GROUP EVIDENCE OF  
COVERAGE  
AND DISCLOSURE FORM  
LIBERTY Dental Plan of California, Inc.  
This Evidence of Coverage and Disclosure Form provides the following  
information:  
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The advantages of your LIBERTY Dental Plan and how to use your  
benefits  
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An evidence of coverage  
How to enroll in the plan  
Answers to your frequently asked questions  
Information required by the state of California in regards to your dental plan.  
STATE OF CALIFORNIA DEPARTMENT OF MANAGED HEALTH  
CARE (DMHC) COMPLAINT PROCEDURE  
The DMHC has established a toll-free number for you as a member to utilize  
should you have a complaint against a health care service plan. This number  
is 888-HMO-2219. As a member you may file a complaint against  
LIBERTY Dental Plan; however, you may only do so after contacting your  
plan directly to utilize its complaint resolution process.  
A member may immediately file a complaint with the California DMHC in  
the event of a dental emergency situation. In addition a member may also  
file a complaint in the event that the plan does not satisfactorily resolve the  
complaint (grievance) within thirty (30) days of filing with your health care  
service plan.  
This brochure will provide you with the information you should know about  
your Dental Plan. It explains clearly how it works and the many advantages  
LIBERTY Dental Plan provides you.  
LIBERTY Dental Plan BENEFITS ARE EASY TO USE  
Dental Benefits should be simple to use for you and your family. Our plans  
offer comprehensive dental coverage without claim forms, prohibitive  
deductibles, or restrictive annual maximums.  
The difference with LIBERTY Dental Plan: good provider selection, clear  
communication, and, most importantly, requiring the dentists to perform to  
the standards of the participating contract they signed with the plan.  
That is the difference in LIBERTY Dental Plan. We have open  
communication and provide excellent support to our panel of participating  
dentists.  
Our goal is to provide you with the comprehensive dental benefits you  
purchased. We pledge to support your choice of LIBERTY Dental Plan by  
giving you confidence through the excellent customer service you deserve.  
After all, isn’t that what it is all about?  
At LIBERTY Dental Plan, you get quality dental benefits at a very  
reasonable price.  
THE LIBERTY Dental Plan ADVANTAGES  
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No Claim Forms  
No Deductibles or Maximums  
Low Out-of-Pocket Costs  
Selection of Pre-screened Dentists & Specialists  
Multi-Lingual Provider Network  
Change Dentist Selection Any Time  
Orthodontic Coverage  
Most Pre-existing Conditions Covered  
Network Dentists Provide 24-hour Access to Emergency Care  
Toll-Free Member Assistance Lines  
The hearing and speech impaired may use the California Relay Service  
toll-free telephone numbers (800) 735-2929 (TTY) or (888) 877-5378  
(TTY) to contact the department.  
This booklet includes your Evidence of Coverage and Disclosure From.  
Please keep this together with your records and your Schedule of Benefits,  
which includes the member co-payments, exclusions and limitations of the  
benefits and additional provisions of your dental plan.  
This is a summary of how your LIBERTY Dental Plan dental plan works.  
This Evidence of Coverage and Disclosure Form will assist you in properly  
understanding your dental plan.  
EOC – Group (No Dependents)  
Revised 04/11  
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This Evidence of Coverage and Disclosure Form constitutes only a summary  
of the dental plan. The Agreement between LIBERTY Dental Plan of  
California, Inc. and the Employer must be consulted to determine the exact  
terms and conditions of coverage.  
SECOND OPINION  
At no cost to you, you may request a second dental opinion, when  
appropriate, by directly contacting Member Services either by calling the  
toll-free number (888) 703-6999 or by writing to: LIBERTY Dental Plan,  
P.O. Box 26110, Santa Ana, CA 92799-6110. Your primary care dentist  
may also request a second dental opinion on your behalf by submitting a  
Standard Specialty or Orthodontic Referral Form with appropriate x-rays.  
All requests for a second dental opinion are approved by LIBERTY Dental  
Plan within five (5) days of receipt of such request. Upon approval,  
LIBERTY Dental Plan will make the appropriate second dental opinion  
arrangements and advise the attending dentist of your concerns. You will  
then be advised of the arrangement so an appointment can be scheduled.  
Upon request, you may obtain a copy of LIBERTY Dental Plan’s policy  
description for a second dental opinion.  
YOUR DENTAL PLAN  
LIBERTY Dental Plan has been providing and administering dental benefits  
in California for over twenty-five (25) years. LIBERTY Dental Plan is in  
the on-going process of enhancing our statewide panel of participating  
dentists and specialists to accommodate the needs of our Subscribers.  
Our goal is to provide Californians with appropriate dental benefits,  
delivered by highly qualified dental professionals in a comfortable setting.  
All of LIBERTY Dental Plan’s contracted private practice dentists have  
undergone strict credentialing procedures, background checks and office  
evaluations. In addition, each LIBERTY Dental Plan participating dentist  
must adhere to strict contractual guidelines. All dentists are pre-screened  
and reviewed on a regular basis. Our Provider Relations Department  
conducts a quality assessment program which includes ongoing contract  
management to assure compliance with continuing education, accessibility  
for members, appropriate diagnosis and treatment planning. In addition, we  
conduct random surveys of member groups to evaluate their view of the  
dental plan overall. This includes both Primary Care Dentists (General  
Dentists) and Specialists. Your Primary Care Dentist will provide for all of  
your dental care needs, including referring you to a specialist should it be  
necessary.  
EOC – Group (No Dependents)  
Revised 04/11  
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When you join LIBERTY Dental Plan, you must choose a Primary Care  
Dentist. If you desire to make a change, you may do so at any time. (Please  
note: Your request to change dentists will not be processed if you have an  
outstanding balance with your current dentist.) Simply contact our Member  
Services Department toll-free at (888) 703-6999 or submit a change request  
in writing to: LIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA  
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2799-6110. Your requested change to a Primary Care Dentist will be in  
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effect on the first (1 ) day of the following month if the change is received  
by LIBERTY Dental Plan prior to the twentieth (20 ) of the current month.  
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NOTE: Those enrolling in plans CA80, CA90, Prestige II or Prestige III are  
not required to select a Primary Care Dentist at the point of enrollment. To  
access care under one of these plans, simply contact a LIBERTY Dental Plan  
provider who is contracted to provide services under your selected plan for  
an appointment. The Primary Care Dentist will then contact LIBERTY  
Dental Plan to verify your eligibility.  
All services and benefits described in this publication are covered only if  
provided by a contracted LIBERTY Dental Plan participating Primary Care  
Dentist or Specialist. The only time you may receive care outside the  
network is for emergency dental services as described herein under  
“Emergency Dental Care”.  
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES  
FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL  
RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU  
UPON REQUEST.  
WHO IS ELIGIBLE TO ENROLL  
You are eligible to enroll in LIBERTY Dental Plan. You must live in the  
plan service area. Prospective Group Subscribers must also meet their  
employer’s eligibility requirements.  
WHAT IF I HAVE A QUESTION ABOUT MY DENTAL PLAN  
LIBERTY Dental Plan provides toll-free telephone access to covered  
members. Just call our Member Services Department if you have a question  
or inquiry. Our Member Service representatives will be glad to provide you  
information or resolve your inquiry. Call (888) 703-6999, between the  
hours of 8:00 a.m. to 5:00 p.m. (PST) Monday through Friday.  
HOW DO I RECEIVE CARE  
You must choose a Primary Care Dentist when you enroll in the plan. (See  
note under “Your Dental Plan” regarding selecting a Primary Care Dentist  
EOC – Group (No Dependents)  
Revised 04/11  
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for plans CA80, CA90, Prestige II and Prestige III.) This dentist will be  
responsible for providing the dental care needs for you, including referring  
you to a specialist should it be necessary (remember you can change dentists  
at anytime by calling LIBERTY Dental Plan or by submitting a request for  
provider change in writing). A directory of participating dentists will be sent  
to you upon request.  
You may select any LIBERTY Dental Plan contracted provider accepting  
your plan. However, you may want to consider a choice convenient to your  
residence or work.  
As a member, you should be able to make an appointment to be seen for  
dental hygiene and routine care within three weeks of the date of your  
request. This is based upon available schedule times.  
HOW TO MAKE AN APPOINTMENT  
After completing your enrollment form, you are eligible to receive care on  
the first of the month following LIBERTY Dental Plan’s receipt of your  
enrollment application and notification of your eligibility by your employer  
or group administrator.  
Be sure to identify yourself as a member of LIBERTY Dental Plan when you  
call the dentist for an appointment. We also suggest that you keep this  
material handy and take this information and the Schedule of Benefits and  
applicable Limitations and Exclusions with you when you go to your  
appointment. You can then reference benefits and applicable co-payments  
which are the out-of-pocket costs associated with your plan.  
HOW DO I FILE A CLAIM FORM  
There are no claim forms to worry about with your plan. LIBERTY Dental  
Plan prepays participating Primary Care Dentists in advance for covered  
services (less applicable co-payments of your plan).  
IS PRIOR BENEFIT AUTHORIZATION NECESSARY  
No prior benefit authorization is required in order to receive dental services  
from your Primary Care Dentist. The Primary Care Dentist 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 Dentist is responsible for communicating the  
results of the comprehensive oral evaluation and advising of available  
benefits and associated cost.  
EOC – Group (No Dependents)  
Revised 04/11  
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If your Primary Care Dentist encounters a situation that requires the services  
of a specialist, LIBERTY Dental Plan requires a preauthorization  
submission, which will be responded to within five (5) business days of  
receipt, unless urgent.  
If you or your Primary Care Dentist encounter an urgent condition in which  
there is an imminent and serious threat to your health, including but not  
limited to the potential loss of life, limb, or other major body function, or the  
normal timeframe for the decision making process as described above would  
be detrimental to your life or health, the response to the request for referral  
should not exceed seventy-two (72) hours from the time of receipt of such  
information. The decision to approve, modify or deny will be communicated  
to the Primary Care Dentist within twenty-four (24) hours of the decision. In  
cases where the review is retrospective, the decision shall be communicated  
to the enrollee within thirty (30) days of the receipt of the information.  
In the event that you need to be seen by a specialist, LIBERTY Dental Plan  
does require prior benefit authorization. Your Primary Care Dentist is  
responsible for obtaining authorization for you to receive specialty care.  
In the instance that there are no contracted specialty providers listed in the  
Provider Directory for your county, benefits will be provided to you as if the  
specialty providers were contracted with the plan.  
If your specialty referral preauthorization is denied or you are dissatisfied  
with the preauthorization, please refer to Page 9, GRIEVANCE  
PROCEDURES.  
INDEPENDENT MEDICAL REVIEW  
In cases which result in the denial of the preauthorization requests by a  
LIBERTY Dental Plan Provider, Subscribers may request a form for the  
independent medical review of their case by contacting LIBERTY Dental  
Plan at (888) 703-6999 or writing to: LIBERTY Dental Plan, P.O. Box  
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6110, Santa Ana, CA 92799-6110. You may also request the forms from  
the Department of Managed Health Care. The Department of Managed  
Health Care may be reached at (888) HMO-2219 or by visiting their website  
at: http://www.hmohelp.ca.gov.  
EMERGENCY DENTAL CARE  
All affiliated LIBERTY Dental Plan Primary Care Dental offices provide  
availability of emergency dental care services twenty-four (24) hours per  
day, seven (7) days per week.  
EOC – Group (No Dependents)  
Revised 04/11  
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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-  
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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)  
Revised 04/11  
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Name and address of the dentist providing the emergency  
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 that  
includes:  
The reason for the denial.  
Reference to the pertinent 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.  
Please refer to Page 9, GRIEVANCE PROCEDURES.  
CONTINUITY OF CARE  
Current Members:  
Current Members may have the right to the benefit of completion of care  
with their terminated provider for certain specified dental conditions. Please  
call the Plan at (888) 703-6999 to see if you may be eligible for this benefit.  
You may request a copy of the Plan's Continuity of Care Policy. You must  
make a specific request to continue under the care of your terminated  
provider. We are not required to continue your care with that provider if you  
are not eligible under our policy or if we cannot reach agreement with your  
terminated provider on the terms regarding your care in accordance with  
California law.  
New Members:  
A New Member may have the right to the qualified benefit of completion of  
care with their non-participating provider for certain specified dental  
conditions. Please call the Plan at (888) 703-6999 to see if you may be  
eligible for this benefit. You may request a copy of the Plan's Continuity of  
Care Policy. You must make a specific request to continue under the care of  
your current provider. We are not required to continue your care with that  
provider if you are not eligible under our policy or if we cannot reach  
agreement with your provider on the terms regarding your care in accordance  
with California law. This policy does not apply to new Members of an  
individual subscriber contract.  
LIBERTY DENTAL PLAN MEMBER SERVICES DEPARTMENT  
LIBERTY Dental Plan Member Services provides toll-free customer service  
support Monday through Friday 8:00 a.m. to 5:00 p.m. on