupal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) 52 3240 Pupal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) 60

ROOT CANAL/ ENDODONTIC THERAPY (INCLUDING TREATMENT PLAN, CLINICAL PROCEDURES AND FOLLOW-UP CARE

3310 Anterior (excluding final restoration) 190 3320 Bicuspid (excluding final restoration) 240 3330 Molar (excluding final restoration) 310 3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 125 ENDODONTIC RETREATMENT 3346 Retreatment of previous root canal therapy - anterior 250 3347 Retreatment of previous root canal therapy - bicuspid 310 3348 Retreatment of previous root canal therapy – molar 390 APICOECTOMY/PERIAPICAL SERVICES 3410 Apicoectomy/Periradicular surgery – anterior 150 3421 Apicoectomy/Periradicular surgery – bicuspid (first root) 175 3425 Apicoectomy/Periradicular surgery – molar (first root) 225 3426 Apicoectomy/Periradicular surgery - (each additional root) 75 3430 Retrograde Filling - per root 50 3450 Root amputation - per root 80 OTHER ENDODONTIC PROCEDURES 3910 Surgical procedure for isolation of tooth with rubber dam 70 3920 Hemisection (incl. any root removal) not including root canal therapy 85 SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)

4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant 110

4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or bounded teeth spaces per quadrant 35

4240 Gingival flap procedure, including root planing – four or more contiguous teeth or bounded teeth spaces per quadrant 135

4249 Clinical crown lengthening - hard tissue 105

4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded teeth spaces per quadrant 330

4263 Bone replacement graft - first site in quadrant 315 4264 Bone replacement graft - each additional site in quadrant 120 4270 Pedicle soft tissue graft procedure 175 4271 Free soft tissue graft procedure - including donor site surgery 195 4273 Subepithelial connective tissue graft procedures, per tooth 135

4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) 55

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FORM DN4005 (R. 1/10)

ADA Procedure Name Copayment ADJUNCTIVE PERIODONTAL SERVICES 4320 Provisional splinting – intracoronal 50 4321 Provisional splinting – extracoronal 60 COMPLETE DENTURES (Including Routine Post-Delivery Care) 5110 Complete denture – maxillary 320 5120 Complete denture – mandibular 320 5130 Immediate denture – maxillary 355 5140 Immediate denture – mandibular 355 PARTIAL DENTURES (Including Routine Post-Delivery Care) 5211 Maxillary partial denture – resin base- including any conventional clasps, rests & teeth 300 5212 Mandibular partial denture – resin base – including any conventional clasps, rests & teeth 300

5213 Maxillary partial denture - cast metal framework with resin denture bases - including any conventional clasps, rests & teeth 350

5214 Mandibular partial denture – cast metal framework with resin denture bases - including any conventional clasps, rests & teeth 350

5281 Removable unilateral partial denture - one piece cast metal - including clasps & teeth 85 REPAIRS TO COMPLETE DENTURES 5510 Repair broken complete denture base 40 5520 Replace missing or broken teeth – complete denture (each tooth) 30 REPAIRS TO PARTIAL DENTURES 5610 Repair resin denture base 40 5620 Repair cast framework 42 5630 Repair or replace broken clasp 33 5640 Replace broken teeth - per tooth 33 5650 Add tooth to existing partial denture 40 5660 Add clasp to existing partial denture 45 DENTURE REBASE PROCEDURES 5710 Rebase complete maxillary denture 80 5711 Rebase complete mandibular denture 80 5720 Rebase maxillary partial denture 75 5721 Rebase mandibular partial denture 75 DENTURE RELINE PROCEDURES 5730 Reline complete maxillary denture (chairside) 75 5731 Reline complete mandibular denture (chairside) 75 5740 Reline maxillary partial denture (chairside) 60 5741 Reline mandibular partial denture (chairside) 60 5750 Reline complete maxillary denture (laboratory) 85 5751 Reline complete mandibular denture (laboratory) 85 5760 Reline maxillary partial denture (laboratory) 80 5761 Reline mandibular partial denture (laboratory) 80 OTHER REMOVABLE PROSTHETIC SERVICES 5810 Interim complete denture (maxillary) 120 5811 Interim complete denture (mandibular) 120 5820 Interim partial denture (maxillary) 100 5821 Interim partial denture (mandibular) 100 5850 Tissue conditioning – maxillary 32 5851 Tissue conditioning – mandibular 32 FIXED PARTIAL DENTURE PONTICS 6210 Pontic - cast high noble metal 320 6211 Pontic - cast predominantly base metal 300 6212 Pontic - cast noble metal 310 6240 Pontic - porcelain fused to high noble metal 320

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FORM DN4005 (R. 1/10)

ADA Procedure Name Copayment 6241 Pontic - porcelain fused to predominantly base metal 300 6242 Pontic - porcelain fused to noble metal 310 RETAINERS 6545 Retainers - cast metal for resin bonded fixed prosthesis 100 FIXED PARTIAL DENTURE RETAINERS - CROWN 6750 Crown - porcelain fused to high noble metal 320 6751 Crown - porcelain fused to predominantly base metal 300 6752 Crown - porcelain fused to noble metal 310 6780 Crown - 3/4 cast high noble metal 270 6790 Crown - full cast high noble metal 320 6791 Crown - full cast predominantly base metal 300 6792 Crown – full cast noble metal 310 OTHER FIXED PARTIAL DENTURE SERVICES 6940 Stress breaker 42 6950 Precision attachment 95 6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated 80 6972 Prefabricated Post and Core in addition to fixed partial denture retainer 70 6973 Core build up for retainer, including any pins 65 6976 Each additional indirectly fabricated post — same tooth 42 6977 Each additional prefabricated post and core 40

SURGICAL EXTRACTIONS (Includes Local Anesthesia, Suturing, if Needed and Routine Post Operative Care)

7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 60

7220 Removal of impacted tooth – soft tissue 75 7230 Removal of impacted tooth – partially bony 95 7240 Removal of impacted tooth – completely bony 120 7241 Removal of impacted tooth – completely bony with unusual surgical complications 140 7250 Surgical removal of residual tooth roots (cutting procedure) 55 OTHER SURGICAL PROCEDURES 7280 Surgical access of an unerupted tooth 135 7286 Biopsy of oral tissue - soft 60 ALVEOLOPLASTY - Surgical Preparation of Ridge for Dentures

7310 Alveoloplasty - in conjunction with extractions – four or more teeth or tooth spaces per quadrant 50

7320 Alveoloplasty - not in conjunction with extractions – four or more teeth or tooth spaces per quadrant 55

SURGICAL INCISION 7510 Incision & drainage of abscess – intraoral soft tissue 40 7520 Incision & drainage of abscess – extraoral soft tissue 35 OTHER REPAIR PROCEDURES 7960 Frenulectomy (frenectomy or frenotomy) - separate procedure 60 7971 Excision of pericoronal gingiva 52 LIMITED ORTHODONTIC TREATMENT 8010 Limited ortho. treatment of the primary dentition 475 8020 Limited ortho. treatment of the transitional dentition 495 8030 Limited ortho. treatment of the adolescent dentition 515 8040 Limited ortho. treatment of the adult dentition 555 INTERCEPTIVE ORTHODONTIC TREATMENT 8050 Interceptive orthodontic treatment of the primary dentition 725

8060 Interceptive orthodontic treatment of the transitional dentition 825

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FORM DN4005 (R. 1/10)

ADA Procedure Name Copayment COMPREHENSIVE ORTHODONTIC TREATMENT 8070 Comprehensive orthodontic treatment of the transitional dentition 1,950 8080 Comprehensive orthodontic treatment of the adolescent dentition 2,100 8090 Comprehensive orthodontic treatment of the adult dentition 2,250 MINOR TREATMENT TO CONTROL HARMFUL HABITS 8210 Removable appliance therapy 455 8220 Fixed appliance therapy 420 OTHER ORTHODONTIC SERVICES 8660 Pre-orthodontic treatment visit 120 8670 Periodic orthodontic treatment visit (as part of contract) 80 8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 190 ANESTHESIA 9230 Analgesia (Nitrous Oxide) 25 9241 Intraveneous Sedation – First 30 minutes 90 9242 Intraveneous Sedation – Each additional 15 minutes 32 PROFESSIONAL CONSULTATION

9310 Consultation — diagnostic service provided by dentist or physician other than requesting dentist or physician 35

PROFESSIONAL VISITS 9400 Broken appointment charge – per 15 minutes (without 24 hours prior notice) 10 MISCELLANEOUS SERVICES 9910 Application of desensitizing medicament 8 9911 Application of desensitizing resin (cervical and/or root surface) 8 9940 Occlusal guard, by report 180 9951 Occlusal adjustment - limited 50 9952 Occlusal adjustment - complete 110 9974 Internal Bleaching - per tooth 95

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FORM DN4005 (R. 1/10)

PLAN LIMITATIONS

The following exclusions and limitations shall apply:

Services for injuries and conditions which are covered under Workers’ Compensation or Employers’ Liability Laws;

Services which are provided without cost to the Covered Employee and/or Dependent(s) by any municipality, county or other political subdivision (with the exception of Medicaid);

Services which, in the opinion of the participating DENTIST, are not necessary for the Covered Employee and/or Dependent(s) health;

Payment of any claim or bill will not be made for prohibited referrals; Cosmetic, elective, or aesthetic dentistry, which in the opinion of the participating DENTIST

are not necessary for the patient’s dental health; Oral surgery requiring the setting of fractures or dislocations; Services with respect to malignancies, cysts or neoplasms, or hereditary, congenital or

developmental malformations; Dispensing of drugs, except those used as a local anesthetic; Hospitalization for any dental procedure; Loss or theft of bridgework or dentures previously supplied under the PLAN; Replacement of a bridge, crown, or denture within five (5) years after the date it was originally

installed; Any implantation; General anesthesia; Services that cannot be performed because of the general health of the patient; Teeth Cleaning (Prophylaxis) at intervals of less than six (6) months; Unlisted procedures will be provided at the dentist’s charges; Services which are obtained outside the dental office in which enrolled and which are not pre-

authorized by the PLAN. This does not apply to out-of-area emergency dental services; Services rendered by a Pedodontist (Pediatric Dentist) are considered Specialty Care and

must be approved by the Covered Employee’s and/or Dependent(s) General Participating DENTIST;

All services listed on the Schedule of Benefits and Member Copayments will be provided by a general Participating Dentist or an approved Specialist; provided, however, that a general DENTIST will refer the Covered Employee and/or Dependent(s) to an approved Specialist or recommend that the Covered Employee and/or Dependent(s) contact an approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an approved Specialist, with an exception for out-of-area emergency care, and a referral to a non-participating general dentist or specialist;

Services which cannot be performed in the dental office of the “Personal Participating DENTIST” or “Approved Specialist” due to the special needs or health related conditions of the Covered Employee and/or Dependent(s).

OUT-OF-AREA EMERGENCY CARE: Covered Employees and/or Dependent(s) are covered for emergency dental treatment to alleviate acute pain, along with treatment arising from accidental injury or illness while temporarily more than 50 miles from their "Personal Participating DENTIST." Limited to $50 per Covered Employee and/or Dependent(s) per emergency. ALL PRICES ARE EXCLUSIVE OF GOLD

MD/TDN/SOB AMEND (1/13) 1 GRP PROD/PC5

The Dental Network, Inc. 10455 Mill Run Circle

Owings Mills, Maryland 21117 410-847-9060

An independent licensee of the Blue Cross and Blue Shield Association

SCHEDULE OF BENEFITS AND COPAYMENTS AMENDMENT

This amendment is effective on the effective date of the Schedule of Benefits and Copayments to which this amendment is attached. The Schedule of Benefits and Copayments Provider Choice - Plan PC – 5 is amended as follows:

I. The American Dental Association procedure codes listed below are added:

ADA Code Procedure Name Copayment

1208 Topical application of fluoride Included in the $5

Office Visit Copay for Basic Dental Services

4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $35

4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft

$195

4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site

$135

II. The Procedure Names for the American Dental Association procedure codes listed below

are replaced with the following revised nomenclature:

ADA Code Procedure Name

0210 Intraoral - complete series of radiographic images 0220 Intraoral - periapical first radiographic image 0230 Intraoral - periapical each additional radiographic image 0240 Intraoral - occlusal radiographic image 0270 Bitewing - single radiographic image 0272 Bitewings - two radiographic images 0274 Bitewings - four radiographic images 0277 Vertical bitewings - 7 to 8 radiographic images 0330 Panoramic radiographic image 0340 Cephalometric radiographic image 2799 Provisional crown – further treatment or completion of diagnosis necessary

prior to final impression

MD/TDN/SOB AMEND (1/13) 2 GRP PROD/PC5

III. The American Dental Association procedure codes listed below are deleted:

ADA Code Procedure Name

1203 Topical application of fluoride - child 1204 Topical application of fluoride - adult 4271 Free soft tissue graft procedure (including donor site surgery) 6970 Post and core in addition to fixed partial denture retainer, indirectly

fabricated 6972 Prefabricated post and core in addition to fixed partial denture retainer 6973 Core build up for retainer, including any pins 6976 Each additional indirectly fabricated post - same tooth 6977 Each additional prefabricated post - same tooth

This amendment is issued to be attached to the Schedule of Benefits and Copayments. This amendment does not change the terms and conditions of the Schedule of Benefits and Copayments, unless specifically stated herein.

The Dental Network, Inc.

_______________________________ Chester E. Burrell

Chief Executive Officer and President

FORM DN003B (R. 1/10) 1 6/10

The Dental Network, Inc. Group Certificate of Coverage

THE DENTAL NETWORK, INC. (hereinafter referred to as “PLAN”) hereby certifies that the Covered Employee is covered under and subject to all the provisions, definitions, limitations and conditions of this Certificate for the benefits of the PLAN, and is eligible for benefits on the date shown on the Membership Identification Card. The address of the principal administrative office of the PLAN is 10455 Mill Run Circle, RRS# 293, Owings Mills, Maryland 21117. The telephone numbers are 410-847-9060 and toll-free 1-888-833-8464.

FACTS YOU NEED TO KNOW

Q: HOW DOES THE DENTAL NETWORK, INC. PLAN WORK?

A: You pay the reduced rates listed on the Schedule of Benefits as Copayments directly to the dentist. Payment is due upon receipt of a bill for services. If necessary to file a claim, the form may be obtained by calling the Administrative Office at 410-847-9060 or toll-free at 1-888-833-8464 and one will be sent to you within fifteen (15) days.

Q: CAN I USE ANY DENTIST?

A: You may use only the dentist you selected from our list of Participating Dentists upon confirmation by the PLAN.

Q: WHEN CAN I MAKE AN APPOINTMENT WITH MY PLAN DENTIST?

A: An appointment can be made upon confirmation of your coverage effective date or receipt of your Membership Identification Card. Simply call the dentist’s office to arrange an appointment.

Q: DO I HAVE THE OPTION OF CHANGING DENTISTS? IF SO, HOW?

A: Dentists can be easily changed. To transfer coverage to another PLAN dentist, phone Customer Service at 1-888-833-8464 and tell us:

1. Your name and policy number.

2. New PLAN dentist chosen.

3. Reason for changing.

4. Date of last appointment with current dentist.

The PLAN will advise you upon approval of the change. Q: HOW DO I ADD OR DROP COVERAGE OF A DEPENDENT?

A: Simply contact your employer’s payroll office to add or drop dependents.

FORM DN003B (R. 1/10) 2 6/10

Q: HOW DO I RESOLVE MISUNDERSTANDINGS OR GRIEVANCES?

A: All grievances should first be discussed with your PLAN dentist. If you are still not satisfied, write to:

PLAN ADMINISTRATIVE OFFICE • THE DENTAL NETWORK, INC. 10455 MILL RUN CIRCLE, RRS# 293 • OWINGS MILLS, MD 21117

1. DEFINITIONS A. ‘‘Approved Specialist” shall be a licensed specialized dentist who is board eligible, board qualified, or

board certified in one of the specialty areas of periodontics, oral surgery, orthodontics, endodontics, and pedodontics and whose office has executed a contract with the PLAN.

B. “Cost for Services” shall mean amounts payable on a regular prepayment basis by or for the Covered

Employee to the PLAN. C. “Coverage Period” shall mean the month for which the Cost for Services has been prepaid by the

Group for each Covered Employee and Dependent. D. "Covered Employee” shall mean the individual named on the Membership Identification Card for whom

the Cost for Services under the PLAN have been paid prior to the Coverage Period. E. “Covered Employee Copayments” shall mean the cost of dental services to be paid by the covered

Employee directly to the Participating DENTIST. See enclosed Schedule of Benefits and Copayments. F. “Dependents” shall mean the lawful spouse of a Covered Employee and/or unmarried children of the

Covered Employee from and after birth to age twenty-six (26). A legally adopted child of the Covered Employee and/or his spouse shall be treated as a child of the Covered Employee and/or his spouse for purposes of this Certificate. Upon the attainment of age twenty-six (26) (the “PLAN Termination Age”), coverage as a Dependent shall be extended if the child is and continues to be both (1) incapable of self-sustaining employment by reason of mental or physical incapacity and (2) chiefly dependent upon the Covered Employee for support and maintenance, provided proof of such incapacity and dependency is furnished to PLAN by Covered Employee within thirty-one (31) days of the child’s attainment of PLAN Termination Age and subsequently as may be required by the PLAN, but not more often than annually after the two (2) year period following the child’s attainment of PLAN Termination Age. The Cost for Services for continuation of coverage of the incapacitated child shall be at the Dependent child rate, until such time as the coverage of the Covered Employee upon whom the child is dependent terminates.

G. “Participating DENTISTS” shall mean those licensed DENTISTS who have contracted with the PLAN to

provide dental services to Covered Employees and Dependents under the PLAN and whose names appear on the list of Participating DENTISTS. The Participating DENTISTS are independent contractors, and are not employees or agents of the PLAN.

H. “Personal Participating DENTIST’’ shall mean the one Participating DENTIST selected by the Covered

Employee and Dependents from the list of Participating DENTISTS, indicated on the completed Group Enrollment Form, and whose name appears on the Covered Employee’s Membership Identification Card.

FORM DN003B (R. 1/10) 3 6/10

2. ELIGIBILITY FOR BENEFITS A. Eligibility requirements are the covered Employee must have been employed with the Group for at

least ( ) months and work a minimum of ( ) hours per week. If the Eligibility requirements referenced above are blank, please refer to the Group Application or request a copy of the Group Application from the PLAN administrative office.

B. All persons who have enrolled in the PLAN and paid the appropriate Cost for Services on or before the

twentieth (20th) day of the month shall be eligible for benefits commencing on the first (1st) day of the following month which shall be the initial Coverage Period.

C. All Covered Employees and enrolled Dependent(s) become eligible for services on the effective date

indicated on the Membership Identification Card, which will be the date determined in accordance with the terms of Section 2, A or B above. Only the name of the Covered Employee will appear on the Membership Identification Card. Coverage for a newly acquired spouse commences on the date of marriage. Coverage for newly acquired Dependent children, including children who are newborn and/or legally adopted, commences on date of birth or date of court approved adoption. Court ordered coverage for children commences on the effective date of the court order as well as coverage for the eligible Employee if not already covered.

D. If a parent eligible for family members' coverage is required under a “Qualified Medical

Support Order,” to provide health insurance coverage for a child, the PLAN:

1. Shall allow the insuring parent to enroll in family members' coverage and include the child in that coverage regardless of enrollment period restrictions;

2. If the insuring parent is enrolled in health insurance coverage but does not include the child in

the enrollment, the PLAN shall:

a. allow the noninsuring parent, child support enforcement agency, or Department of Health and Mental Hygiene to apply for enrollment on behalf of the child; and

b. include the child in the coverage regardless of enrollment period restrictions; and

3. The PLAN may not terminate health insurance coverage for the child unless written evidence is

provided to the entity that:

a. the order is no longer in effect; b. the child has been or will be enrolled under other reasonable health insurance

coverage that will take effect on or before the effective date of the termination;

c. the GROUP has eliminated family members' coverage for all of its employees; or d. the GROUP no longer employs the insuring parent, except that if the parent elects to

exercise the provisions of the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), coverage shall be provided for the child consistent with the GROUP's plan for postemployment health insurance coverage for dependents.

4. Notwithstanding any other provision of this article, the PLAN may not deny enrollment of a child

under the health insurance coverage of an insuring parent because the child:

a. was born out of wedlock;

b. is not claimed as a dependent on the insuring parent's federal income tax return;

FORM DN003B (R. 1/10) 4 6/10

c. does not reside with the insuring parent or in the service area of the PLAN, or d. is receiving benefits or is eligible to receive benefits under the Maryland Medical

Assistance Program.

5. If a child has health insurance coverage through an insuring parent, the PLAN shall:

a. provide to the noninsuring parent membership cards, claims forms, and any other information necessary for the child to obtain benefits through the health insurance coverage; and process the claims forms and make appropriate payment to the noninsuring parent, Health Care Provider, or Department of Health and Mental Hygiene if the noninsuring parent incurs expenses for health care provided to the child.

6. Within 20 business days after receipt of a medical support notice from an employer, the PLAN:

a. shall determine whether the medical support notice contains: i. the employee's name and mailing address; and ii. the child's name and the child's mailing address or the address of a substituted

official; b. if the medical support notice does not contain the information described in paragraph 6.a

of this subsection, shall complete and forward the appropriate part of the medical support notice to the issuing child support enforcement agency advising that the medical support notice does not constitute a qualified medical child support order; and

c. if the medical support notice contains the information described in paragraph 6.a of this

subsection, shall comply with the following requirements: i. determine the child's eligibility for enrollment; ii. complete and send the appropriate part of the medical support notice to the

employer and the child support enforcement administration; iii. enroll the child if the child is eligible for enrollment, subject to subsection 7 of this

section; iv. send to the employee, child, and custodial parent of the child a written notice that

explains that the coverage of the child is or will become available to the child; and v. send to the custodial parent of the child a written description of:

1) the health insurance coverage; 2) the effective date of coverage; 3) the employee's cost for the health insurance coverage; and 4) if not already provided:

a) a summary plan description; b) any forms, documents, or information necessary to effectuate

coverage; and c) any information necessary to submit claims for benefits.

FORM DN003B (R. 1/10) 5 6/10

7. If the employee's eligibility for health insurance coverage is subject to a waiting period that has not been completed, the PLAN:

a. shall complete and send the appropriate part of the medical support notice to the

GROUP and the issuing child support agency within 20 business days after receipt of the medical support notice from the GROUP; and

b. on the employee's satisfaction of the waiting period, shall complete enrollment of the

child in accordance with this section and send the notice and information required under subsection 6.c of this section.

8. If the employee's health insurance plan requires that the employee be enrolled in order for the

child to be enrolled and the employee is not currently enrolled, the carrier shall enroll both the employee and the child, without regard to enrollment period restrictions, within the time period specified in subsection 6 of this section.

9. If a child is eligible for enrollment, the PLAN shall complete the enrollment without regard to

enrollment period restrictions, within the time periods specified in subsections 6 and 7 of this section.

10. The requirement for notification of the child may be satisfied by notifying the custodial parent if

the child and the custodial parent live at the same address. 3. TERMINATION OR CANCELLATION Coverage shall cease as follows: A. On the date of expiration of the Coverage Period for which the last payment of Cost for Services was

made, but in no event shall coverage cease earlier than the last day of the grace period. Coverage will remain in force during a thirty (30) day grace period allowed for late payment of Cost for Services.

B. For Dependent children, upon the next Cost for Services payment due date following the date the

Dependent ceases to satisfy the requirements of a Dependent as specified in Section 1.F. C. Notwithstanding any limiting age, any unmarried child covered under the Contract as a Dependent of a

Covered Employee who is chiefly dependent for support upon the Covered Employee, and who, at the time of reaching the limiting age, is incapable of self-support because of mental or physical incapacity that commenced prior to the child’s attaining the limiting age, shall continue to be covered under the Contract while remaining so dependent, unmarried, and mentally or physically incapacitated, until the coverage on the Covered Employee upon whom the child is dependent terminates.

D. For Dependent spouses, upon becoming divorced or legally separated from Covered Employee,

coverage will cease at the end of the Coverage Period during which the event occurs. E. If, after reasonable efforts to establish and maintain a satisfactory dentist-patient relationship, the

“Personal Participating DENTIST” is unable to do so, PLAN reserves the right to transfer the Covered Employee and/or a Dependent(s), as the case may be, to a second “Personal Participating DENTIST” of their choice. If the second “Personal Participating DENTIST” is also unable to establish a satisfactory dentist-patient relationship, PLAN reserves the right to terminate the membership of said Covered Employee and/or Dependent(s). In a case involving only a Dependent, only the Dependent’s coverage will be terminated. A thirty (30) day written notice of termination and a pro-rata refund of unearned Cost for Services will be given to the Covered Employee or credited to the Group.

FORM DN003B (R. 1/10) 6 6/10

4. COST FOR SERVICES AND COVERED EMPLOYEE COPAYMENTS A. All Cost for Services are payable on or before the 15th day of the month preceding Coverage Period

in which services may be rendered. A grace period of 30 days will be granted for payment of each Cost for Services due after the first Cost for Services, unless the PLAN does not intend to renew the contract beyond the period for which Cost for Services has been accepted and notice of the intention not to renew is delivered to the contract holder at least 45 days before the Cost for Services is due. During the grace period the contract shall continue in force. Any additional provisions related to the grace period shall be expressly stated in this group dental benefit contract, subject to the following limitations: 1. Unless the PLAN receives a notice of the GROUP’s intention to terminate the policy

before the end of the grace period, the PLAN may collect Cost for Services for the 30-day grace period;

2. If the PLAN receives a notice of intention to terminate the GROUP contract during the

grace period, the PLAN may collect Cost for Services for the period beginning on the first day of the grace period until the date on which notice is received or the date of termination stated in the notice, whichever is later; and

3. If Cost for Services for the 30-day grace period is paid after the grace period ends, the

PLAN may charge interest for the Cost for Services for the GROUP contract, but: a. Interest may not begin to accrue during the 30-day grace period; and b. The interest rate charged may not exceed an effective rate of 6 percent per year.

B. Covered Employee Copayments (as listed in the attached Schedule of Benefits and Copayments) are

payable to the Participating DENTIST at the time service is rendered. C. A Covered Employee shall agree to remain in the PLAN for a minimum of twelve (12) months. In the

event that a Covered Employee voluntarily terminates membership in the PLAN prior to twelve months from the beginning of the first Coverage Period, the Covered Employee may be required to pay the Dentist's charges, less Cost for Services paid to the PLAN and payments made directly by the Covered Employee to the DENTIST (“Covered Employee Copayments”).

5. BENEFITS AND COVERAGE A. Only those persons who satisfy the requirements of Section 2 will be eligible for benefits. B. All dental procedures listed under the attached Schedule of Benefits and Copayments will be

provided, if, in the opinion of the “Personal Participating DENTIST,” they are necessary for the patient’s dental health.

C. COORDINATION OF BENEFITS (COB). The PLAN COB policy is based on the “ADA Guidelines on

Coordination of Benefits” resolved by the American Dental Association.

1. For the purposes of this COB section, the following term is defined.

Dental Plan means any dental insurance policy, including those of nonprofit health service plans, and those of commercial group, blanket and individual policies, any subscriber contracts issued by Health Maintenance Organizations (HMOs), and any other established programs under which the insured may make a claim. The term Dental Plan includes coverage under a governmental plan, or coverage required to be provided by law. This does not include a State

FORM DN003B (R. 1/10) 7 6/10

plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended from time to time.)

2. When a patient has coverage under two or more Dental Plans the following rules should apply:

a. The coverage from those Dental Plans should be coordinated so that the patient

receives the maximum allowable benefit from each Dental Plan. b. The aggregate benefit should be more than that offered by any of the Dental Plans

individually, but not such that the patient receives more than the total charges for the dental services received.

3. In determining order of payment for care, the following rules should apply to Dental Plans:

a. The Dental Plan covering the patient other than as a dependent is the primary Dental

Plan. b. When both Dental Plans cover the patient as a dependent child, the Dental Plan of the

parent whose birthday occurs first in a calendar year should be considered as primary. c. When a determination cannot be made in accordance with the above, the Dental Plan

that has covered the patient for the longer time should be considered as primary.

d. When one of the plans is a medical plan and the other is a Dental Plan, and a determination cannot be made in accordance with the above, the medical plan should be considered as primary.

4. In coordinating care with a Dental Plan which contractually reduces the fees for services which

participating dentists accept as payment in full, the following rules should apply: a. When the reduced fee Dental Plan is primary and treatment is provided by a

participating dentist, the reduced fee is that dentist’s full fee unless the dentist has contractually arranged that the reduced-fee Dental Plan should provide its allowed amount for participating dentists and the secondary Dental Plan should pay the lesser of: its allowed benefit for the service or the difference between the primary Dental Plan care and the dentist’s full fee. The secondary Dental Plan should pay the lesser of: its allowed benefit or the difference between the primary Dental Plan’s benefit and the reduced fee.

b. When the reduced fee Dental Plan is primary and treatment is provided by a

nonparticipating dentist, the reduced fee Dental Plan should provide its allowed amount for nonparticipating dentists and the secondary Dental Plan should pay the lesser of: its allowed benefit for the service or the difference between the primary Dental Plan care and the dentist’s full fee.

c. When a full fee Dental Plan is primary and a reduced fee Dental Plan is secondary, the

full fee Dental Plan should provide its allowed amount for the service and the secondary Dental Plan should pay the lesser of: its allowed benefit for the service or the difference between the primary Dental Plan care and the dentist’s full fee.

5. In coordinating care between an indemnity Dental Plan and a capitation Dental Plan, the

following rules should apply:

a. When the capitation Dental Plan is primary, the capitation payments to the treating dentist remain the capitation Dental Plan’s usual care. The indemnity Dental Plan should pay benefits for the patient’s surcharges or copayments up to the indemnity Dental Plan’s allowable benefit.

FORM DN003B (R. 1/10) 8 6/10

b. When the indemnity Dental Plan is primary, and treatment is received from a capitation-participating dentist, the indemnity Dental Plan should pay its allowable benefit. The capitation payments to the dentist are the secondary coverage since they constitute care up to the capitation Dental Plan’s allowable amount.

c. When the indemnity Dental Plan is primary, and treatment is received from a non-

capitation participating dentist, the indemnity Dental Plan should pay its allowable benefit. The capitation Dental Plan will pay care, in keeping with the capitation Dental Plan’s allowed amount for treatment by nonparticipating dentists.

d. No Dental Plan should contractually direct a dentist to charge a secondary carrier for

more than the amount which would be charged to the patient absent secondary coverage.

D. The fees charged will be the fees listed under “Covered Employee Copayment” for each procedure

completed. Services listed as “NO CHARGE” in the Schedule of Benefits and Copayments will be performed by the Personal Participating DENTIST at no cost to the Covered Employee or Dependent(s).

E. ALTERNATE TREATMENT. Frequently, several methods exist to treat a dental condition. The PLAN

will authorize treatment based upon the allowance for the less expensive procedure provided that the less expensive procedure meets accepted standards of dental treatment. The PLAN’s decision does not commit the Covered Employee to the less expensive procedure. However, if the Covered Employee and the “Participating Dentist” choose the more expensive procedure, the Covered Employee is responsible for the additional charges beyond those authorized or allowed by the PLAN.

F. Only the Personal Participating DENTIST shall have the right to examine and to determine the

professional services to be performed pursuant to the PLAN, except in the instance of referral to a Specialist as defined in this Certificate or in the event of an out-of-area dental emergency as provided for in this Section, I.

G. If a conflict arises regarding the quality and extent of work, the case in question will be submitted to the

PLAN Dental Director for resolution. See Section 17 for procedure for Complaints and Grievances. H. A ninety (90) day extension of benefits is applicable to all dental services begun while coverage was in

effect, i.e., if a dental service was begun while coverage was in effect for the Covered Employee’s and/or Dependent(s). PLAN agrees that the “Personal Participating DENTIST” will complete such dental services within 90 days with no change in or addition to the Covered Employee’s and/or Dependent(s) Copayments. This extension of benefits provision is not applicable where a Covered Employee’s and/or Dependent(s) benefits terminate due to non-payment of Cost for Services by the individual. Orthodontic coverage shall be provided, in accordance with the policy in effect at the time the Covered Employee and/or Dependent(s)’ coverage terminates, for sixty (60) days after the date the coverage terminates if the orthodontist has agreed to or is receiving monthly payments; or until the later of sixty (60) days after the date coverage terminates or the end of the quarter in progress, if the orthodontist has agreed to accept or is receiving payments on a quarterly basis.

I. Covered Employee and/or Dependent(s), when temporarily more than fifty (50) miles from their

"Personal Participating DENTIST" may have emergency care rendered by any licensed DENTIST. Emergency care is defined as “emergency dental treatment to alleviate acute pain, along with treatment arising from accidental injury or illness.” PLAN pays for emergency out-of-area care up to Fifty Dollars ($50) per person per emergency. PLAN will reimburse the Covered Employee and/or Dependent(s) upon presentation of bonafide documentation of emergency care expenses. Written notice to PLAN of claim is not required before twenty (20) days after the occurrence or commencement of the loss covered by the policy. The PLAN may not invalidate or reduce a claim if it is shown that it was not reasonably possible to give notice within 20 days, and notice was given as soon as was reasonably possible.

FORM DN003B (R. 1/10) 9 6/10

6. REFERRALS

Any covered specialty services received by Covered Employee and/or Dependent(s) must be approved in writing by Covered Employee and/or Dependent(s) “Personal Participating DENTIST.” Should the “Personal Participating DENTIST” wish to refer Covered Employee and/or Dependent(s) to a non-Approved Specialist, the referral must be approved, in writing, by the PLAN to be eligible for coverage.

A standing specialist referral will be made if the “Personal Participating DENTIST,” in consultation with the specialist, determines that the patient needs continuing care from the specialist for conditions or diseases that are life threatening, degenerative, chronic, disabling, and require specialized care. The specialist shall have expertise in treating the life threatening, degenerative, chronic, or disabling disease or condition and be part of the PLAN’s provider panel. The standing referral shall be made in accordance with a written treatment plan for a covered service developed by the “Personal Participating DENTIST,” the specialist, and the Covered Employee and/or Dependent. The treatment plan may limit the number of visits to the specialist, limit the period of time in which visits to the specialist are authorized, and require the specialist to communicate regularly with the “Personal Participating DENTIST” regarding the treatment and health status of the Covered Employee or Dependent.

A Covered Employee or Dependent may request a referral to a specialist who is not part of the PLAN’s provider panel if the Covered Employee or Dependent is diagnosed with a condition or disease that requires specialist medical care and the PLAN does not have in its provider panel a specialist with the professional training and expertise to treat the condition or disease, or if the PLAN cannot provide reasonable access to a specialist with the professional training and expertise to treat the condition or disease without unreasonable delay and/or travel. For purposes of calculating any deductible, copayment amount, or coinsurance payable by the Covered Employee or Dependent, the PLAN shall treat services received as if the service was provided by a provider on the PLAN’s provider panel. A decision by the PLAN not to provide access to or coverage of treatment by a specialist in accordance with this section constitutes an Adverse Decision if the decision is based on a finding that the proposed service is not medically necessary, appropriate, or efficient.

If a PLAN DENTIST refers the Covered Employee or Dependent to a specialist who is not a PLAN DENTIST, the PLAN shall be responsible for payment of the specialist’s charges to the extent the charges exceed the copayment specified in the enclosed Schedule of Benefits.

CLAIMS PROCEDURES FOR “OUT-OF-AREA EMERGENCY CARE AND REFERRALS TO NON-PARTICIPATING SPECIALISTS.“ In order to institute payment procedures in the case of out-of-area emergency care and/or an approved referral to a specialist who is not a "Participating DENTIST," it shall be necessary for the Covered Employee and/or Dependent(s) making such claim to submit a fully completed claim form to PLAN. PLAN will provide claim forms to Covered Employee and/or Dependents upon request and within 15 days. In the event that the out-of-area provider and/or non-Participating DENTIST has accepted assignment of the Covered Employee and/or Dependents rights to payment hereunder, the claim form shall so indicate. The PLAN shall make the payment of its portion of the charge directly to the provider or providers pursuant to such authorization. If the Covered Employee and/or Dependents has made payment of the PLAN benefit to an out-of-area provider and/or non-Participating DENTIST, the claim form shall be accompanied by proof of such payment in a manner satisfactory to PLAN and a designation by the Covered Employee and/or Dependent or the person to whom reimbursement should be made. PLAN shall then reimburse the Covered Employee and/or Dependent or his/her designee directly. If the PLAN does not provide claim forms within 15 days after notice of claim is received, the Covered Employee and/or Dependent are considered to have complied with the requirements of the contract as to proof of loss if the Covered Employee and/or Dependent submit, within the time fixed in the contract for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made.

FORM DN003B (R. 1/10) 10 6/10

All claims must be submitted to the PLAN on American Dental Association approved claim forms. You may contact the PLAN to obtain such forms. The claim form must be submitted to the PLAN within twelve (12) months of the date of service. Failure to provide a written claim within twelve (12) months will invalidate and/or reduce the obligation under this contract, unless the Covered Employee can show that it was not possible to send a written claim. The Covered Employee shall then furnish a written claim as soon as reasonably possible. Benefits payable for any loss will be paid not more than thirty (30) days after receipt of written proof of loss.

7. PLAN LIMITATIONS The following exclusions and limitations shall apply: PLAN LIMITATIONS

Services for injuries and conditions which are covered under Workers’ Compensation or Employers’ Liability Laws;

Services which are provided without cost to the Covered Employee and/or Dependent(s) by any municipality, county or other political subdivision (with the exception of Medicaid);

Services which, in the opinion of the participating DENTIST, are not necessary for the Covered Employee and/or Dependent(s) health;

Payment of any claim or bill will not be made for prohibited referrals; Cosmetic, elective, or aesthetic dentistry, which in the opinion of the participating DENTIST are not

necessary for the patient’s dental health; Oral surgery requiring the setting of fractures or dislocations; Services with respect to malignancies, cysts or neoplasms, or hereditary, congenital or

developmental malformations; Dispensing of drugs, except those used as a local anesthetic; Hospitalization for any dental procedure; Loss or theft of bridgework or dentures previously supplied under the PLAN; Replacement of a bridge, crown, or denture within five (5) years after the date it was originally

installed; Any implantation; General anesthesia; Services that cannot be performed because of the general health of the patient; Teeth Cleaning (Prophylaxis) at intervals of less than six (6) months; Unlisted procedures will be provided at the dentist’s charges; Services which are obtained outside the dental office in which enrolled and which are not pre-

authorized by the PLAN. This does not apply to out-of-area emergency dental services; Services rendered by a Pedodontist (Pediatric Dentist) are considered Specialty Care and must be

approved by the Covered Employee’s and/or Dependent(s) "Personal Participating DENTIST;" All services listed on the Schedule of Benefits and Member Copayments will be provided by a

general Participating Dentist or an approved Specialist; provided, however, that a general DENTIST will refer the Covered Employee and/or Dependent(s) to an approved Specialist or recommend that the Covered Employee and/or Dependent(s) contact an approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an approved Specialist, with an exception for out-of-area emergency care, and a referral to a non-participating general dentist or specialist;

Services which cannot be performed in the dental office of the “Personal Participating DENTIST” or “Approved Specialist” due to the special needs or health related conditions of the Covered Employee and/or Dependent(s).

OUT-OF-AREA EMERGENCY CARE: Covered Employees and/or Dependent(s) are covered for emergency dental treatment to alleviate acute pain, along with treatment arising from accidental injury or illness while temporarily more than 50 miles from their "Personal Participating DENTIST." Limited to $50 per Covered Employee and/or Dependent(s) per emergency. ALL PRICES ARE EXCLUSIVE OF GOLD

FORM DN003B (R. 1/10) 11 6/10

8. DENTAL RECORDS

The dental records of all Covered Employees and Dependents concerning services performed hereunder shall remain the property of the “Personal Participating DENTIST.” The Covered Employee and/or Dependent(s) may be subject to a charge for the duplication of dental records and radiographs in accordance with Maryland law.

9. CHANGE IN COST FOR SERVICES

PLAN reserves the right to change the Cost for Services or Covered Employee Copayments on an annual basis. Notice of any change will be given sixty (60) days prior to the date of renewal of coverage under the PLAN.

10. REFUNDS

After a period of not less than twelve (12) months, if the Covered Employee voluntarily terminates his enrollment in the PLAN the following refund schedule will apply:

A. Services rendered - no refund of Cost for Services. B. No services rendered - refund of Cost for Services prorated. 11. MAJOR DISASTERS AND OTHER CATASTROPHES

In the event of major disaster or epidemic, Participating DENTISTS shall render dental services as provided in this Certificate insofar as is practical, according to their best judgment, within the limitations of such facilities and personnel as are then available, but the PLAN and the Participating DENTISTS shall have no liability or obligation for the delay or failure to provide or arrange for such services if such delay or failure is the result of such disaster or epidemic, except as may be mandated by the Insurance Commissioner of the State of Maryland. If, during the term of this Certificate, none of the Participating DENTISTS or Approved Specialists can render necessary care and treatment to the Covered Employee and/or Dependent(s) due to circumstances not reasonably within the control of the PLAN, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes or the disability of a significant number of the Participating DENTISTS, the Covered Employee may seek treatment from an independent licensed DENTIST of his own choosing. The PLAN will reimburse the Covered Employee for such services; provided, however, that the PLAN will reimburse the Covered Employee for services which are listed in the Schedule of Benefits and Copayments as “No Charge,” only to the extent that such fees are approved by the PLAN, and the PLAN will further reimburse the Covered Employee for those services listed in the Schedule of Benefits and Copayments for which there is a monetary surcharge, to the extent that the dentist's charges for such services exceed the reduced charge for such services as set forth in the Schedule of Benefits and Copayments. The Covered Employee shall be required to give written proof of loss. The PLAN agrees to be subject to the jurisdiction of the Maryland Insurance Commissioner with respect to any determination of the impossibility of providing services by PLAN DENTISTS.

12. CHANGING DENTISTS

Covered Employee and/or Dependent(s) may transfer coverage for themselves and Dependents to another Participating DENTIST. Transfers may be made with notification to the PLAN Administrative Office which includes the Covered Employee’s and/or Dependent(s) Name and Policy Number, new “Personal Participating DENTIST” selected, the reason for changing and the date of the last appointment with current “Personal Participating DENTIST.” Transfers will not be authorized if a Covered Employee and/or Dependent(s) has an outstanding balance owed to a Participating DENTIST. Transfers will be effective on the first day of the following month.

FORM DN003B (R. 1/10) 12 6/10

13. BROKEN APPOINTMENTS The Covered Employee and/or Dependents may cancel or break an appointment without penalty if the dental office is given advance notice of twenty-four (24) hours or more. If sufficient advance notice is not given, the Covered Employee and/or Dependent(s) is responsible for the payment of a fee as specified in the Schedule of Benefits and Copayments.

14. REMEDIES IN CASE OF DEFAULT In the event that a “Personal Participating DENTIST” is unable to provide care and treatment to a Covered Employee or Dependent during the Coverage Period, the Covered Employee shall be obligated to select another “Personal Participating DENTIST” from the list of Participating DENTISTS, and the Covered Employee shall notify the PLAN of such change.

15. PROFESSIONAL LIABILITY INSURANCE Participating DENTISTS and Approved Specialists shall at all times carry professional liability insurance with annual coverage of not less than One Million Dollars ($1,000,000) per occurrence and Three Million Dollars ($3,000,000) in the aggregate, and shall provide proof of such coverage to the PLAN upon demand.

16. HOW TO RECEIVE BENEFITS In order to make an appointment, the Covered Employee must telephone the office of the “Personal Participating DENTIST” selected. The Covered Employee must pay the fees listed on the Schedule of Benefits and Copayments directly to the “Personal Participating DENTIST” who renders treatment.

17. COMPLAINTS AND GRIEVANCES

Definitions: A. “Adverse Decision” means a utilization review determination made by appropriate review agent, the

PLAN, or a Health Care Provider acting on behalf of the PLAN, that a proposed or delivered health care service: 1. is or was not dentally necessary, appropriate, or efficient. 2. may result in non-coverage of health care service.

“Adverse Decision” does not include a decision concerning a subscriber’s status as a Covered Employee and/or Dependent.

B. “Complaint” means a protest filed with the Commissioner involving an Adverse Decision or Grievance Decision concerning the Covered Employee and/or Dependent.

C. “Filing Date” means the earlier of:

1. five days after the date of mailing, or 2. the date of receipt.

D. “Grievance” means a protest filed by a Covered Employee and/or Dependent or a Health Care Provider on behalf of a patient with a private review agent’s internal grievance process regarding an Adverse Decision concerning a patient. “Grievance” does not include a verbal request for reconsideration of a utilization review determination.

FORM DN003B (R. 1/10) 13 6/10

E. “Grievance Decision” means a final determination by the PLAN that arises from a Grievance filed with the PLAN under its internal grievance process regarding an Adverse Decision concerning a Covered Employee and/or Dependent(s).

F. “Health Care Provider” means an individual who is licensed under the health occupation articles to

provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the Covered Employee and/or Dependent(s).

Emergency Grievance:

The PLAN has an expedited procedure for use in cases of emergency for purposes of rendering a Grievance Decision within twenty-four (24) hours after filing the Grievance. The Covered Employee and/or Dependent(s) and/or Health Care Provider acting on behalf of the Covered Employee and/or Dependent(s) should request a grievance form. The PLAN will fax this form as directed by the Covered Employee and/or Dependent(s) and/or Health Care Provider acting on behalf of the Covered Employee and/or Dependent(s). The Covered Employee and/or Dependent(s) and/or Health Care Provider should complete the grievance form and fax it back to the PLAN at the fax number 410-337-7950. In the event that a determination needs to be made regarding the existence of an emergency case, our Dental Director will make the determination. An expedited review of an Adverse Decision in accordance with this regulation is required if the: 1. Adverse Decision is rendered for health care services that are proposed but have not been

delivered; and 2. services are necessary to treat a condition or illness that without immediate attention would:

a. seriously jeopardize the life or health of the Covered Employee and/or Dependent(s) or the Covered Employee and/or Dependent(s) ability to regain maximum function, or

b. cause the Covered Employee and/or Dependent(s) to be in danger to self or others.

If the PLAN does not have sufficient information to complete its internal grievance process the PLAN will notify and assist the Covered Employee and/or Dependent(s) or Covered Employee and/or Dependent(s) representative in gathering information from the appropriate sources without delay. The Covered Employee and/or Dependent(s) or provider acting on the Covered Employee and/or Dependent(s) behalf may file a Complaint with the Insurance Commissioner if the Covered Employee and/or Dependent(s) or provider acting on the Covered Employee and/or Dependent(s) behalf has not received a Grievance Decision within twenty-four (24) hours after the emergency Grievance was filed. For an emergency case, within one (1) day after a decision has been orally communicated to the Covered Employee and/or Dependent(s) or Health Care Provider, The PLAN shall send notice in writing of any Grievance Decision to the Covered Employee and/or Dependent(s) and the Health Care Provider if acting on behalf of the Covered Employee and/or Dependent(s).

The written notice will state in detail in clear, understandable language the specific factual basis for the PLAN’s decision; reference the specific criteria and standards, including interpretive guidelines, on which the decision was based, and may not use only generalized terms such as “experimental procedure not covered”, “cosmetic procedure not covered”, “service included under another procedure”, or “not medically necessary”. It will also state the name, business address, and business telephone number of the Dental Director and include the following information:

Dental Director The Dental Network, Inc. 10455 Mill Run Circle, RRS# 293 Owings Mills, Maryland 21117 410-847-9060

FORM DN003B (R. 1/10) 14 6/10

The Covered Employee and/or Dependent(s) or a provider on behalf of the Covered Employee and/or Dependent(s) has a right to file a Complaint with the Commissioner (address listed below), within thirty (30) working days after receipt of the PLAN’s Grievance Decision.

Maryland Insurance Administration Appeal and Grievance Unit 200 St. Paul Place, Suite 2700 Baltimore, MD 21202 1-800-492-6116 or 410-468-2000 Fax 410-468-2270

Non-Emergency Procedures:

The PLAN will allow a Grievance to be filed on behalf of a Covered Employee and/or Dependent(s) by a Health Care Provider. The PLAN also provides that a final decision be rendered on a Grievance involving a prospective denial within 30 working days after Grievance Filing Date, except for emergency cases or if the Covered Employee and/or Dependent(s) or Health Care Provider agrees in writing to an extension of no longer than thirty (30) working days. The Grievance must be filed within ninety (90) days of the date of notification of an Adverse Decision. The Grievance may be filed orally or in writing and must contain relevant documentation, which contains sufficient detail to identify the nature of the problem. The PLAN will notify the Covered Employee and/or Dependent(s) or Health Care Provider within five (5) working days after the Filing Date, that it does not have sufficient information to complete the grievance process and that it cannot proceed with review unless additional information is provided and that the PLAN will assist the Covered Employee and/or Dependent(s) or provider in gathering the necessary information without further delay. The PLAN will render a final decision within 45 working days after the date on which the Grievance is filed when the Grievance involves a retrospective denial; and allow a Covered Employee and/or Dependent or a Health Care Provider on behalf of a Covered Employee and/or Dependent to file a Grievance within 180 days after the Covered Employee and/or Dependent receives an Adverse Decision. THERE IS HELP AVAILABLE TO YOU IF YOU WISH TO DISPUTE THE DECISION OF THE PLAN ABOUT PAYMENT FOR HEALTHCARE SERVICES. You may contact the Health Advocacy Unit of Maryland’s Consumer Protection Division at:

Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor Baltimore, Maryland 21202 410-528-1840 or 1-877-261-8807 (toll-free) Fax 410-576-6571 [email protected]

With the written consent of a Covered Employee and/or Dependent(s) or Health Care Provider the period of time for making a final decision may be extended for a period of no longer than thirty (30) working days. In the case of a non-emergency Grievance, oral communication will be made within 24 hours after decision has been made. The PLAN will document in writing any Grievance Decision that has been orally communicated to the Covered Employee and/or Dependent(s) or Health Care Provider within five (5) working days after the decision has been made. A notice will be sent to the Covered Employee and/or Dependent(s) and any Health Care Provider who filed a Grievance on behalf of the Covered Employee and/or Dependent(s). A Complaint may be filed if the Covered Employee and/or Dependent(s) or Health Care Provider filing a Grievance on behalf of the Covered Employee and/or Dependent(s) has not received a Grievance Decision on or before the 30th working day after the Filing Date of the Grievance concerning services not yet rendered, or the forty-fifth (45) working day for a

FORM DN003B (R. 1/10) 15 6/10

retrospective denial, unless the Covered Employee and/or Dependent or Health Care Provider filing a Grievance on behalf of a Covered Employee and/or Dependent agrees in writing to an extension for a period of no longer than 30 working days.

A Covered Employee and/or Dependent or a Health Care Provider filing a Complaint on behalf of a Covered Employee and/or Dependent may file a Complaint with the Commissioner without first filing a Grievance with the PLAN and receiving a final decision on the Grievance if the Covered Employee and/or Dependent or a Health Care Provider provides sufficient information and supporting documentation in the Complaint that demonstrates a compelling reason to do so.

This notice will state in detail in clear, understandable language the specific factual basis for the PLAN’s decision; reference the specific criteria and standards, including interpretive guidelines, on which the decision was based, and may not use only generalized terms such as “experimental procedure not covered,” “cosmetic procedure not covered,” “service included under another procedure,” or “not medically necessary.” It will also state the name, business address, and business telephone number of the Dental Director and include the following information:

The Covered Employee and/or Dependent(s) or a provider on behalf of the Covered Employee and/or Dependent(s) has a right to file a Complaint with the Commissioner (address listed below), within thirty (30) working days after receipt of the PLAN’s Grievance Decision.

Maryland Insurance Administration Appeal and Grievance Unit 200 St. Paul Place, Suite 2700 Baltimore, MD 21202 1-800-492-6116 or 410-468-2000 Fax 410-468-2270

18. COVERAGE DECISION COMPLAINT PROCESS

A. Definitions:

“Appeal” means a protest filed by a Covered Employee and/or Dependent or Health Care Provider with the PLAN under its internal appeal process regarding a coverage decision concerning a Covered Employee and/or Dependent. “Appeal Decision” means a final determination by the PLAN that arises from an appeal filed with the PLAN under its appeal process regarding a coverage decision concerning a Covered Employee and/or Dependent. “Coverage Decision” means an initial determination by the PLAN that results in non-coverage of a health care service. “Urgent Medical Condition” means a condition that satisfies either of the following: 1. A medical condition, including a physical condition, a mental condition, or a dental condition,

where the absence of medical attention within 72 hours could reasonably be expected by an individual, acting on behalf of the PLAN, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine to result in:

a. Placing the Covered Employee and/or Dependent’s life or health in serious jeopardy; b. The inability of the Covered Employee and/or Dependent to regain maximum function; c. Serious impairment to bodily function;

FORM DN003B (R. 1/10) 16 6/10

d. Serious dysfunction of any bodily organ or part; or e. The Covered Employee and/or Dependent remaining seriously mentally ill with symptoms

that cause the Covered Employee and/or Dependent to be danger to self or others; or 2. A medical condition, including a physical condition, a mental condition, or a dental condition,

where the absence of medical attention within 72 hours in the option of a Health Care Provider with knowledge of the Covered Employee and/or Dependent’s medical condition, would subject the Covered Employee and/or Dependent to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage decision.

B. The PLAN shall render a final decision in writing to a Covered Employee and/or Dependent, and a

Health Care Provider acting on behalf of the Covered Employee and/or Dependent, within 60 working days after the date on which the appeal is filed. The PLAN’s internal appeal process must be exhausted prior to filing a Complaint with the Commissioner. A Covered Employee and/or Dependent or a Health Care Provider filing a Complaint on behalf of a Covered Employee and/or Dependent may file a Complaint with the Maryland Insurance Commissioner without filing an appeal with the PLAN only if the coverage decision involves an urgent medical condition for which care has not been rendered. Within 30 calendar days after a coverage decision has been made, the PLAN shall send a written notice of the coverage decision to the Covered Employee and/or Dependent and the treating Health Care Provider which states in clear, understandable language, the specific factual basis for the PLAN’s decision and include the following information: 1. The Covered Employee and/or Dependent, or a Health Care Provider acting on behalf of the

Covered Employee and/or Dependent, has a right to file an appeal with the PLAN. 2. That the Covered Employee and/or Dependent, or a Health Care Provider acting on behalf of

the Covered Employee and/or Dependent, may file a Complaint with the Maryland Insurance Commissioner without first filing an appeal, if the coverage decision involves an urgent medical condition for which care has not been rendered;

3. The Maryland Insurance Commissioner’s address, telephone number, and facsimile number:

Maryland Insurance Administration Life and Health Complaint Department 200 St. Paul Place, Suite 2700 Baltimore, MD 21202 1-800-492-6116 or 410-468-2244 Fax 410-468-2260

4. The Health Advocacy Unit is available to assist the Covered Employee and/or Dependent in

both mediating and filing an appeal under the PLAN’s internal appeal process and can be reached at:

Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor Baltimore, Maryland 21202 410-528-1840 or 1-877-261-8807 (toll-free) Fax 410-576-6571 [email protected]

Within 30 calendar days after the appeal decision has been made, the PLAN shall send to the Covered Employee and/or Dependent, and the Health Care Provider acting on behalf of the Covered Employee

FORM DN003B (R. 1/10) 17 6/10

and/or Dependent, a written notice of the appeal decision which states in clear, understandable language the specific factual basis for the PLAN’s decision and includes the statement that the Covered Employee and/or Dependent, or a Health Care Provider acting on behalf of the Covered Employee and/or Dependent, has a right to file a Complaint with the Maryland Insurance Commission within 60 working days after receipt of the PLAN’s appeal decision at:


The Maryland Insurance Commissioner shall issue in writing a final decision on all Complaints filed and provide notice in writing to all parties of the opportunity and time period for requesting a hearing to be held to contest a final decision of the Maryland Insurance Commissioner. Any complaints about the PLAN other than coverage decisions or Grievances may be forwarded to:


19. PRIVACY NOTIFICATION

When the Covered Employee and/or Dependent(s) apply for any type of insurance, they disclose information about themselves and/or members of their family. The collection, use, and disclosure of this information is regulated by law. Safeguarding the Covered Employee and/or Dependent(s) personal and/or financial information is something the PLAN takes very seriously. The PLAN may collect nonpublic, personal, financial and medical information about the Covered Employee and/or Dependent(s) from various sources, including:

Information provided on application or other forms, such as name, address, social security number, age, and gender.

Information pertaining to Covered Employee and/or Dependent(s) relationship with the PLAN, its affiliates, or others such as policy coverage, premiums, and claims payment history.

Information (as described in preceding paragraphs) that the PLAN obtains from any of our affiliates.

Information the PLAN receives from other sources such as Covered Employee and/or Dependent(s) employer, provider, and other third parties.

At no time does the PLAN disclose the Covered Employee and/or Dependent(s) health and/or financial information to anyone outside of the PLAN unless the PLAN has proper authorization from the Covered Employee and/or Dependent(s) or the PLAN is permitted or required to do so by law. The PLAN maintains physical, electronic, and procedural safeguards in accordance with federal and state standards that protects the Covered Employee and/or Dependent(s) information. In addition, the PLAN limits access to the Covered Employee and/or Dependent(s) personal information to those the PLAN employees, brokers, group health plan administrators, providers, and agents who need to know this information to conduct the PLAN business or to provide products or services to the Covered Employee and/or Dependent(s).

FORM DN003B (R. 1/10) 18 6/10

In order to protect the Covered Employee and/or Dependent(s) privacy, affiliated and nonaffiliated entities are subject to strict confidentiality. When the PLAN shares information with a nonaffiliated entity it is because it is a critical business partner that assists the PLAN in providing services to the Covered Employee and/or Dependent(s). The information the PLAN provides can only be used to provide services the PLAN has asked them to perform for the PLAN or for the Covered Employee and/or Dependent(s) and/or the Covered Employee and/or Dependent(s) group health plan. If the PLAN collects personally identifiable medical and/or financial information, the PLAN will not share this information either internally or externally for any purpose other than the underwriting or administration of an insurance policy or claim or as otherwise specifically disclosed when the information is collected from the Covered Employee and/or Dependent(s) with their consent. The PLAN periodically reviews its policies and reserves the right to change them. If the PLAN changes its privacy policy, the PLAN will continue its commitment to keep the Covered Employee and/or Dependent(s) personal information secure—it is our highest priority. The Covered Employee and/or Dependent(s) can always review the PLAN current policy and procedures online at www.carefirst.com. For questions, please contact the PLAN by calling the Customer Service telephone number listed on the Covered Employee and/or Dependent(s) Membership Identification Card.

20. LEGAL ACTION An action at law or in equity may not be brought to recover on this contract before the expiration of sixty (60) days after written proof of loss has been furnished in accordance with the requirements of this contact and after the expiration of three (3) years after the written proof of loss is required to be furnished.

21. ASSIGNMENT AND DELEGATION The PLAN may assign this Group Certificate of Coverage for the Covered Employee and/or Dependent(s) and its rights hereunder and delegate its duties hereunder to any entity into which it is merged or which substantially acquires all its assets.

22. BLUE CROSS AND BLUE SHIELD DISCLOSURE

Group, on behalf of itself and its participants hereby expressly acknowledges its understanding this contract constitutes a contract solely between Group and PLAN, which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the “Association”) permitting PLAN to use the Blue Cross and/or Blue Shield Service Mark(s) in the State of Maryland and that PLAN is not contracting as the agent of the Association. Group, on behalf of itself and its participants further acknowledges and agrees that it has not entered into this contract based upon representations by any person other than PLAN and that no person, entity, or organization other than PLAN shall be held accountable or liable to Group for any of PLAN’s obligations to Group created under this contract. This paragraph shall not create any additional obligations whatsoever on the part of PLAN other than those obligations created under other provisions of this contract.

ENCLOSURES: 1. Schedule of Benefits and Copayments

2. Membership Identification Card

MD/TDN/DOL APPEAL (R. 9/11) CP 1 Group – Certificate of Coverage

The Dental Network , Inc. 10455 Mill Run Circle


An independent licensee of the BlueCross and BlueShield Association

BENEFIT DETERMINATION AND APPEAL AND GRIEVANCE PROCEDURES AMENDMENT

This amendment is effective on the effective date or renewal date of the Certificate of Coverage to which this amendment is attached. The Certificate of Coverage is amended as follows: This amendment contains certain terms that have a specific meaning as used herein. These terms are capitalized and defined in Section A below, and/or in the Certificate of Coverage to which this document is attached. These procedures replace all prior procedures issued by the Plan, which afford Members recourse pertaining to denials and reductions of claims for benefits by the Plan. These procedures only apply to Claims for Benefits. Notification required by these procedures will only be sent when a Member requests a benefit or files a claim in accordance with the Plan’s procedures. The sections entitled “Complaints and Grievances” and “Coverage Decision Complaint Process” of the Certificate of Coverage are deleted and replaced with the following: TABLE OF CONTENTS A. DEFINITIONS B. SCOPE AND PURPOSE C. CLAIMS PROCEDURES D. CLAIMS PROCEDURES COMPLIANCE E. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS F. MANNER AND CONTENT OF NOTIFICATION OF ADVERSE BENEFIT

DETERMINATIONS G. APPEALS AND GRIEVANCES OF ADVERSE BENEFIT DETERMINATIONS H. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS ON

REVIEW (GRIEVANCE DECISIONS) I. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS ON

REVIEW (APPEAL DECISIONS) J. MANNER AND CONTENT OF NOTIFICATION OF GRIEVANCE DECISIONS AND

APPEAL DECISIONS K. FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF ADVERSE

BENEFIT DETERMINATIONS, GRIEVANCE DECISIONS OR APPEAL DECISIONS) L. MEMBER COMMENTS AND QUALITY COMPLAINTS M. DEEMED EXHAUSTION OF INTERNAL CLAIMS AND APPEAL PROCESS


A. DEFINITIONS The following terms shall have the meaning ascribed to such terms whenever such terms are used in these Claims Procedures. Adverse Benefit Determination means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a Plan, and including, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental/Investigational or not Medically Necessary or appropriate. An Adverse Benefit Determination also includes any Rescission of coverage (whether or not, in connection with the Rescission, there is an adverse effect on any particular benefit at that time).

Adverse Decision means a utilization review determination that: 1. A proposed or delivered health care service covered under the Member’s contract is or was

not Medically Necessary, appropriate, or efficient; and 2. May result in non-coverage of the health care service. Adverse Decision does not include a

Coverage Decision. Appeal means a protest filed by a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member with the Plan under its internal appeal process regarding a Coverage Decision.

Appeal Decision means final determination by the Plan that arises from an Appeal.

Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with a Plan’s reasonable procedure for filing benefit claims. A Claim for Benefits includes any Pre-Service Claims and any Post-Service Claims.

Claim Involving Urgent Care means any claim for medical care or treatment that involves an Emergency Case or a Urgent Medical Condition. Whether a claim is a Claim Involving Urgent Care is to be determined by an individual acting on behalf of the Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; however, any claim that a physician with knowledge of the Member's medical condition determines is a Claim Involving Urgent Care shall be treated as a Claim Involving Urgent Care for purposes of these Claims Procedures. Claims Procedures means, collectively, the procedures governing the filing of benefit claims, Notification of benefit determinations, and Grievances and Appeals of Adverse Benefit Determinations for Members. Compelling Reason means a showing that the potential delay in receipt of a health care service until after the Member, the Member’s Representative or Health Care provider acting on behalf of the Member exhausts the internal grievance process and obtains a final decision under the grievance process could result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, or the Member remaining seriously mentally ill with symptoms that cause the Member to be in danger to self or others. Complaint means a protest filed with the Maryland Insurance Commissioner involving an Adverse Benefit Determination, Appeal Decision or Grievance Decision. Coverage Decision means:


1. An initial determination by the Plan or the Plan’s Designee that results in non-coverage of a health care service;

2. An determination by the Plan that that an individual is not eligible for coverage under the

Certificate of Coverage; or 3. A determination by the Plan that results in the Rescission of an individual’s coverage

under the Certificate of Coverage; A Coverage Decision includes nonpayment of all or part of a Claim for Benefits. A Coverage Decision does not include an Adverse Decision or a Pharmacy Inquiry. Designee of the Commissioner means any person to whom the Commissioner has delegated the authority to review and decide Complaints, including an administrative law judge to whom the authority to conduct a hearing has been delegated for recommended or final decision. Emergency Case means medical services are necessary to treat a condition or illness that, without immediate medical attention, would either (i) seriously jeopardize the life or health of the Member or the Member’s ability to regain maximum function, or (ii) cause the Member to be in danger to self or others. Filing Date means the earlier of: 1. 5 days after the date of mailing; or

2. The date of receipt.

Grievance means a protest filed by a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member through the Plan’s internal Grievance process regarding an Adverse Decision. Grievance Decision means a final determination by the Plan that arises from a Grievance.

Group Health Plan means an employee welfare benefit Plan within the meaning of Section 3(1) of the Act to the extent that such Plan provides "medical care" within the meaning of Section 733(a) of the Employee Retirement and Income Security Act (“ERISA” or “Act”). Health Advocacy Unit means the Health Education and Advocacy Unit in the Division of Consumer Protection of the Office of the Attorney General established under Title 13, Subtitle 4A of the Commercial Law Article, Annotated Code of Maryland. Health Care Provider, as used in this amendment, means: 1. An individual who is licensed under the Health Occupations Article, Annotated Code of

Maryland, to provide health care services in the ordinary course of business or practice of a profession and is a treating provider of the Member; or

2. A hospital as defined in Title 19 Subtitle 3 of the Health-General Article. Member, as used in this amendment, means an individual entitled to receive health care benefits under this Certificate of Coverage. Member’s Representative means an individual who has been authorized by a Member to file a Grievance, Appeal or a Complaint on behalf of a Member. Notice or Notification means the delivery or furnishing of information to an individual in a manner appropriate with respect to material required to be furnished or made available to an individual.


Pharmacy Inquiry means an inquiry submitted by a pharmacist or pharmacy on behalf of a Member to the Plan, Plan Designee or pharmacy benefits manager at the point of sale about the scope of pharmacy coverage, pharmacy benefit design, or formulary under the Plan. Plan means that portion of the Group Health Plan established by the Group that provides for health care benefits for which The Dental Network, Inc. is the carrier under Certificate of Coverage.

Plan Designee, for purposes of these Claims Procedures, means The Dental Network, Inc.. Post-Service Claim means any claim for a benefit that is not a Pre-Service Claim. Pre-Service Claim means any claim for a benefit with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. Relevant. A document, record, or other information shall be considered Relevant to a Member's claim if such document, record, or other information: 1. Was relied upon in making the benefit determination; 2. Was submitted, considered, or generated in the course of making the benefit

determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;

3. Demonstrates compliance with the administrative processes and safeguards required

pursuant to these Claims Procedures in making the benefit determination; or 4. Constitutes a statement of policy or guidance with respect to the Plan concerning the

denied treatment option or benefit for the Member's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Rescission means a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to pay required premiums or contributions towards the cost of coverage.

Urgent Medical Condition means a condition that satisfies either of the following: 1. A medical condition, including a physical condition, a mental condition, or a dental

condition, where the absence of medical attention within 72 hours could reasonably be expected by an individual, acting on behalf of the Plan, applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, to result in:

a. Placing the member's life or health in serious jeopardy; b. The inability of the member to regain maximum function; c. Serious impairment to bodily function; d. Serious dysfunction of any bodily organ or part; or e. The member remaining seriously mentally ill with symptoms that cause the

member to be a danger to self or others; or

2. A medical condition, including a physical condition, a mental health condition, or a dental condition, where the absence of medical attention within 72 hours in the opinion of a Health Care Provider with knowledge of the Member's medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage decision.


B. SCOPE

The Plan’s Claims Procedures were developed in accordance with Section 503 of the Employee Retirement Income Security Act of 1974 (ERISA or the Act), 29 U.S.C. 1133, 1135, which sets forth minimum requirements for employee benefit plan procedures pertaining to Claims For Benefits by Members.

C. CLAIMS PROCEDURES

These procedures govern the filing of benefit claims, Notification of benefit determinations, and Appeals and Grievances of Adverse Benefit Determinations (hereinafter collectively referred to as Claims Procedures) for Members. These Claims Procedures do not preclude a Member’s Representative or Health Care Provider acting on behalf of a Member from acting on behalf of such Member in pursuing a Claim for Benefits, Grievance or Appeal of an Adverse Benefit Determination, or a Complaint to the Maryland Insurance Commissioner. Nevertheless, the Plan has established reasonable procedures for determining whether an individual has been authorized to act on behalf of a Member. These Claims Procedures contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations and Adverse Benefit Determinations are made in accordance with governing Plan documents and, where appropriate, Plan provisions have been applied consistently with respect to similarly situated Members.

D. CLAIMS PROCEDURES COMPLIANCE 1. Failure to follow Pre-Service Claims Procedures. In the case of a failure by a Member or a

Member’s Representative to follow the Plan’s procedures for filing a Pre-Service Claim the Member or representative shall be notified of the failure and the proper procedures to be followed in filing a Claim for Benefits. This Notification shall be provided to the Member, the Member’s Representative, or Health Care Provider acting on behalf of the Member, as appropriate, as soon as possible, but not later than 5 days (24 hours in the case of a failure to file a Claim Involving Urgent Care) following the failure. Notification may be oral, unless written Notification is requested by the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member. The above shall apply only in the case of a failure that: a. Is a communication by a Member, the Member’s Representative, or Health Care

Provider acting on behalf of the Member that is received by the person or organizational unit designated by the Plan or Plan Designee that handles Claims for Benefits; and

b. Is a communication that names a specific Member; a specific medical condition

or symptom; and a specific treatment, service, or product for which approval is requested.

2. Civil Action. A Member is not required to file more than the Appeals process described

herein prior to bringing a civil action under ERISA. E. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS

1. In general. Except as provided in paragraph E.2 below, if a claim is wholly or partially

denied, the Member shall be notified in accordance with paragraph F. herein, of the Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after receipt of the claim by the Plan or the Plan’s Designee, unless it is determined that special circumstances require an extension of time for processing the claim (for example, the legitimacy of the claim or the appropriate amount of reimbursement is in


dispute and additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary; or the claim is not clean and the specific information necessary for the claim to be considered a clean claim). If it is determined that an extension of time for processing is required, written Notice of the extension shall be furnished to the Member prior to the termination of the initial 30-day period. In no event shall such extension exceed a period of 30 days from the end of such initial period. The extension Notice shall indicate the special circumstances requiring an extension of time and the date by which the benefit determination will be rendered.

2. The Member shall be notified of the determination in accordance with the following, as

appropriate.

a. Expedited Notification of benefit determinations relating to Claims Involving Urgent Care. In the case of a Claim Involving Urgent Care, the Member shall be notified of the benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 24 hours after receipt of the claim unless the Member fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such a failure, the Member shall be notified as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information necessary to complete the claim. The Member shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. Notification of any Adverse Benefit Determination pursuant to this paragraph shall be made in accordance with paragraph F. herein. The Member shall be notified of the benefit determination as soon as possible, but in no case later than 48 hours after the earlier of: i. Receipt of the specified information, or ii. The end of the period afforded the Member to provide the specified

additional information.

b. Concurrent care decisions. If an ongoing course of treatment has been approved to be provided over a period of time or number of treatments: i. Any reduction or termination of such course of treatment (other than by

Plan amendment or termination) before the end of such period of time or number of treatments shall constitute an Adverse Benefit Determination. The Member shall be notified in accordance with paragraph E.2.e herein, of the Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow the Member to appeal and obtain a determination on review of that Adverse Benefit Determination before the benefit is reduced or terminated.

ii. Any request by a Member to extend the course of treatment beyond the

period of time or number of treatments that is a Claim Involving Urgent Care shall be decided as soon as possible, taking into account the medical exigencies. The Member shall be notified of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim, provided that any such claim is made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments. Notification of any Adverse Benefit Determination concerning a request to extend the course of treatment, whether involving urgent care or not, shall be made in accordance with paragraph F. herein, and an Appeal shall be governed by paragraphs G.2, G.3 and G.4 herein as appropriate.

iii. If a health care service for a Member has been preauthorized or approved

by the Plan or the Plan’s Designee, the Plan may not deny


reimbursement to the Health Care Provider for the preauthorized or approved service delivered to the Member unless:

1) The information submitted regarding the service was fraudulent

or intentionally misrepresentative; 2) Critical information required by the Plan or the Plan’s Designee

was omitted such that the Plan or Plan Designee’s determination would have been different had it known the critical information;

3) A planned course of treatment for the Member was not

substantially followed by the Health Care Provider; or 4) On the date the preauthorized service was delivered:

a) the Member was not covered by the Plan;

b) the Plan or the Plan’s Designee maintained an automated eligibility verification system that was available to the Provider by telephone or via the Internet; and

c) according to the verification system, the Claimant was not covered by the Plan.

iv. Continued coverage will be provided pending the outcome of an appeal.

c. Other claims for health care benefits. In the case of a claim that is not an urgent

care claim or a concurrent care decision the Member shall be notified of the benefit determination in accordance with the below “Pre-Service Claims” or “Post-Service Claims,” as appropriate. i. Pre-Service Claims. In the case of a Pre-Service Claim, the Member shall

be notified of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim. This period may be extended one time for up to 15 days, provided that the Plan or the Plan’s Designee both determines that such an extension is necessary due to matters beyond its control, and notifies the Member, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If such an extension is necessary due to a failure of the Member to submit the information necessary to decide the claim, the Notice of extension shall specifically describe the required information, and the Member shall be afforded at least 45 days from receipt of the Notice within which to provide the specified information. Notification of any Adverse Benefit Determination pursuant to this paragraph shall be made in accordance with paragraph G. herein.

Authorization of Pre-Service Claims. The Plan or the Plan’s Designee will determine whether to authorize or certify a Pre-Service Claim within 2 working days following receipt of all necessary information. If information is needed to make a decision which was not included in the initial request for authorization or certification, the Plan or the Plan’s Designee will notify the Health Care Provider within 3 calendar days of the initial request that additional information is needed.

ii. Post-Service Claims. In the case of a Post-Service Claim, the Member

shall be notified, in accordance with paragraph G. herein, of the Adverse Benefit Determination within a reasonable period of time, but not later


than 30 days after receipt of the claim. This period may be extended one time for up to 15 days, provided that the Plan or the Plan’s Designee both determines that such an extension is necessary and notifies the Member, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If such an extension is necessary, the Plan or the Plan’s Designee will send a Notice of receipt and status of the claim that states the legitimacy of the claim or the appropriate amount of reimbursement is in dispute and additional information is necessary to determine if all or part of the claim will be reimbursed and what specific additional information is necessary; or that the claim is not clean and the specific additional information necessary for the claim to be considered a clean claim. The Member shall be afforded at least 45 days from receipt of the Notice within which to provide the specified information.

d. Rescission determinations. The Plan shall provide 30-days advance written

Notice of any proposed Rescission of coverage for any individual. e. Calculating time periods. For purposes of paragraph E. herein the period of time

within which a benefit determination is required to be made shall begin at the time a claim is filed, without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended as permitted pursuant to paragraph E.2 above due to a Member's failure to submit information necessary to decide a claim, the period for making the benefit determination shall be tolled from the date on which the Notification of the extension is sent to the Member until the date on which the Member responds to the request for additional information.

F. MANNER AND CONTENT OF NOTIFICATION OF ADVERSE BENEFIT

DETERMINATIONS 1. This section sets forth the manner and content of Notifications by the Plan of Adverse

Benefit Determinations. 2. In the case of an Adverse Decision, the Plan or the Plan’s Designee shall send a Member,

the Member’s Representative or Health Care Provider acting on behalf of the Member written or electronic Notification of any Adverse Benefit Determination. In the case of an Adverse Decision relating a Claim for Benefits that is not a Claim Involving Urgent Care, the Plan or the Plan’s Designee shall send the written or electronic Notification within 5 working days after the Adverse Decision has been made. The Notification shall set forth, in a manner calculated to be understood by the Member, the Member’s Representative or Health Care Provider: a. The identity of the claim involved (including the date of service, the Health Care

Provider and the claim amount (if applicable). b. The specific reason or reasons for the Adverse Decision; c. Reference to the specific Plan provisions on which the Adverse Decision is

based; d. A description of any additional material or information necessary for the

Member, the Member’s Representative or Health Care Provider acting on behalf of the Member to perfect the claim and an explanation of why such material or information is necessary;

e. A description of the Plan’s review procedures and the time limits applicable to

such procedures, including a statement of the Member's right to bring a civil action under Section 502(a) of the Act following an Adverse Decision;


f. The Medical Director’s name, business address and business telephone number; g. If an internal rule, guideline, protocol, diagnosis code, treatment code, or other

similar criterion was relied upon in making the Adverse Decision , either (i) the specific rule, guideline, protocol, diagnosis code (and its corresponding meaning), treatment code (and its corresponding meaning) or other similar criterion; or (ii) a statement that such a rule, guideline, protocol, diagnosis code, treatment code, or other similar criterion was relied upon in making the Adverse Decision and that a copy of such rule, guideline, protocol, diagnosis code (and its corresponding meaning) or treatment code (and its corresponding meaning), or other criterion will be provided free of charge to the Member upon request; or

h. If the Adverse Decision is based on a Medical Necessity or Experimental/Investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Member’s medical circumstances.

i. In the case of an Adverse Decision by the Plan or the Plan’s Designee concerning a Claim Involving Urgent Care, a description of the expedited review process applicable to such claims. This information may be provided orally to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within the timeframe prescribed in paragraph E.2. herein. The Member, the Member’s Representative or Health Care Provider acting on behalf of the Member must be provided a written or electronic Notification no later than one (1) day after the oral Notification.

j. That the Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member has a right to file a Complaint with the Commissioner within 4 months after receipt of the Plan’s Grievance Decision;

k. That a Complaint may be filed without first filing a Grievance if

i. The Plan notifies the Member in writing that it has waived the requirement that its internal grievance process be exhausted before filing a Complaint with the Commissioner;

ii. The Plan has failed to comply with any of the requirements of the internal

grievance procedure described in this amendment; or iii. the Member, the Member’s Representative or Health Care Provider

acting on behalf of the Member filing a Grievance on behalf of the Member can demonstrate a Compelling Reason to do so as determined by the Commissioner;

l. The Commissioner’s address, telephone number, and facsimile number;

m. A statement that the Health Advocacy Unit is available to assist the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance; and

n. The Health Advocacy Unit’s address, telephone number, facsimile number, and

electronic mail address.

3. In the case of a Coverage Decision, the Plan or the Plan Designee must within 30 calendar days provide Member, Member’s Representative and the treating Health Care Provider, a written Notice of the Coverage Decision. The statement must state in detail, in clear, understandable language, the specific factual basis for the Plan’s decision and must include the following information:


a. Where applicable, the identity of the claim involved (including the date of service, the Health Care Provider and the claim amount )..

b. The specific reason or reasons for the Coverage Decision; c. Reference to the specific Plan provisions on which the Coverage Decision is

based; d. A description of any additional material or information necessary for the

Member, the Member’s Representative or Health Care Provider acting on behalf of the Member to perfect the claim and an explanation of why such material or information is necessary;

e. A description of the Plan’s review procedures and the time limits applicable to

such procedures, including a statement of the Member's right to bring a civil action under Section 502(a) of the Act following a Coverage Decision;

f. That the Member, Member’s Representative or Health Care Provider acting on

behalf of the Member has a right to file an Appeal with the Plan or the Plan’s Designee;

g. In the case of a Coverage Decision by the Plan or the Plan’s Designee concerning

a Claim Involving Urgent Care, a description of the expedited review process applicable to such claims. This information may be provided orally to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within the timeframe prescribed in paragraph E.2. herein. The Member, the Member’s Representative or Health Care Provider acting on behalf of the Member must be provided a written or electronic Notification no later than one (1) day after the oral Notification.

h. That the Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member has a right to file a Complaint with the Commissioner within 4 months after receipt of the Plan’s Appeal Decision;

i. That the Member, Member’s Representative or Health Care Provider acting on

behalf of the Member may file a Complaint with the Commissioner without first filing an Appeal, if the Coverage Decision involves a Claim Involving Urgent Care which has not been rendered;

j. The Commissioner’s address, telephone number, and facsimile number;

k. A statement that the Health Advocacy Unit is available to assist the Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing an Appeal; and

l. The Health Advocacy Unit’s address, telephone number, facsimile number, and

electronic mail address.

4. Adverse Benefit Determinations are made under the direction of the Medical Director.

G. APPEALS AND GRIEVANCES OF ADVERSE BENEFIT DETERMINATIONS 1. To file an Appeal or Grievance of an Adverse Benefit Determination, a Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member, may contact the Plan at the address and telephone number located on the Member’s ID Card; or submit a written request and any supporting record of medical documentation within 180 days of receipt of the written Notification of the Adverse Benefit Determination to the following:


Mail Administrator P.O. Box 14114

Lexington, KY 40512-4114 410- 581-3000

The Health Advocacy Unit is available to assist the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance or Appeal. See Section K for additional information.

2. a. A Member has the opportunity to submit written comments, documents, records,

and other information relating to the Claim for Benefits; b. A Member shall be provided, upon request and free of charge, reasonable access

to, and copies of, all documents, records, and other information Relevant to the Member's Claim for Benefits;

c. The Plan or the Plan’s Designee shall take into account all comments,

documents, records, and other information submitted by the Member relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

3. In addition to the requirements of paragraphs G.2.a through c herein, the following apply:

a. The Plan or the Plan’s Designee shall provide for a review that does not afford

deference to the initial Adverse Benefit Determination and will be conducted by an individual who is neither the individual who made the Adverse Benefit Determination that is the subject of the Appeal or Grievance, nor the subordinate of such individual;

b. In deciding a Grievance of any Adverse Benefit Determination that is based in

whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental/Investigational, or not Medically Necessary or appropriate, the Plan or the Plan’s Designee shall consult with a Health Care Provider with the same specialty as the treatment under review.

c. Upon request, the Plan or the Plan’s Designee will identify medical or vocational

experts whose advice was obtained on behalf of the Plan in connection with a Member's Adverse Benefit Determination, without regard to whether the advice was relied upon in making the benefit determination;

d. Health Care Provider engaged for purposes of a consultation under paragraph

H.3.b herein shall be individuals who were neither consulted in connection with the Adverse Benefit Determination that is the subject of the Appeal or Grievance, nor subordinates of any such individuals; and

e. In the case of a Claim Involving Urgent Care, a request for an expedited Appeal

or Grievance of an Adverse Benefit Determination may be submitted orally or in writing by the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member; and the Plan or the Plan’s Designee must notify the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member of its determination in writing within 24 hours of receipt of the expedited request for Appeal or Grievance.

4. Full and fair review. The Plan or the Plan’s Designee shall allow a Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member to review the claim file and to present evidence and written testimony as part of the internal claims and Appeals or Grievances process. Specifically, in addition to the requirements of paragraphs G.2.a through c herein, the following apply:


a. The Plan or the Plan’s Designee shall provide the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member, free of charge, with any new or additional evidence considered, relied upon, or generated by the Plan or the Plan’s Designee (or at the direction of the Plan or the Plan’s Designee) in connection with the claim; such evidence will be provided as soon as possible and sufficiently in advance of the date on which the Grievance Decision or Appeal decision is required to be provided under paragraph H. herein, to give the Member a reasonable opportunity to respond prior to that date; and

b. Before the Plan or the Plan’s Designee issues a Grievance Decision or an Appeal

Decision based on a new or additional rationale, the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member shall be provided, free of charge, with the rationale; the rationale shall be provided as soon as possible and sufficiently in advance of the date on which the Notice of Appeal Decision or Grievance Decision is required to be provided under paragraphs H or I. herein, to give the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member a reasonable opportunity to respond prior to that date.

H. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS ON

REVIEW (GRIEVANCE DECISIONS) 1. The Plan or the Plan’s Designee shall notify a Member, the Member’s Representative or

Health Care Provider acting on behalf of the Member of its benefit determination on review of an Adverse Decision in accordance with the following, as appropriate. a. Urgent care claims. In the case of a Claim Involving Urgent Care, the Member,

the Member’s Representative or Health Care Provider acting on behalf of the Member shall be notified, in accordance with paragraph J. herein, of the Grievance Decision as soon as possible, taking into account the medical exigencies, but not later than 24 hours after receipt of the Member's request for review of an Adverse Decision. A written Notification must be provided to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within 24 hours of the orally communicated Grievance Decision.

b. Pre-service claims. In the case of a Pre-Service Claim, the Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member shall be notified, in accordance with paragraph J herein, of the Grievance Decision within a reasonable period of time appropriate to the medical circumstances. Oral Notification shall be provided not later than 30 days after the filing date of the Member, the Member’s Representative’s or Health Care Provider’s request for review of an Adverse Decision. A written Notification must be provided to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within 5 working days of the Grievance Decision.

c. Post-service claims. In the case of a Post-Service Claim, the Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member shall be notified, in accordance with item J herein, of the Grievance Decision within a reasonable period of time. Oral Notification shall be provided not later than 45 working days after the filing date of the Member’s, the Member’s Representative’s or Health Care Provider’s request for review of an Adverse Decision. A written Notification must be provided to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within 5 working days of the Grievance Decision.

2. If the Plan or the Plan’s Designee does not have sufficient information to complete its Grievance Decision, the Plan or the Plan’s Designee must notify the Member, the


Member’s Representative or Health Care Provider acting on behalf of the Member within five (5) working days after the Filing Date of the Grievance by the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member with the Plan or the Plan’s Designee. The Plan or the Plan’s Designee Notification shall: a. Notify the Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member that it cannot proceed with reviewing the Grievance unless additional information is provided; and

b. Assist the Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member in gathering the necessary information without further delay.

3. The Plan or the Plan’s Designee may extend the 30-day or 45-working day period

required for making an Grievance Decision under paragraph H.1.b., c. with the written consent of the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member who filed the Grievance on behalf of the Member. With the written consent of the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member who filed the Grievance on behalf of the Member, the Plan or the Plan’s Designee may extend the period for making a final decision for an additional period of not longer than 30 working days. The Plan’s extension request must describe the special circumstances necessitating the extension and the date on which the benefit determination will be made.

4. Calculating time periods. For purposes of Section H. herein, the period of time within

which a Grievance Decision shall be made begins at the time a Grievance is received by the Plan or the Plan’s Designee, without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. In the event that a period of time is extended as permitted pursuant to paragraph H.2 herein due to a Member’s, the Member’s Representative’s or Health Care Provider 's failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the Notification of the extension is sent to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member until the date on which the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member responds to the request for additional information.

5. In the case of Grievance, upon request, the Plan or the Plan’s Designee shall provide such

access to, and copies of Relevant documents, records, and other information described in paragraphs G.2, G.3, and G.4 herein as is appropriate.

I. TIMING OF NOTIFICATION OF ADVERSE BENEFIT DETERMINATIONS ON

REVIEW (APPEAL DECISIONS) 1. The Plan or the Plan’s Designee shall notify a Member, the Member’s Representative or

Health Care Provider acting on behalf of the Member of its Appeal Decision no later than 60 working days after the filing date of the Member, the Member’s Representative ‘s or Health Care Provider’s Appeal. A written Notification must be provided to the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member within 30 days of the Appeal Decision.

2. The Plan or the Plan’s Designee may extend the 60-working day period required for making an Appeal Decision under I.1 with the written consent of the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member who filed the Appeal on behalf of the Member. With the written consent of the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member who filed the Appeal on behalf of the Member, the Plan or the Plan’s Designee may extend


the period for making a final decision for an additional period of not longer than 30 working days. The Plan’s extension request must describe the special circumstances necessitating the extension and the date on which the benefit determination will be made.

3. Calculating time periods. For purposes of Section I. herein, the 60-working day period

within which a benefit determination on review shall be made, subject to any extension granted pursuant to paragraph I.2 above, begins at the time an Appeal is received by the Plan or the Plan’s Designee, without regard to whether all the information necessary to make an Appeal Decision accompanies the filing.

J. MANNER AND CONTENT OF NOTIFICATION OF GRIEVANCE DECISION OR

APPEAL DECISION

The Plan or the Plan’s Designee shall provide a Member, the Member’s Representative or Health Care Provider acting on behalf of the Member with written or electronic Notification after it has provided oral communication of the Grievance Decision or Appeal Decision. The Notification shall set forth, in a manner calculated to be understood by the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member: 1. The identity of the claim involved (including the date of service, the Health Care

Provider and the claim amount (if applicable)). 2. The specific factual basis for the adverse determination; 3. Reference to the specific criteria and standards, including interpretive guidelines, on

which the benefit determination is based; 4. A statement that the Member is entitled to receive, upon request and free of charge,

reasonable access to, and copies of, all documents, records, and other information Relevant to the Member's Claim For Benefits;

5. A statement describing any voluntary Appeal or Grievance procedures offered by the

Plan and the Member's right to obtain the information about such procedures, and a statement of the Member's right to bring an action under Section 502(a) of the Act; and

6. a. If an internal rule, guideline, protocol, diagnosis code, treatment code, or other

similar criterion was relied upon in making the adverse determination , either (i) the specific rule, guideline, protocol, diagnosis code (and its corresponding meaning), treatment code (and its corresponding meaning) or other similar criterion; or (ii) a statement that such a rule, guideline, protocol, diagnosis code, treatment code, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, diagnosis code (and its corresponding meaning) or treatment code (and its corresponding meaning), or other criterion will be provided free of charge to the Member upon request; or

b. If the Adverse Benefit Determination is based on a Medical Necessity or

Experimental/Investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Member's medical circumstances, or a statement that such explanation will be provided free of charge upon request; and

c. You and your plan may have other voluntary alternative dispute resolution

options, such as mediation. One way to find out what may be available it so contact your local U.S. Department of Labor Office and your State insurance regulatory agency.


7. In the case of a Grievance involving an Adverse Decision, a statement that includes the following information:

a. The name, business address and business telephone number of the Medical

Director who made the decision; b. That the Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member has a right to file a Complaint with the Commissioner within 4 months after receipt of the Grievance Decision;

c. The Commissioner’s address, telephone number, and facsimile number; d. A statement that the Health Advocacy Unit is available to assist the Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member with filing a Complaint with the Commissioner;

e. The Health Advocacy Unit’s address, telephone number, facsimile number and

electronic mailing address; f. The Employee Benefit Security Administration’s telephone number and website

address; and g. A Notice that, when filing a Complaint with the Commissioner, the Member or a

legally authorized designee of the Member will be required to authorize the release of any medical records of the Member that may be required to be reviewed for the purpose of reaching a decision on the Complaint.

8. In the case of an Appeal involving a Coverage Decision, a statement that includes the

following information:

a. That the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member has a right to file a Complaint with the Commissioner within 4 months after receipt of the Appeal Decision; and

b. The Commissioner’s address, telephone number, and facsimile number;

c. The Employee Benefit Security Administration’s telephone number and website address; and

d. A statement that the Health Advocacy Unit is available to assist the Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member with filing a Complaint with the Commissioner;

e. The Health Advocacy Unit’s address, telephone number, facsimile number and

electronic mailing address; and f. A Notice that, when filing a Complaint with the Commissioner, the Member or a

legally authorized designee of the Member will be required to authorize the release of any medical records of the Member that may be required to be reviewed for the purpose of reaching a decision on the Complaint.

9. Grievance Decisions and Appeal Decisions are made under the direction of the Chief

Medical Officer:

10455 Mill Run Circle Owings Mills, Maryland 21117-4208

410-581-3000


K. FILING OF COMPLAINT AFTER RECEIPT OF NOTIFICATION OF GRIEVANCE DECISIONS OR APPEAL DECISIONS

1. Within 4 months after the date of receipt of an Appeal Decision or a Grievance Decision, a

Member, the Member’s Representative or Health Care Provider acting on behalf of the Member may file a Complaint with the Commissioner for review of the Grievance Decision or Appeal Decision.

2. A Member, the Member’s Representative or Health Care Provider acting on behalf of the

Member may file a Complaint without first exhausting the Plan’s internal Grievance or Appeals process if:

a. In the case of an Adverse Decision:

i. The Plan or the Plan’s Designee waives the requirement that the internal

Grievance process be exhausted before filing a Complaint with the Commissioner;

ii. The Plan or the Plan’s Designee has failed to comply with any of the

requirements of the internal Grievance process; iii. The Member, the Member’s Representative or Health Care Provider acting

on behalf of the Member provides sufficient information and supporting documentation in the Complaint to demonstrate a Compelling Reason.

b. In the case of a Coverage Decision, the Complaint involves an Urgent Medical

Condition for which care has not been rendered. 3. The remaining provisions of this paragraph K. apply to Complaints regarding Adverse

Decisions and Grievance Decisions. a. The Commissioner shall notify the Plan or the Plan’s Designee of the Complaint

within five working days after the date the Complaint is filed with the Commissioner.

b. Except for an Emergency Case (Claim Involving Urgent Care), the Plan or the

Plan’s Designee shall provide to the Commissioner any information requested by the Commissioner no later than seven working days from the date the Plan or the Plan’s Designee receives the request for information.

4. a. Except as provided in paragraph K.4.b below, the Commissioner shall make a final

decision on a Complaint: i. Within 45 days after a Complaint is filed regarding a Pre-Service Claim; ii. Within 45 days after a Complaint is filed regarding a Post-Service Claim;

and iii. Within 24 hours after a Complaint is filed regarding a Claim Involving

Urgent Care.

b. The Commissioner may extend the period within which a final decision is to be made under paragraph.K.4.a. for up to an additional 30 working days if: i. the Commissioner has not yet received information requested by the

Commissioner; and ii. the information requested is necessary for the Commissioner to render a

final decision on the Complaint.


5. The Commissioner shall seek advice from an independent review organization or medical expert for Complaints filed with the Commissioner that involve a question of whether a Pre-Service Claim or a Post-Service Claim is Medically Necessary. The Commissioner shall select an independent review organization or medical expert to advise on the Complaint in the manner set forth in Section 15-10A-05 of the Insurance Article.

6. The Plan or the Plan’s Designee shall have the burden of persuasion that its Adverse

Decision or Grievance, as applicable, is correct during the review of a Complaint by the Commissioner or Designee of the Commissioner, and in any hearing held regarding the Complaint.

7. As part of the review of a Complaint, the Commissioner or Designee of the Commissioner

may consider all of the facts of the case and any other evidence deemed Relevant.

8. Except as provided below, in responding to a Complaint, the Plan or the Plan’s Designee may not rely on any basis not stated in its Adverse Benefit Determination. a. The Commissioner may allow the Plan or the Plan’s Designee, a Member, the

Member’s Representative or Health Care Provider acting on behalf of the Member to provide additional information as may be relevant for the Commissioner to make a final decision on the Complaint.

b. The Commissioner shall allow the Member, the Member’s Representative or

Health Care Provider acting on behalf of the Member at least 5 working days to provide the additional information.

c. The Commissioner’s use of additional information may not delay the

Commissioner’s decision on the Complaint by more than five working days.

9. The Commissioner may request the Member or a legally authorized designee of the Member to sign a consent form authorizing the release of the Member’s medical records to the Commissioner or Designee of the Commissioner that are needed in order for the Commissioner to make a final decision on the Complaint.

10. Subject to paragraphs H, a Member, the Member’s Representative or Health Care Provider

acting on behalf of the Member may file a Complaint with the Commissioner if the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member does not receive the Plan’s Grievance Decision within the following timeframes:

a. Within 30 days after the filing date of a Grievance regarding a Pre-Service Claim;

b. Within 45 working days after the filing date of a Grievance regarding a Post-

Service Claim; and

c. Within 24 hours after the receipt of a Grievance regarding a Claim Involving Urgent Care.

Note: the Health Advocacy Unit is available to assist the Member, the Member’s Representative or Health Care Provider acting on behalf of the Member in both mediating and filing a Grievance. Contact the Health Advocacy Unit at:

Health Education and Advocacy Unit

Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor

Baltimore, MD 21202 410- 528-1840 or 1-877- 261-8807

Fax: 410- 576-6571 E-mail: [email protected]


L. MEMBER COMMENTS AND QUALITY COMPLAINTS The Plan provides Members an opportunity to present comments or any other questions or concerns with regard to operations or administration of the Plan, and file a quality complaint regarding the quality of any Plan service. All comments and quality complaints should be addressed to the Member Services Department. In the event that you are dissatisfied with a determination of the Member Services Department, the procedures listed below must be followed. Inquiries, comments, and complaints concerning the nature of your medical care should also be addressed to the Member Services Department. That department will also assist you in filing a quality complaint after all other avenues of resolution have been exhausted. A Member may complain to the Department of Health and Mental Hygiene, Office of Licensing and Certification Programs regarding the operation of The Plan. The address and telephone number of the Department is available through our Member Services Department. The Member may also contact the Maryland Insurance Administration at:

Maryland Insurance Administration

Inquiry and Investigation, Life and Health 200 St. Paul Place

Suite 2700 Baltimore, MD 21202-2272

410-468-2244 M. DEEMED EXHAUSTION OF INTERNAL CLAIMS AND APPEAL PROCESS

If the Plan fails to adhere to the minimum requirements for Claims Procedures relating to Claims for Benefits by Members or Section 15-10A-02 of the Insurance Code, Annotated Code of Maryland, the Member is deemed to have exhausted the internal appeals and grievance processes of paragraph G through J herein. Accordingly the Member may initiate an external review under paragraph K of this section, as applicable. The Member is also entitled, where applicable, to pursue any available remedies under section 502(a) of ERISA or under State law, as applicable, on the basis that the Plan has failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the Claim for Benefits. If a Member, where applicable, chooses to pursue remedies under section 502(a) of ERISA under such circumstances, the Claim for Benefits, Grievance, or Appeal is deemed denied on review without the exercise of discretion by an appropriate fiduciary.

This amendment is issued to be attached to Certificate of Coverage. This amendment does not change the terms and conditions of the Certificate of Coverage, unless specifically stated herein.




MD/TDN/PARTNER (R. 10/12) Grp Cert Coverage 12/12 1




DOMESTIC PARTNER ELIGIBILITY RIDER

This rider is effective on the effective date or renewal date of the Group Certificate of Coverage to which it is attached. A Member’s termination date under this rider will be determined in the same as any other Member’s termination date under the terms of the Group Certificate of Coverage. This rider is issued by The Dental Network, Inc. to be attached to and become part of the Group Certificate of Coverage. This rider contains certain terms that have a specific meaning as to the eligibility of a Domestic Partner and the Dependent Child of a Domestic Partner. These terms are capitalized and are defined in Section A of this rider, in the subsequent sections, or in the Group Certificate of Coverage to which this rider is attached. This rider contains specific requirements applicable to the eligibility of a Domestic Partner and the eligibility of a Dependent Child of a Domestic Partner that are in addition to the eligibility requirements of the Covered Employee and other Dependents contained in the Group Certificate of Coverage to which this rider is attached. TABLE OF CONTENTS SECTION A - DEFINITIONS SECTION B - ELIGIBILITY AND ENROLLMENT SECTION A - DEFINITIONS 1. The definition of Dependent in the Group Certificate of Coverage is hereby amended to include

the eligible Domestic Partner of a Covered Employee and the Dependent Child(ren) of a Domestic Partner as defined in this rider.

2. The Group Certificate of Coverage is amended to add the following definitions:

Dependent Child(ren) of a Domestic Partner means an individual who meets the eligibility guidelines stated in the Group Certificate of Coverage for the eligible children of a spouse. Domestic Partner means a person who cohabitates/resides with the Covered Employee in a Domestic Partnership. Domestic Partnership means a relationship between a Covered Employee and Domestic Partner that meets the criteria stated in Section B.1.b.

SECTION B - ELIGIBILITY AND ENROLLMENT The Group Certificate of Coverage is amended to include the following:

1. Eligibility of Covered Employee’s Domestic Partner. The Covered Employee may enroll his/her eligible Domestic Partner. An eligible Domestic Partner will be eligible for coverage to the same extent as a Covered Employee’s spouse.

a. Requirements for Coverage. To be eligible for coverage as the Domestic Partner

of a Covered Employee, the following conditions must be met:


i. The individual must be eligible for coverage as a Domestic Partner in a Domestic Partnership as defined in Section B.1.b.

ii. The Covered Employee must elect coverage for his/her Domestic

Partner.

iii. Cost for Services payments must be made as required under this Group Certificate of Coverage.

b. Domestic Partnership means a relationship between a Covered Employee and a

Domestic Partner that satisfies the requirements of either Section B.1.b.i or Section B.1.b.ii below:

i. The Covered Employee and Domestic Partner are lawfully married

under the laws of any state or jurisdiction in which the marriage was performed, or are registered with any state or other jurisdiction authorized to perform such registrations. There are no requirements for proof of such a relationship that are not also applied to any other married couple.

ii. If the requirement in Section B.1.b.i above has not been met, the Covered

Employee and Domestic Partner must meet all of the following requirements:

1). The Covered Employee and the Domestic Partner are the same

sex or opposite sex and both are at least eighteen (18) years of age and have the legal capacity to enter into a contract;

2) The Covered Employee and the Domestic Partner are not parties

to a civil union, domestic partnership, or legally recognized marriage with anyone else;

3) The Covered Employee and Domestic Partner are not related to

the other by blood or marriage within four (4) degrees of consanguinity under civil law rule;

4) The Covered Employee and Domestic Partner share a common

primary residence. The Covered Employee must submit one (1) of the following documents as proof of a shared common primary residence:

a) Common ownership of the primary residence via joint

deed or mortgage agreement;

b) Common leasehold interest in the primary residence;

c) Driver’s license or State-issued identification listing a common address; or,

d) Utility or other household bill with both the name of the

Covered Employee and the Domestic Partner appearing.

5) The Covered Employee and Domestic Partner are Financially Interdependent, as defined in this rider, and submit documentary evidence of their committed relationship of financial interdependence, existing for at least six (6) consecutive months prior to application.


c. Financially Interdependent means the Covered Employee and Domestic Partner can establish that they are in a committed relationship of financial interdependence in which each individual contributes to some extent to the other individual’s maintenance and support with the intention of remaining in the relationship indefinitely. Financial Interdependence can be established by submitting documentation from any one (1) of the following criteria: i. Joint bank account or credit account;

ii. Designation of one partner as the other’s primary beneficiary with

respect to life insurance or retirement benefits;

iii. Designation of one partner as the primary beneficiary under the other partner’s will;

iv. Mutual assignments of valid durable powers of attorney under §13-601

of the Estates and Trusts Article of the Annotated Code of Maryland, or the applicable laws of any state or the District of Columbia;

v. Mutual valid written advanced directives under §5-601 of the Health-

General Article of the Annotated Code of Maryland, or the applicable laws of any state or the District of Columbia, approving the other partner as health care agent;

vi. Joint ownership or holding of investments; or vii. Joint ownership or lease of a motor vehicle.

2. Eligibility of a Child of a Domestic Partner. The Covered Employee may enroll the Domestic

Partner’s eligible child as a Dependent Child(ren) of a Domestic Partner as defined in this rider. 3. Enrollment Opportunities. The terms and conditions for the enrollment of a Domestic Partner

or the eligible child of a Domestic Partner under the Group Certificate of Coverage will be the same, respectively, as that of a Covered Employee’s spouse and the eligible child of a Covered Employee’s spouse.

First Eligibility Date for an eligible: a. Domestic Partner shall be the date established by the Group’s enrollment procedures.

b. Dependent Child(ren) of a Domestic Partner shall be the same as that of the Domestic

Partner, if the child meets the definition of a Dependent Child(ren) of a Domestic Partner, as stated in this rider. Otherwise, the First Eligibility Date for the child of a Domestic Partner will be the date on which the child first meets the definition of Dependent Child(ren) of a Domestic Partner, as stated in this rider.

This rider is issued to be attached to and become a part of the Group Certificate of Coverage.




MD/TDN/DEPENDENT AGE (R. 11/11) 1 Grp Cert Cov

The Dental Network , Inc. 14055 Mill Run Circle


An independent licensee of the BlueCross and BlueShield Association

EXPANSION OF DEPENDENT COVERAGE AMENDMENT REVISED

This amendment is effective on the effective date of the Group Certificate of Coverage to which this amendment is attached. TABLE OF CONTENTS SECTION A – DEFINITION OF DEPENDENT CHILD SECTION B – ELIGIBILITY SECTION C – TERMINATION The Group Certificate of Coverage is amended as follows: A. DEFINITION OF DEPENDENT CHILD For the purposes of this amendment, a Dependent child is a child who is:

1. The natural child, stepchild, adopted child of the Subscriber or the Subscriber’s covered Spouse;

2. A child placed with the Subscriber or the Subscriber’s covered Spouse for legal

Adoption; or

3. A child under testamentary or court appointed guardianship, other than temporary guardianship for less than 12 months’ duration, of the Subscriber or the Subscriber’s covered Spouse;

All provisions of the Group Certificate of Coverage that define or describe the eligibility of a Dependent child who is described above for coverage under the Group Certificate of Coverage are revised to include a Dependent child described above who has not attained his or her 26th birthday notwithstanding the Dependent child’s:

1. Financial dependency on an individual covered under the Group Certificate of Coverage; 2. Marital status; 3. Residency with an individual covered under the Group Certificate of Coverage; 4. Student status; 5. Employment; 6. Eligibility for other coverage; or 7. Satisfaction of any combination of the above factors.

The Group Certificate of Coverage states the eligibility requirements for grandchildren. These are not changed by this amendment.

MD/TDN/DEPENDENT AGE (R. 11/11) 2 Grp Cert Cov

B. ELIGIBILITY All provisions of the Group Certificate of Coverage that state that the eligibility for coverage of a Dependent child described in Section A above is based on any factor other than the relationship between the Dependent child and an individual covered under the Group Certificate of Coverage are deleted. All requirements that the Dependent child described in Section A above, prior to his or her 26th birthday, be financially dependent on an individual covered under the Certificate of Coverage, that the Dependent child share a residence with an individual covered under the Certificate of Coverage, that the Dependent child meet certain student status requirements, that the Dependent child be unmarried, that the Dependent child not be eligible for other coverage, or that the Dependent child not be employed, are deleted. Nothing in this amendment should be construed to amend any requirement related to the eligibility of a Dependent child over the age of 26 or to alter any requirement related to the eligibility of a dependent grandchild. The Group Certificate of Coverage states the eligibility requirements for grandchildren. These are not changed by this amendment. C. TERMINATION All provisions of the Group Certificate of Coverage that state that the coverage of a Dependent child described in Section A above will terminate when the Dependent child marries, ceases to be financially dependent on an individual covered under the Group Certificate of Coverage, ceases to share a residence with an individual covered under the Group Certificate of Coverage, ceases to be a full-time or part-time student, is eligible for other coverage, becomes employed full-time or part-time, or reaches the Dependent child’s 25th birthday are deleted. The Group Certificate of Coverage is amended to provide that the coverage of a Dependent child described in Section A above will terminate on the date the Dependent child reaches his or her 26th birthday or the age stated in the Eligibility Schedule, whichever is greater. The Limiting Age will not apply to a Dependent child described in Section A above, who at the time of reaching the Limiting Age, is incapable of self-support because of mental or physical incapacity that started before the Dependent child attained the Limiting Age, provided the incapacitated Dependent child is unmarried and dependent on an individual covered under the Group Certificate of Coverage. Coverage of the incapacitated Dependent child described in Section A above will continue for as long as the Dependent child remains incapable of self-support because of a mental or physical incapacity, unmarried, and dependent on an individual covered under the Group Certificate of Coverage. The Group Certificate of Coverage states the Limiting Age and termination of coverage provisions for grandchildren. These are not changed by this amendment. This amendment is issued to be attached to the Group Certificate of Coverage. This amendment does not change the terms and conditions of the Group Certificate of Coverage, unless specifically stated herein.




MD/TDN/PREV FREQ & DEP TERM AMEND (10/12) Group COC Prev Freq/Dep EOM




DENTAL PREVENTIVE FREQUENCY LIMITING CHANGE AND

DEPENDENT TERMINATION AMENDMENT This amendment is effective on the effective date of the Group Certificate of Coverage to which this amendment is attached. I. The Group Certificate of Coverage is amended as follows:

A. Section 1. Definitions, the item below is added:

Contract Term means the period of time during which benefits are eligible for coverage. The Contract Term is one (1) year from the effective date (or renewal date) of the Group Certificate of Coverage.

B. Section 7. Plan Limitations, the item below is deleted:

Teeth Cleaning (Prophylaxis) at intervals of less than six (6) months; C. Section 7. Plan Limitations, the item below is added:

Teeth Cleaning (Prophylaxis) limited to twice per Contract Term. D. Section 3. Termination or Cancellation, item B is deleted and replaced with:

B. For Dependent children, coverage shall terminate upon the end of the month

following the date the Dependent child reaches his or her 26th birthday.

II. The Schedule of Benefits and Copayments is amended as follows:

A. Section, Plan Limitations, the item below is deleted:

Teeth Cleaning (Prophylaxis) at intervals of less than six (6) months; B. Section, Plan Limitations, the item below is added:

Teeth Cleaning (Prophylaxis) limited to twice per Contract Term. This amendment is issued to be attached to the Group Certificate of Coverage. This amendment does not change the terms and conditions of the Group Certificate of Coverage, unless specifically stated herein.




The example shows how Dr. Jones, an obstetrician gynecologist, would be compensated under each method of payment.

A physician (or other provider) is an employee of the HMO and is paid compensation (monetary wages) for providing specific healthcare services.

Since Dr. Jones is an employee of an HMO, she receives her usual bi-weekly salary regardless of how may patients she sees or the numberof services she provides. During the months of providing pre-natal care to Mrs. Smith, who is a member of the HMO, Dr. Jones’ salary isunchanged. Although Mrs. Smith’s baby is delivered by Cesarean section, a more complicated procedure than a vaginal delivery, the method of delivery will not have any effect upon Dr. Jones’ salary.

A physician (or group of physicians) is paid a fixed amount of money per month by an HMO for each patient who chooses the physician(s)to be his or her doctor. Payment is fixed without regard to the volume of services that an individual patient requires.

Under this type of contractual arrangement, Dr. Jones participates in an HMO network. She is not employed by the HMO. Her contract withthe HMO stipulates that she is paid a certain amount each month for patients who select her as their doctor. Since Mrs. Smith is a member ofthe HMO, Dr. Jones monthly payment does not change as a result of her providing ongoing care to Mrs. Smith. The capitation amount paid toDr. Jones is the same whether or not Mrs. Smith requires obstetric services.

A physician (or other provider) charges a fee for each patient visit, medical procedure, or medical service provided. An HMO pays the entirefee for physicians it has under contract and an insurer pays all or part of that fee, depending on the type of coverage. The patient isexpected to pay the remainder.

Dr. Jones’ contract with the insurer or HMO states that Dr. Jones will be paid a fee for each patient visit and each service she provides. Theamount of payment Dr. Jones receives will depend upon the number, types, and complexity of services, and the time she spends providingservices to Mrs. Smith. Because Cesarean deliveries are more complicated than vaginal deliveries, Dr. Jones is paid more to deliver Mrs. Smith’sbaby than she would be paid for a vaginal delivery. Mrs. Smith may be responsible for paying some portion of Dr. Jones’ bill.

Payment is less than the rate usually received by the physician (or other provider) for each patient visit, medical procedure, or service.This arrangement is the result of an agreement between the payer, who gets lower costs and the physician (or other provider), who usuallygets an increased volume of patients.

Like fee-for-service, this type of contractual arrangement involves the insurer or HMO paying Dr. Jones for each patient visit and each delivery;but, under this arrangement, the rate, agreed upon in advance, is less than Dr. Jones’ usual fee. Dr. Jones expects that in exchange for agreeing toaccept a reduced rate, she will serve a certain number of patients. For each procedure that she performs, Dr. Jones will be paid a discounted rateby the insurer or HMO.

A physician (or other provider) is paid an additional amount over what he or she is paid under salary, capitation, fee-for-service, orother type of payment arrangement. Bonuses may be based on many factors, including member satisfaction, quality of care, control ofcosts and use of services.

An HMO rewards its physician staff or contracted physicians who have demonstrated higher than average quality and productivity. BecauseDr. Jones has delivered so many babies and she has been rated highly by her patients and fellow physicians, Dr. Jones will receive a monetaryaward in addition to her usual payment.

The HMO or insurer and the physician (or other provider) agree in advance that payment will cover a combination of services providedby both the physician (or other provider) and the hospital for an episode of care.

This type of arrangement stipulates how much an insurer or HMO will pay for a patient’s obstetric services. All office visits for prenatal andpostnatal care, as well as the delivery, and hospital-related charges are covered by one fee. Dr. Jones, the hospital, and other providers(such as an anesthesiologist) will divide payment from the insurer or HMO for the care provided to Mrs. Smith.

Our compensation to providers who offer health care services to our insured members or enrollees may be based on a variety of payment mechanisms such as fee-for-service payments, salary, or capitation. Bonuses may be used with these various types of payment methods.

If you desire additional information about our methods of paying providers, or if you want to know which method(s) apply to your health care provider, please call our Member Services Department at the number listed on your identification card, or write to:

B. PROVIDER PAYMENT METHODS

TDN utilizes the following methods of paying physicians (dentists) who render health care (dental) services to our enrollees: capitation, fee-for-service, and discounted fee-for-service.

C. DISTRIBUTION OF PREMIUM DOLLARS

The bar graph illustrates the proportion of every $100 in premium used by The Dental Network, Inc. to pay providers (dentists) for medical care (dental care) expenses, and the proportion used to pay for plan administration. The provider payment method percentages for TDN are approximately 47% discounted fee-for-service and approximately 53% capitated.

TDN-DISCLOSURE 12/13 Eff. 1/1/14

A. METHODS OF PAYING PHYSICIANS

Terms

This table shows definitions of how insurance carriers may pay physicians (or other providers) for your health care services with a simple example of how each payment mechanism works.

Case Rate

Bonus

DiscountedFee-for- Service

Fee-for-Service

Salary

Capitation

The Dental Network, Inc.10455 Mill Run Circle

Owings Mills, Maryland 21117Attention: Member Services

COMPENSATION AND PREMIUM DISCLOSURE STATEMENT

0%

20%

40%

60%

80%

100%

Claims

79%

21%Plan Administration

Para información o preguntas en Español, por favor llame al número del servicio al cliente que aparece en su tarjeta de membresia para su plan Dental.For information or questions in Spanish, please call the Customer Service

number on your Dental Network Membership Card for your dental plan.

10455 Mill Run Circle, RRS# 293 • Owings Mills, MD 21117-4208Telephone 410-847-9060 • Fax 410-339-5360

Toll Free 888-833-8464www.carefirst.com

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