Grimmway Enterprises, Inc - FOR PPO MEMBERS

LIBERTY Dental Plan does not guarantee the availability of any particular dentist. You are free to choose any dentist for treatment, but it is to your advantage to choose a LIBERTY Dental Plan PPO dentist. This is because his or her fees are approved in advance by LIBERTY Dental Plan. LIBERTY Dental Plan PPO providers have agreed to a pre-negotiated amount per covered procedure. The only amount chargeable to the member by an in network provider is the actual member percentage (based on the Plan) of the pre-negotiated amount, deducible amount, amount over calendar year maximum, and non-covered services. Out-of-network providers have no agreement, so the amount chargeable to the member can be any amount over the percentage payable by the Plan. Plan payment is based on the regional usual and customary fee. PPO providers are only available in California, so any claim from a provider outside of California will be paid on the out-of-network payment schedule. You can call LIBERTY Dental Plan at (888) 703-6999 to receive provider information.

If you or your dentist has a pre-treatment benefit estimate for services that are not performed prior to February 1, 2009, please have your dentist re-submit the estimate request to LIBERTY Dental Plan. We will work with you and your dentist to get it processed as soon as possible.