In the event you require Emergency Dental Care, contact your Primary Care
Dentist to schedule an immediate appointment. For urgent or unexpected
dental conditions that occur after-hours or on weekends, contact your
Primary Care Dentist for instructions on how to proceed.
If after you contact your Primary Care Dentist and are advised that your
Primary Care Dentist is not available, simply contact any licensed dentist to
receive care. Liberty Dental will reimburse you for dental expenses up to a
maximum of seventy-five dollars ($75), less applicable co-payments.
The Plan provides coverage for emergency dental services only if the
services are required to alleviate severe pain or bleeding or if an enrollee
reasonably believes that the condition, if not diagnosed or treated, may lead
to disability, dysfunction or death.
Emergency Dental Service and care include (and are covered by
LIBERTY Dental Plan), as defined in the California Health & Safety Code,
a dental screening, examination, evaluation by dentist or dental specialist to
determine if an emergency dental condition exists, and to provide care that
would be acknowledged as within professionally recognized standards of
care and in order to alleviate any emergency symptoms in a dental office.
Medical and/or psychiatric emergencies are not covered by LIBERTY
Dental Plan if the services are rendered in a hospital setting which are
covered by a Medical Plan, or if LIBERTY Dental Plan determines the
services were not dental in nature.
Emergency services and care (and are not covered by LIBERTY Dental
Plan) also means an additional screening and examination, and evaluation
by a physician, or other personnel to the extent permitted by applicable law
and within the scope of licensure and clinical privileges, to determine if a
psychiatric emergency medical condition exists, and the care and treatment
necessary to relieve or eliminate the psychiatric emergency medical
condition, within the capability of the facility. LIBERTY Dental Plan does
not provide coverage for such emergency services and care.
Reimbursement for Emergency Dental Care: If the requirements in the
section titled “Emergency Dental Care” are satisfied, LIBERTY Dental Plan
will cover up to $75 of such services per calendar year. If you pay a bill for
covered Emergency Dental Care, submit a copy of the paid bill to LIBERTY
Dental Plan, Claims Department, P.O. Box 26110, Santa Ana, CA 92799-
110. Please include a copy of the claim from the provider’s office or a
legible statement of services/invoice. Please forward to LIBERTY Dental
Plan with the following information:
Your membership information.
Individual’s name that received the emergency services.
EOC – Group (No Dependents)