LDP.EOC –FL Individual (08/11)
There are three types of claims: (1) Pre-Service Claims; (2) Post-Service Claims; and (3) Claims Involving Urgent Care. It is
important that Members become familiar with the types of claims that can be submitted to Liberty Dental Plan of Florida, Inc. and
the time frames and other requirements that apply.
A. Urgent Care Claims
Initial Claim - An Urgent Care Claim shall be deemed to be filed on the date received by Liberty Dental Plan of Florida, Inc. We
shall notify the Member of Our benefit determination (whether adverse or not) as soon as possible, taking into account the dental
exigencies, but not later than 72 hours after We receive, either orally or in writing, the Urgent Care Claim, unless the Member fails
to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the dental plan. If
such information is not provided, Liberty Dental Plan of Florida, Inc. shall notify the Member as soon as possible, but not later
than 24 hours after We receive 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. Liberty Dental Plan of Florida, Inc. shall notify the Member of Our benefit determination as soon as possible, but in
no case later than 48 hours after the earlier of:
1. Liberty Dental Plan of Florida, Inc.’s receipt of the specified information; or
2. The end of the period afforded the Member to provide the specified additional information.
If the Member fails to supply the requested information within the 48-hour period, the Claim shall be denied. Liberty Dental Plan
of Florida, Inc. may notify the Member of its benefit determination orally or in writing. If the notification is provided orally, a
written or electronic notification shall be provided to the Member no later than 3 days after the oral notification. A Member or a
provider acting on behalf of the Member, who is not satisfied with the benefit determination, may appeal an Urgent Care Claim to:
Send in writing to LIBERTY Dental Plan
P.O. Box 26110, Santa Ana, CA 92799-6110,
Or
LIBERTY Dental Plan’s Member Services Department facsimile at:
(888) 334-6034,
Or
Contact a LIBERTY Dental Plan Member Services Representative at:
(877) 877-1893,
B. Pre-Service Claims
Initial Claim – A Pre-Service Claim shall be deemed to be filed on the date received by Liberty Dental Plan of Florida, Inc. We
shall notify the Member of Our benefit determination (whether adverse or not) within a reasonable period of time appropriate to
the dental circumstances, but not later than 15 days after We receive the Pre-Service Claim. Liberty Dental Plan of Florida, Inc.
may extend this period one time for up to 15 days, provided that Liberty Dental Plan of Florida, Inc. determines that such an
extension is necessary due to matters beyond control and notifies the Member, before the expiration of the initial 15-day period, of
the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If such an extension
is necessary because the Member failed 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
In the case of a failure by a Member to follow the Plan's procedures for filing a Pre-Service Claim, the Member shall be notified of
the failure and the proper procedures to be followed in filing a Claim for benefits not later than five (5) days following such
failure. The Plan's 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. If the
Member fails to supply the requested information within the 45-day period, the Claim shall be denied. A Member may appeal a
Pre-Service Claim as set forth in the Appeals Section.
C. Post-Service Claims
Initial Claim – A Post-Service Claim shall be deemed to be filed on the date received by Health Plan. Liberty Dental Plan of
Florida, Inc. shall notify the Member of Liberty Dental Plan of Florida, Inc.’s Adverse Benefit Determination within a reasonable
period of time, but not later than 30 days after the Plan receives the Post-Service Claim. The Health Plan may extend this period
one time for up to 15 days, provided that Liberty Dental Plan of Florida, Inc. determines that such an extension is necessary due to
matters beyond Liberty Dental Plan of Florida, Inc.’s control and notifies the Member, before the expiration of the initial 30-day
period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If such an
extension is necessary because the Member failed to submit the information necessary to decide the Post-Service 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. The Plan's period for making the benefit determination shall be