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How Your Covered CA Dental Plan Works

We thank you for considering LIBERTY as your dental Primary Care Provider of choice. The following provides important information about how your plan works. For further assistance, please contact LIBERTY at (888)844-3344 Monday through Friday 8:00 am to 5:00 pm.

Access to Care

On your LIBERTY Dental plan, benefits are provided for in-network services only. If you go to Providers outside of the network, you will have to pay all the cost, unless you received pre-approval from LIBERTY or you had Emergency Dental Care and are unable to reach your Primary Care Provider.

If Your PCD is not available, or if You are out of the area and cannot contact LIBERTY for assistance in locating another contracted Dental Office, contact any licensed dentist to receive emergency care. LIBERTY will reimburse You for covered dental expenses up to a maximum of seventy-five dollars ($75), less applicable Co-payments. You should notify LIBERTY as soon as possible after receipt of Emergency Dental Services, preferably within 48 hours. If it is determined that Your treatment was not due to a dental emergency, the services of any Non-Participating Provider will not be covered.

Your Primary Care Provider will provide for all of your dental care needs, including referring you to a specialist should it be necessary. After you join LIBERTY Dental plan, you may choose any Primary Care Provider within our network. To find a Primary Care Provider nearest you, simply contact our Member Services Department toll-free at (888)844-3344.

You may also review a listing of dentists near you.

Balance Billing

Balance billing is when a provider bills you for the difference between what they bill, and the amount covered by the plan.

There is no balance billing on your Family Dental HMO Plan. LIBERTY has contracted with network providers to accept member copayments as payment in full. Member copayments are payable to the dental office at the time you receive services and are subject to Out-of-Pocket Maximums if the services are covered as a Pediatric benefit.

Pediatric benefits apply for Enrollees ages 0 to the age of 19. Adult benefits are not subject to Out-of-Pocket Maximums. There may be other costs incurred for optional and non-covered services that do not apply toward Out-of-Pocket Maximums. For more details, please review your Schedule of Benefits.

Submitting Claims

LIBERTY contracts with in-network providers to accept member copayments as payment in full and to bill LIBERTY directly for services rendered. If you pay a bill for covered Emergency Dental Care, you may submit a copy of the paid bill to LIBERTY Dental Plan, Claims Department, PO Box 26110, Santa Ana, CA 92799-6110. Include a copy of the claim from the Provider’s office or a legible statement of services/invoice. Please forward to LIBERTY the following information along with your claim:

  • Your membership information
  • Individual’s name that received the Emergency Dental Services
  • Name and address of the dentist providing the Emergency Dental Service.
  • A statement explaining the circumstances surrounding the emergency visit.

If additional information is needed, you will be notified in writing. If any part of your claim is denied you will receive a written explanation of benefits (EOB) within 30 days of LIBERTY Dental Plan’s receipt of the claim.

Claims for Emergency Dental Care must be submitted to LIBERTY as soon as possible after receipt of Emergency Dental Services, preferably within 48 hours. For further assistance, please contact LIBERTY at (888) 844-3344, Monday through Friday 8:00 am to 5:00 pm.

Grace Periods for Individual Dental Plan Enrollees

LIBERTY’s Family Dental HMO Plan has a grace period, which is a period of days you must make the necessary premium payment before your coverage is termed.

This plan has a one-month grace period. This means that if any required premium is not paid on or before the date it is due, it may be paid during the period immediately following the premium due date. Your coverage will stay in effect during the grace period. If payment is not received by the end of the grace period, termination for non-payment will be effective on midnight of the last day of the grace period month for which premiums were last received.

Retroactive Denials of Claims

LIBERTY may deny a previously paid claim if your coverage has been retroactively terminated. In this situation, only claims paid for services performed after your termination date will be denied due to not being eligible for services; and your provider may directly bill you for the costs of services. You and your provider will be notified of a retroactive denial through a written Explanation of Benefits (EOB).

While timely premium payment is the best way to avoid a retroactive denial of a claim, it is also a standard that network providers contact LIBERTY to verify eligibility at the time of your dental appointment. For information about your member rights and responsibilities, please refer to your Evidence of Coverage.

Seeking a Refund

If duplicate payment has been sent, you may contact LIBERTY about your payment at (888) 844-3344, Monday through Friday 8:00 am to 5:00 pm.

Medical Necessity

Medical Necessity or Medically Necessary: A Covered Service that meets Plan guidelines for appropriateness and reasonableness by virtue of a clinical review of submitted information. Covered Services may be reviewed for Medical Necessity prior to or after rendering. Payment for services occurs for Covered Services that are deemed Medically Necessary by the Plan.

If a service requires proof of medical necessity, your treating dentist will include the appropriate documentation at the time a claim is submitted. Services may not be covered if the recommended treatment does not meet the plan’s requirements for medical necessity, appropriateness, dental care setting, or level of care or effectiveness, or is not a covered service.

Services determined to be unnecessary, or which do not meet accepted standards of dental practice are not covered and cannot be billable to the member by a contracted dentist unless the dentist notified the member of his/her financial liability prior to treatment and the member chooses to receive the treatment.

Pre-authorizations

No prior benefit authorization is required in order to receive dental services from your Primary Care Provider. Your Primary Care Provider has the authority to make most coverage determinations. The coverage determinations are achieved through comprehensive oral evaluations which are covered by your plan. Your Primary Care Provider is responsible for communicating the results of the comprehensive oral evaluation and advising of available benefits and associated cost.

If you need to be seen by a specialist, LIBERTY Dental Plan does require prior benefit authorization. Your Primary Care Provider is responsible for obtaining authorization for you to receive specialty care.

Once a specialty referral is processed, the Member, the referring Primary Care Provider who originally submitted the referral, and the Specialist receive a copy of the approved referral which includes the services approved, the Member Copayment and the amount we will pay the Specialist (according to their contracted fees). Once the services have been performed by the Specialist, the Specialist will send the Plan a claim form and we will pay the Specialist directly for the approved services.

Explanation of Benefits

An Explanation of Benefits (EOB) is a statement that explains which services were paid on your behalf, the amount your plan covered, and the copay that was due and paid at the time of the office visit. EOBs are sent by mail within thirty (30) days of LIBERTY’s receipt of a claim.

If any part of your claim is denied you will receive a written EOB within thirty (30) days of LIBERTY Dental Plan’s receipt of the claim that includes:

  • The reason for the denial.
  • Reference to the Evidence of Coverage provisions on which the denial is based.
  • Notice of your right to request reconsideration of the denial, and an explanation of the grievance procedures.

How to Read an EOB

LIBERTY’s EOBs have three main sections:

  • Claim information is provided at the top and includes the subscriber and patient name, ID number, claim number, the dentist’s name and the date the claim was reviewed.
  • Coverage information includes a list of services the provider billed for by the Date of Service (DOS) and the American Dental Association Code along with the description of the service, the tooth, surface and quantity and the Member Co-pay that was paid at the time of the office visit.
  • Below the totaled amounts is the Service Line Explanation. This section includes any additional information, including reasons for claim denials.

Coordination of Benefits

The coordination of benefits is a process that ensures that the payment of services is not paid multiple times when one person has several dental plans. This can include situations where a child is enrolled on two different dental plans because each parent has his or her own separate dental policy.

As a LIBERTY Member, You will always receive Your Benefits. LIBERTY does not consider Your Individual Plan secondary to any other coverage You might have. You are entitled to receive benefits as listed in this EOC document despite any other coverage You might have in addition. However, any Covered California coverage that You have that is embedded into a full service health plan will act as the primary payor when You have a supplemental pediatric dental benefit through a family benefit plan.

 

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California

How Your Covered CA Dental Plan Works

We thank you for considering LIBERTY as your dental Primary Care Provider of choice. The following provides important information about how your plan works. For further assistance, please contact LIBERTY at (888)844-3344 Monday through Friday 8:00 am to 5:00 pm.

Access to Care

On your LIBERTY Dental plan, benefits are provided for in-network services only. If you go to Providers outside of the network, you will have to pay all the cost, unless you received pre-approval from LIBERTY or you had Emergency Dental Care and are unable to reach your Primary Care Provider.

If Your PCD is not available, or if You are out of the area and cannot contact LIBERTY for assistance in locating another contracted Dental Office, contact any licensed dentist to receive emergency care. LIBERTY will reimburse You for covered dental expenses up to a maximum of seventy-five dollars ($75), less applicable Co-payments. You should notify LIBERTY as soon as possible after receipt of Emergency Dental Services, preferably within 48 hours. If it is determined that Your treatment was not due to a dental emergency, the services of any Non-Participating Provider will not be covered.

Your Primary Care Provider will provide for all of your dental care needs, including referring you to a specialist should it be necessary. After you join LIBERTY Dental plan, you may choose any Primary Care Provider within our network. To find a Primary Care Provider nearest you, simply contact our Member Services Department toll-free at (888)844-3344.

You may also review a listing of dentists near you.

Balance Billing

Balance billing is when a provider bills you for the difference between what they bill, and the amount covered by the plan.

There is no balance billing on your Family Dental HMO Plan. LIBERTY has contracted with network providers to accept member copayments as payment in full. Member copayments are payable to the dental office at the time you receive services and are subject to Out-of-Pocket Maximums if the services are covered as a Pediatric benefit.

Pediatric benefits apply for Enrollees ages 0 to the age of 19. Adult benefits are not subject to Out-of-Pocket Maximums. There may be other costs incurred for optional and non-covered services that do not apply toward Out-of-Pocket Maximums. For more details, please review your Schedule of Benefits.

Submitting Claims

LIBERTY contracts with in-network providers to accept member copayments as payment in full and to bill LIBERTY directly for services rendered. If you pay a bill for covered Emergency Dental Care, you may submit a copy of the paid bill to LIBERTY Dental Plan, Claims Department, PO Box 26110, Santa Ana, CA 92799-6110. Include a copy of the claim from the Provider’s office or a legible statement of services/invoice. Please forward to LIBERTY the following information along with your claim:

  • Your membership information
  • Individual’s name that received the Emergency Dental Services
  • Name and address of the dentist providing the Emergency Dental Service.
  • A statement explaining the circumstances surrounding the emergency visit.

If additional information is needed, you will be notified in writing. If any part of your claim is denied you will receive a written explanation of benefits (EOB) within 30 days of LIBERTY Dental Plan’s receipt of the claim.

Claims for Emergency Dental Care must be submitted to LIBERTY as soon as possible after receipt of Emergency Dental Services, preferably within 48 hours. For further assistance, please contact LIBERTY at (888) 844-3344, Monday through Friday 8:00 am to 5:00 pm.

Grace Periods for Individual Dental Plan Enrollees

LIBERTY’s Family Dental HMO Plan has a grace period, which is a period of days you must make the necessary premium payment before your coverage is termed.

This plan has a one-month grace period. This means that if any required premium is not paid on or before the date it is due, it may be paid during the period immediately following the premium due date. Your coverage will stay in effect during the grace period. If payment is not received by the end of the grace period, termination for non-payment will be effective on midnight of the last day of the grace period month for which premiums were last received.

Retroactive Denials of Claims

LIBERTY may deny a previously paid claim if your coverage has been retroactively terminated. In this situation, only claims paid for services performed after your termination date will be denied due to not being eligible for services; and your provider may directly bill you for the costs of services. You and your provider will be notified of a retroactive denial through a written Explanation of Benefits (EOB).

While timely premium payment is the best way to avoid a retroactive denial of a claim, it is also a standard that network providers contact LIBERTY to verify eligibility at the time of your dental appointment. For information about your member rights and responsibilities, please refer to your Evidence of Coverage.

Seeking a Refund

If duplicate payment has been sent, you may contact LIBERTY about your payment at (888) 844-3344, Monday through Friday 8:00 am to 5:00 pm.

Medical Necessity

Medical Necessity or Medically Necessary: A Covered Service that meets Plan guidelines for appropriateness and reasonableness by virtue of a clinical review of submitted information. Covered Services may be reviewed for Medical Necessity prior to or after rendering. Payment for services occurs for Covered Services that are deemed Medically Necessary by the Plan.

If a service requires proof of medical necessity, your treating dentist will include the appropriate documentation at the time a claim is submitted. Services may not be covered if the recommended treatment does not meet the plan’s requirements for medical necessity, appropriateness, dental care setting, or level of care or effectiveness, or is not a covered service.

Services determined to be unnecessary, or which do not meet accepted standards of dental practice are not covered and cannot be billable to the member by a contracted dentist unless the dentist notified the member of his/her financial liability prior to treatment and the member chooses to receive the treatment.

Pre-authorizations

No prior benefit authorization is required in order to receive dental services from your Primary Care Provider. Your Primary Care Provider has the authority to make most coverage determinations. The coverage determinations are achieved through comprehensive oral evaluations which are covered by your plan. Your Primary Care Provider is responsible for communicating the results of the comprehensive oral evaluation and advising of available benefits and associated cost.

If you need to be seen by a specialist, LIBERTY Dental Plan does require prior benefit authorization. Your Primary Care Provider is responsible for obtaining authorization for you to receive specialty care.

Once a specialty referral is processed, the Member, the referring Primary Care Provider who originally submitted the referral, and the Specialist receive a copy of the approved referral which includes the services approved, the Member Copayment and the amount we will pay the Specialist (according to their contracted fees). Once the services have been performed by the Specialist, the Specialist will send the Plan a claim form and we will pay the Specialist directly for the approved services.

Explanation of Benefits

An Explanation of Benefits (EOB) is a statement that explains which services were paid on your behalf, the amount your plan covered, and the copay that was due and paid at the time of the office visit. EOBs are sent by mail within thirty (30) days of LIBERTY’s receipt of a claim.

If any part of your claim is denied you will receive a written EOB within thirty (30) days of LIBERTY Dental Plan’s receipt of the claim that includes:

  • The reason for the denial.
  • Reference to the Evidence of Coverage provisions on which the denial is based.
  • Notice of your right to request reconsideration of the denial, and an explanation of the grievance procedures.

How to Read an EOB

LIBERTY’s EOBs have three main sections:

  • Claim information is provided at the top and includes the subscriber and patient name, ID number, claim number, the dentist’s name and the date the claim was reviewed.
  • Coverage information includes a list of services the provider billed for by the Date of Service (DOS) and the American Dental Association Code along with the description of the service, the tooth, surface and quantity and the Member Co-pay that was paid at the time of the office visit.
  • Below the totaled amounts is the Service Line Explanation. This section includes any additional information, including reasons for claim denials.

Coordination of Benefits

The coordination of benefits is a process that ensures that the payment of services is not paid multiple times when one person has several dental plans. This can include situations where a child is enrolled on two different dental plans because each parent has his or her own separate dental policy.

As a LIBERTY Member, You will always receive Your Benefits. LIBERTY does not consider Your Individual Plan secondary to any other coverage You might have. You are entitled to receive benefits as listed in this EOC document despite any other coverage You might have in addition. However, any Covered California coverage that You have that is embedded into a full service health plan will act as the primary payor when You have a supplemental pediatric dental benefit through a family benefit plan.