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CALIFORNIA
INDIVIDUAL PLAN
COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM
Contains information for Enrollees covered by an Individual Plan from
LIBERTY Dental Plan of California, Inc.
Interpretation and translation services may be available for Members with limited English proficiency, including translation of
documents into certain threshold languages. To ask for language services call 888-703-6999.
[Spanish (Español)
IMPORTANTE: ¿Puede leer esta noticia? Si no, alguien le puede ayudar a leerla. Además, es posible que reciba esta noticia escrita en
su propio idioma. Para obtener ayuda gratuita, llame ahora mismo al 1-888-703-6999.]
Hereinafter in this document, LIBERTY Dental Plan of California, Inc. may be referred to as “LIBERTY” or “the Plan.”
This COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM constitutes
only a summary of the dental plan. The dental plan contract must be consulted to
determine the exact terms and conditions of coverage.
A specimen of the dental plan contract will be furnished upon request.
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE
CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU
UPON REQUEST.
Section I of this document contains a Benefit Matrix for general reference and comparison of Your Benefits under this plan followed by
an Overview of Your Dental Benefit Plan.
Section II of this document contains definitions of terms used throughout this document.
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I. GENERAL INFORMATION OVERVIEW OF YOUR DENTAL BENEFIT PLAN
BENEFITS MATRIX
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS
AND IS A SUMMARY ONLY. THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE
FORM AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION
OF COVERAGE BENEFITS AND LIMITATIONS.
(A) Deductibles
None
(B) Lifetime Maximums
None
(C) Professional services
An Enrollee may be required to pay a Copayment amount for each procedure as shown
in the Description of Benefits and Copayments, subject to the Limitations and
Exclusions.
Copayments range by category of service.
Examples are as follows:
Diagnostic Services .................................. No Cost - $100.00
Preventive Services .................................. No Cost - $258.00
Restorative Services .................................. No Cost - $500.00
Periodontic Services ................................. No Cost - $685.00
Prosthodontic Services ............................... $10.00 - $850.00
Oral and Maxillofacial Surgery .................. $8.00 - $2,625.00
Orthodontic Services ............................. No Cost - $2,300.00
Note: Some services may not be covered. Certain services may be covered only if
provided by specified Dentists, or may be subject to additional charges. Limitations
apply to the frequency with which some services may be obtained. For example:
bitewing x-rays in conjunction with periodic examinations are limited to one series of
four films in any 6 consecutive month period; Full upper and/or lower denture are not to
be replaced within 36 consecutive months unless the existing denture is unsatisfactory
and cannot be made satisfactory by reline or repair.
(D) Outpatient Services Not Covered
(E) Hospitalization Services Not Covered
(F) Emergency Dental Coverage
The Enrollee may receive a maximum Benefit of up to $75 per emergency for out-of -
area Emergency Services.
(G) Ambulance Services Not Covered
(H) Prescription Drug Services Not Covered
(I) Durable Medical Equipment Not Covered
(J) Mental Health Services Not Covered
(K) Chemical Dependency Services Not Covered
(L) Home Health Services Not Covered
(M) Other Not Covered
Each individual procedure within each category listed above that is covered under the Program has a specific
Copayment, which is shown in the Schedule of Benefits and in the Combined Evidence of Coverage.
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A. HOW TO USE YOUR LIBERTY DENTAL PLAN
This booklet is Your Evidence of Coverage (EOC). It explains what LIBERTY covers and does not cover. Also read Your Schedule of
Benefits (on page 18), which lists co-pays and other fees. Your LIBERTY Dental Plan is an Individual dental plan. To be eligible for
this coverage, You must meet the eligibility requirements as stated in this document.
B. HOW TO CONTACT LIBERTY
Our Member Services Department is here to help You. Call us if You have a question or a problem:
LIBERTY Dental Plan of California, Inc.
P.O. Box 26110
Santa Ana, CA 92799-6110
Member Services (Toll-Free): (888) 703-6999
Website: www.LIBERTYDentalPlan.com
C. LIBERTY’S SERVICE AREA
LIBERTY has a Service Area, which is the entire state of California. This is the area in which LIBERTY provides dental coverage.
You must live or work in the Service Area. You must receive all dental service services within the Service Area, unless You need
emergency or Urgent Care. If You move out of the Service Area You must tell LIBERTY.
D. LIBERTY’S NETWORK
Our network is all the General Dentists and dental Specialists that LIBERTY has contracted with to provide services to our Members.
You must get Your dental services from Your Primary Care Provider and other Providers who are in the network. Call 888-703-6999 to
ask for a LIBERTY Provider Directory or use the website.
If You go to Providers outside the network, You will have to pay all the cost, unless You received pre-approval from LIBERTY or You
had an emergency or You needed Urgent Care away from home. If You are new to LIBERTY or LIBERTY ends Your Provider’s
contract, You can continue to see Your current dentist in some cases. This is called continuity of care (see page 9).
E. YOUR PRIMARY CARE PROVIDER (see page 6)
When You join LIBERTY, in most cases You need to choose a Primary Care Provider to whom You will be assigned. This is usually a
General Dentist who provides Your basic care and coordinates the care You need from other dental specialty Providers.
EXCEPTION: Some LIBERTY plans do not require You to choose and be assigned to a Primary Care Provider. On those plans, You
may access services from any contracted Primary Care Provider in the network. Refer to Your Schedule of Benefits to determine if
Your plan requires You to choose and be assigned to a Primary Care Provider.
F. LANGUAGE AND COMMUNICATION ASSISTANCE (see page 16)
If English is not Your first language, LIBERTY provides interpretation services and translation of certain written materials in Your
preferred language. To ask for language services call 888-703-6999. If You have a preferred language, please notify us of Your
personal language needs by calling 888-703-6999.
G. HOW TO GET DENTAL CARE WHEN YOU NEED IT
Call Your Primary Care Provider first for all Your care, unless it is an emergency.
You usually need a referral and pre-approval to get care from a Provider other than Your Primary Care Provider. See the next
section.
The care must be medically necessary for Your health. Your dentist and LIBERTY follow guidelines and policies to decide if
the care is medically necessary. If You disagree with LIBERTY about whether a service You want is medically necessary,
You can file a Grievance or, in some cases, You may request an Independent Medical Review (see page 15).
The care must be a service that LIBERTY covers. Covered dental services are also called Benefits. To see what services
LIBERTY covers, see the Schedule of Benefits in Appendix I.
H. REFERRALS AND PRE-AUTHORIZATIONS (see page 8)
You need a referral from Your Primary Care Provider and pre-approval from LIBERTY for services to be provided by a Specialist or to
receive a second opinion or to see a dentist who is not in LIBERTY’s network. Pre-approval is also called Pre-Authorization.
Make sure Your Primary Care Provider gives You a referral and gets pre-approval if it is required.
If You do not have a referral and pre-approval when it is required, You will have to pay all of the cost of the service.
You do not need a referral and pre-approval to see Your Primary Care Provider, or to get emergency care or Urgent Care.
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I. EMERGENCY CARE (see page 7)
Emergency care is covered anywhere in the world. If it is an emergency, call 9-1-1 or go to the nearest hospital. It is an emergency if
You reasonably believe that not getting immediate care could be dangerous to Your life or to a part of Your body. Emergency care may
include care for a bad injury, severe pain, or a sudden serious dental illness. Go to Your Primary Care Provider for follow-up care. Do
not go back to the emergency room for follow-up care.
J. URGENT CARE (see page 7)
Urgent care is care that You need soon to prevent a serious health problem. Urgent care is covered anywhere in the world.
K. CARE WHEN YOU ARE OUT OF THE LIBERTY SERVICE AREA (see page 7)
Only Emergency and Urgent Care is covered outside of the LIBERTY Service Area.
L. COSTS (see the “SCHEDULE OF BENEFITSin Appendix I and “What You Pay” on page 9)
The Premium is what You pay to LIBERTY to keep coverage.
A Co-payment is the amount that You must pay to the Provider for a particular covered procedure.
After You pay Your Co-payments, LIBERTY pays for the rest of any covered service.
M. IF YOU HAVE A COMPLAINT ABOUT YOUR LIBERTY DENTAL PLAN (see page 13)
LIBERTY provides a Grievance resolution process. You can file a complaint (also called an appeal or a grievance) with LIBERTY for
any dissatisfaction You have with LIBERTY, Your Benefits, a claim determination, a benefit or coverage determination, Your Provider
or any aspect of Your dental Benefit Plan. If You disagree with LIBERTY’s decision about Your complaint, You can get help from the
State of California’s HMO Help Center. In some cases, the HMO Help Center can help You apply for an Independent Medical Review
(IMR) or file a complaint. IMR is a review of Your case by doctors who are not part of Your health plan.
N. FISCAL SEPARATION OF DECISION MAKING
It is LIBERTY’s policy that all clinical review decisions made by staff and or contractors are based solely on appropriateness of care
and services and the existence of coverage. LIBERTY does not reward or incentivize reviewers for issuing denials for coverage or care,
nor provide incentives that would encourage decisions that result in underutilization.
LIBERTY’s Utilization Management staff annually signs an attestation that review decisions were made based solely on
appropriateness of care and services and existence of coverage.
II. DEFINITIONS OF USEFUL TERMS CONTAINED IN THIS DOCUMENT
The following terms are used in this EOC document:
Authorization: The notification of approval by LIBERTY that You may proceed with treatment requested.
Benefits: Services covered by Your LIBERTY dental plan.
Benefit Plan: The LIBERTY dental product that You purchased to provide coverage for dental services.
Benefit Year: The year of coverage of Your LIBERTY dental plan.
Capitation: Pre-paid payments made by LIBERTY to a Contracted General Dentist Provider to provide services to assigned Members.
Charges: The fees requested for proposed services or services rendered.
Contracting Dentist: A dentist with LIBERTY Members in accordance with LIBERTY’s rules and regulations.
Covered Services: Services listed in this document as a benefit of this dental plan.
Co-payment: Any amount charged to a Member at the time of service for Covered Services. Fixed co-payment amounts are listed in
the Schedule of Benefits.
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Dental Records: Refers to diagnostic aid, intraoral and extra-oral radiographs, written treatment record including but not limited to
progress notes, dental and periodontal chartings, treatment plans, consultation reports, or other written material relating to an
individual’s medical and dental history, diagnosis, condition, treatment, or evaluation.
Dependent: Any eligible Member of a Subscriber’s family who is enrolled in LIBERTY Dental Plan.
Dental Necessity or Dentally 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 Dental Necessity prior to o has signed a
contract to provide services to or after rendering. Payment for services occurs for Covered Services that are deemed Dentally Necessary
by the Plan.
Disputed Dental Service: Any service that is the subject of a dispute filed by either Member or Provider.
Domestic Partner: A person that is in a committed life-sharing relationship with the Member.
Emergency Care / Emergency Dental Service: Emergency Dental Service and care include (and are covered by LIBERTY Dental
Plan) dental screening, examination, evaluation by a 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 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.
Enrollee: see Member.
Exclusion: A statement describing one or more services or situations where coverage is not provided for dental services by the Plan.
General Dentist: A licensed dentist who provides general dental services and who does not identify as a Specialist.
Grievance: Any expression of dissatisfaction; also known as a complaint. See Grievance Section of EOC for pertinent rules,
regulations and processes.
Independent Medical Review (IMR): A California program where certain denied services may be subject to an external review. For
Individual Plans, IMR is only available for medical services.
Individual Plan: A dental Benefit Plan providing coverage for an individual person. A spouse or covered Dependent may also be
included on the same Individual Plan as the Subscriber.
In-Network Benefits: Benefits available to You when You receive services from a Contracted Provider
Member: Subscriber or eligible Dependent(s) who are actually enrolled in the Plan. Also known as Enrollee.
Non-Participating Provider: A dentist that has no contract to provide services for LIBERTY.
Out-of Area Coverage: Benefits provided when You are out of the Plan’s Service Area, or away from Your Primary Care Provider.
Our-of Area Urgent Care: Urgent services that are needed while You are located out of the Service Area or away from Your Primary
Care Provider.
Participating Dental Group, Dental Office, or Provider: A dental facility and its dentists that are under contract to provide services
to LIBERTY Members in accordance with LIBERTY’s rules and regulations.
Plan: LIBERTY Dental Plan of California, Inc.
Pre-Authorization: A document submitted in Your behalf requesting an advance determination and approval to render desired
treatment services for You.
Premium: The fee paid to LIBERTY for this Benefit Plan.
Primary Care Provider: A dentist affiliated with LIBERTY to provide services to covered Members of the Plan. The Primary Care
Dentist is responsible to provide or arrange for needed dental services.
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Professional Services: Dental services or procedures provided by a licensed dentist or approved auxiliaries.
Provider: A contracted dentist providing services under contract with the Plan.
Specialist: A Dentist that has received advanced training in one of the dental specialties approved by the American Dental Association
as a dental specialty, and practices as a Specialist. Examples are Endodontists, Oral and Maxillofacial Surgeon, Periodontists and
Pediatric Dentist.
Subscriber: Member, Enrollee or “You” are equivalent in this document.
Surcharge: An amount charged in addition to a listed Co-payment for a requested service or feature
Terminated Provider: A dentist that formerly delivered services under contract that is no longer associated with the Plan.
Service Area: The counties in California where LIBERTY provides coverage.
Urgent Care: See Emergency Care
Usual Charges: A dentist’s usual charge for a service
You: Pertains to Individual Members.
III. ACCESS TO SERVICES SEEING A DENTIST
LIBERTY Dental Plan contracts with General Dentists and Specialists to provide services covered by Your Plan. Contact us toll-free at
(888) 703-6999 or via our website, www.LIBERTYdentalplan.com
, to find a dentist in Your area. All services and Benefits described
in this publication are covered only if provided by a contracted Primary Care Provider or Specialist. The only time You may receive
care outside the network is for Emergency Dental Services as described herein under “Emergency Dental Care” or “Urgent Care.”
A. FACILITIES
LIBERTY makes available Primary Care Providers (General Dentist) and Specialists throughout the state of California within a
reasonable distance from Your home or workplace. Contact LIBERTY toll-free at 888-703-6999 or via website at
www.LIBERTYdentalplan.com to find a dentist in Your area.
Our goal is to provide You 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 participating dentist must adhere to strict contractual guidelines. All dentists are pre-screened
and reviewed on a regular basis. We conduct a quality assessment program which includes ongoing contract management to assure
compliance with continuing education, accessibility for Members, appropriate diagnosis and treatment planning. Your Primary Care
Dentist will provide for all of Your dental care needs including referring You to a Specialist, should it be necessary. All Enrollees shall
have a residence or workplace within thirty (30) minutes or fifteen (15) miles of a Primary Care Dental office.
B. DENTAL HEALTH EDUCATION
For further information on using Your dental Benefits, please see the website at www.LIBERTYdentalplan.com
. The website contains
other helpful information on dental and oral health information to assist You in assessing Your risk of future dental disease, home care
measures You can take to keeping Your teeth and mouth healthy. Further, the condition of Your teeth, gums and mouth can have
profound effect on Your total overall health. Information on how Your oral health can affect Your overall health conditions such as
cardiovascular conditions, diabetes, obesity, pregnancy and pre- and peri-natal health as well as other health conditions can be found on
the website.
C. CHOICE OF PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHAT PROVIDER DENTAL
SERVICES MAY BE OBTAINED
1. General Dentistry/Primary Care Dentistry: Except as noted below under Exception, when You join
LIBERTY Dental Plan, You must choose a Primary Care Dentist to which You will be assigned. Your assigned
Primary Care Provider is responsible for coordinating any specialty care dental services You might need. You must
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obtain general dental services from Your assigned Primary Care Provider. Your assigned Primary Care Provider will
share information with any Specialist to coordinate Your overall care.
Unless otherwise noted in the Exception below, if You do not select a Primary Care Provider, one will be chosen for You by
LIBERTY upon Your enrollment and You will be notified of this assignment.
2. Changing Primary Care Dentists: You may contact LIBERTY at any time to change Your Primary Care
Provider. Contact our Member Services Department toll-free at (888) 703-6999 (during regular business hours) or
submit a change request in writing to: LIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA, 92799-6110. Your
requested change to a Primary Care Dentist will be in effect on the first (1
st
) day of the following month if the change
is received by LIBERTY Dental Plan prior to the twentieth (20
th
) of the current month. Your request to change
dentists will not be processed if You have an outstanding balance with Your current dentist.
3. Exception: To determine if Your plan requires provider office pre-assignment, please refer to the first page
of Your Schedule of Benefits beginning on page 18. If Your plan does not require provider office pre-assignment, in
order to access care under one of those plans, contact a LIBERTY Dental Plan provider who is contracted to provide
services under Your selected plan for an appointment. The Primary Care Provider will then contact LIBERTY Dental
Plan to verify Your eligibility. You may obtain information on contracted providers by phone or website. Refer to
Your Schedule of Benefits to determine if Your plan requires You to choose and be assigned to a Primary Care
Provider, or if You may access services from any contracted Primary Care Provider in the network.
4. Care from a Dental Specialist: You may only obtain care from a dental Specialist only after Your referral
to a Specialist has been submitted by Your assigned Primary Care Provider to LIBERTY for approval. You may only
receive services from a dental Specialist that have been Pre-Authorized for You by LIBERTY. Your Specialist will
submit a Pre-Authorization for services to LIBERTY for Pre-Authorization.
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”.
D. URGENT CARE
Urgent care is care You need within 24 to 72 hours, and are services needed to prevent the serious deterioration of Your dental health
resulting from an unforeseen illness or injury for which treatment cannot be delayed. The Plan provides coverage for urgent 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. Contact Your assigned Primary Care Provider for Your urgent
needs during business hours or after hours. If You are out of the area, You may contact LIBERTY for referral to another contracted
dentist that can treat Your urgent condition. For after-hours Urgent Care outside the Service Area, You may proceed to find a dentist
who can assist You. LIBERTY will reimburse You for covered dental expenses up to a maximum of seventy-five dollars ($75) less
applicable Co-payments per calendar year. You should notify LIBERTY as soon as possible after receipt of Urgent Care services
preferable within 48 hours. If it is determined that Your treatment was not due to a dental emergency, the services of any non-
contracted dentist will not be covered.
E. EMERGENCY DENTAL CARE
All affiliated LIBERTY Dental Plan Primary Care Dental offices provide availability of Emergency Dental Services twenty-four (24)
hours per day, seven (7) days per week. 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. If You encounter a dental emergency condition or situation 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, You may also wish to
consider contacting the “911” emergency response system. The use of such system should be done so responsibly.
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 Your Primary Care Dentist is not available, or if You are out of the area and cannot contact LIBERTY to redirect You to 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-contracted dentist will not be covered.
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Emergency Dental Service (covered by Your LIBERTY Dental Plan) is defined in the California Health & Safety Code, to include a
dental screening, examination, evaluation by dentist or Specialist to determine if an emergency dental condition exists, and to provide
care that would be acknowledged as within professionally recognized standards of dental care and in order to alleviate any emergency
symptoms in a dental office.
Reimbursement for Emergency Dental Care: If the requirements in the section titled “Emergency Dental Care” are satisfied,
LIBERTY 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, 92799-6110. 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 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 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. You may also
refer to the EOC section, GRIEVANCE PROCEDURES below.
F. SECOND OPINION
At no cost to You, You may request a second dental opinion diagnosis for services covered under Your plan 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 Provider 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
processed by LIBERTY Dental Plan within five (5) business days of receipt of the request, or within 72 hours of receipt for cases
involving an an imminent and serious threat to Your health including, but not limited to, severe pain, potential loss of life, limb, or
major bodily function. 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.
G. REFERRAL TO A SPECIALIST
In the event that You need to be seen by a Specialist, LIBERTY Dental Plan requires that Your Primary Care Provider obtain
Authorization for You to receive specialty care. The Pre-Authorization submission will be responded to within five (5) business days of
receipt, unless urgent.
If Your specialty referral Pre-Authorization is denied or You are dissatisfied with the Pre-Authorization, You have the right to file a
Grievance. See EOC Section X, “GRIEVANCE PROCEDURES”, on page 14.
If Your Primary Care Provider has difficulty locating a Specialist in Your area, contact LIBERTY Member Services for assistance in
locating a Specialist.
Any Specialty services deemed necessary and pre-approved by LIBERTY as medical necessary services are for the treatment prescribed
by the Specialist that proposed the treatment. Treatment plans are not transferrable to another Specialist unless the subsequent
Specialist agrees with the treatment proposed by the prior Specialist.
If You are unable to access in-network Specialty services in a reasonable time period or location (as determined by published access
requirement), You may contact Member Services for assistance in finding another in-network Specialist, or to make arrangements to
access care from an out-of-network Specialist. All Specialty care must be pre-approved for coverage determination, medical necessity
and/or appropriateness to the presenting conditions. In such cases, You would be financially responsible only for the listed copayment
for covered services. You would also be financially responsible for the provider’s usual fee for any non-covered, elective services, or
for services not deemed to be medically necessary upon review by LIBERTY.
H. AUTHORIZATION, MODIFICATION OR DENIAL OF SERVICES
No prior benefit Authorization is required in order to receive general 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
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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.
Referral to a Specialist is the responsibility of Your assigned contracted Primary Care Provider (see Referral to a Specialist above).
Specialty services proposed by any Specialist to whom You are referred must be Pre-Authorized prior to rendering care, except for
Emergency Dental Services (Emergency Dental Care and Urgent Care services described above).
You or Your Providers may call Member Services toll-free at 1-888-703-6999 for information on Pre-Authorization of services policies,
procedures or the status of a particular referral or Pre-Authorization.
Specialty referral and Pre-Authorization of specialty services proposed by the Specialist is processed within 5 days of receipt of all
information necessary to make the determination. When LIBERTY is unable to make the determination within the 5-day requirement,
LIBERTY will notify Your Provider and You of the information needed to complete the review and the anticipated date when the
determination will be made.
Any denial, delay or modification of services will contain a clear and concise description of the utilization review criteria, guideline,
clinical reason or contractual section of the coverage documentation used to make such a determination. Such determinations will
include the name and telephone number of the health care professional responsible for the determination and information on how You
can
Determinations to deny, delay or modify treatment requested on Your behalf will contain information on how You may file a Grievance
based on this determination.
Urgent requests: 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, based on the nature of the urgent or emergent condition.
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 (services already provided), the decision shall be communicated to the Enrollee
within thirty (30) days of the receipt of the information.
I. 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 acute or serious chronic dental conditions. Please call the Plan at 1-888-703-6999 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 acute or serious chronic dental conditions. Please call the Plan at 1-888-703-6999 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.
J. LANGUAGE ASSISTANCE
Interpretation and translation services may be available for Members with limited English proficiency, including translation of
documents into certain threshold languages. To ask for language services call 888-703-6999.
IV. FEES AND CHARGES WHAT YOU PAY
A. PREMIUMS AND PREPAYMENT FEES
Premiums are due to LIBERTY Dental Plan prior to the month of coverage.
Your Premium and payment terms are listed in Appendix 2, including mailing address for payments.
Premiums must be paid for the period in which services are received.
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B. CHANGES TO BENEFITS AND PREMIUMS
LIBERTY Dental Plan may change the covered Benefits, Co-payments, and Premium rates from time to time. LIBERTY Dental Plan
will not decrease the covered Benefits or increase the Premium rates during the term of the agreement without giving notice to You at
least sixty (60) days before the proposed change.
At renewal, LIBERTY may change the Premium and may provide 60 days’ notice of any Premium change.
C. OTHER CHARGES
You are responsible only for Premiums and listed Co-payments for Covered Services. You may be responsible for other Charges for
non-covered or optional services as described in this Evidence of Coverage document. You should discuss any Charges for non-covered
or optional services directly with Your Provider. In order to be certain which services on Your treatment plan are covered benefits of
Your plan and which services, if any, are non-covered or optional services (for which You may be responsible for paying out-of-
pocket), You may wish to obtain a written disclosure of all services proposed or received, whether covered or not.
If You receive services that require Pre-Authorization without the necessary authorization (other than emergent or Urgent Care services
as medically necessary), You will be responsible for full payment of the Provider’s usual fee to the Provider for any such services.
You may be responsible for additional fees for returned or dishonored checks, cancelled credit card payments, broken or missed
appointment Charges or other administrative Charges such as finance charges for any third party payment organizations as agreed upon
mutually by You and Your Provider as per business arrangements and disclosures made by LIBERTY or the treating Provider.
D. LIABILITY FOR PAYMENT
You are responsible for payment of Premiums and listed Co-payments for any Covered Services subject to the limitations and
Exclusions of Your plan.
You are responsible for the treating dentist’s usual fee in the following situations:
For non-covered services. If You have services from a non-contracted dentist or facility
If a Pre-Authorization was required and You did not have the treatment Pre-Authorized
Services received out of area that are later deemed to not qualify as emergency or Urgent Care services, such as (but not limited
to) routine treatment beyond the stabilization of the emergency situation
Emergency services may be available out-of-network or without Pre-Authorization in some situations (see Emergency Dental Care
section above).
IMPORTANT: Prior to providing You with non-covered services, Your Contracted Dentist should provide You a treatment plan that
includes each anticipated service and the estimated cost. If You would like more information about dental coverage options, You may
contact our Member Services Department at 888-703-6999.
In no event are You ever responsible for any sums owed to a Contracted Dentist by LIBERTY. In the event that LIBERTY fails to pay
a Non-Participating Provider, You may be liable to the Non-Participating Provider for the cost of services You received.
IMPORTANT: If You opt to receive dental services that are not covered services under this plan, a participating dental provider may
charge You his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a
covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the
estimated cost of each service. If You would like more information about dental coverage options, You may call member services at
(888) 703-6999 or Your insurance broker. To fully understand Your coverage, You may wish to carefully review this evidence of
coverage document.
E. PROVIDER REIMBURSEMENT
LIBERTY pays for Covered Services to Contracted Dentists via a variety of arrangements including Capitation, fee-for-service and
supplemental surpayments in addition to Capitation. Reimbursement varies by geographic area, general dentist, specialty dentist and
procedure code. For more information on reimbursement, You may address a request in writing to LIBERTY at the address shown
above.
EOC Individual
Revised 08/16
V. ELIGIBILITY AND ENROLLMENT
A. WHO IS ENTITLED TO BENEFITS
If LIBERTY Dental Plan receives Your completed enrollment form payment by the 20
th
day of the month, You are eligible to receive
care on the first day of the following month. You may call Your selected dentist at any time after the effective date of Your coverage.
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 Evidence of Coverage or the Schedule of Benefits and applicable Limitations and Exclusions in Appendix 1 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, as well as any non-covered treatment.
B. WHO IS ELIGIBLE TO ENROLL
You and Your eligible dependents are eligible to enroll in a LIBERTY dental plan. You must live in the Plan Service Area.
You may enroll Your spouse.
Unmarried dependent children (including adopted) who are under the age of twenty-six (26).
Disabled children dependent upon You for support and are not able to support themselves due to physical or mental handicap.
You must provide proof of disability or handicap at the time You enroll.
New dependents such as new spouse, children placed with You for adoption, and newborns.
VI. COVERED SERVICES
You are covered for the dental services and procedures listed below when necessary for Your dental health in accordance with
professionally recognized standards of practice, subject to the limitations and Exclusions described for each category and for all
services. Please see Schedule of Benefits (Appendix 1) for a detailed listing of specific Covered Services and the Co-payments
applicable to each, and a list of the Exclusions and limitations that are applicable to all dental services covered under Your LIBERTY
Dental Plan.
A. DIAGNOSTIC DENTAL SERVICES
Diagnostic dental services are those that are used to diagnose Your dental condition and evaluate necessary dental treatment, when
deemed necessary for Your dental health in accordance with professionally recognized standards of practice.
You are covered for the Diagnostic dental services listed in Appendix 1, together with related limitations and Exclusions.
B. PREVENTIVE DENTAL SERVICES
Preventive dental services are those that are used to maintain good dental condition or to prevent deterioration of dental condition, when
deemed necessary for Your dental health in accordance with professionally recognized standards of practice:
You are covered for the Preventive dental services listed in Appendix 1, together with related limitations and Exclusions.
C. RESTORATIVE DENTAL SERVICES
Restorative dental services are those that are used to repair and restore the natural teeth to healthy condition, when deemed necessary for
Your dental health in accordance with professionally recognized standards of practice:
You are covered for the Restorative dental services listed in Appendix 1, together with related limitations and Exclusions.
D. ENDODONTIC SERVICES
Endodontic dental services are procedures that involve treatment of the pulp, root canal and roots when deemed necessary for Your
dental health in accordance with professionally recognized standards of practice:
You are covered for the Endodontic dental services listed in Appendix 1, together with related limitations and Exclusions.
E. PERIODONTIC SERVICES
Periodontic dental services are those procedures that involve the treatment of the gum and bone supporting the teeth and the
management of gingivitis (gum inflammation) and periodontitis (gum disease), when deemed necessary for Your dental health in
accordance with professionally recognized standards of practice:
You are covered for the Periodontic dental services listed in Appendix 1, together with related limitations and Exclusions.
EOC Individual
Revised 08/16
F. PROSTHODONTIC SERVICES
Removable prosthodontics is the replacement of lost teeth by a removable prosthesis and the maintenance of those appliances. Fixed
prosthodontics is the replacement of lost teeth by a fixed prosthesis.
You are covered for the Prosthodontic dental services listed in Appendix 1, together with related limitations and Exclusions.
G. ORAL SURGERY SERVICES
Oral surgery services are procedures that involve the extraction of teeth and other surgical procedures as listed in the Schedule of
Benefits.
You are covered for the Oral Surgery dental services listed in Appendix 1, together with related limitations and Exclusions.
H. ADJUNCTIVE DENTAL SERVICES
Adjunctive Dental Services are ancillary services such as anesthesia during dental services, bleaching, mouthguards, etc.
You are covered for the Adjunctive dental services listed in Appendix 1,together with related limitations and Exclusions.
I. ORTHODONTIC SERVICES
Orthodontic services are procedures that involve straightening teeth and treating discrepancies in the bite relationship of the teeth and
jaws. See Appendix 1 for a list of any covered orthodontic services provided in Your Benefit Plan, and any pertinent limitations and
Exclusions.
J. URGENT AND EMERGENCY SERVICES
See information provided above in this Evidence of Coverage document for a description of coverage for Emergency Dental Services,
including out of area urgent services, and how to access them.
K. SERVICES PROVIDED BY A SPECIALIST
See information provided above in this Evidence of Coverage document for a description of coverage for services available performed
by a Specialist, including a list of the types of dental Specialists covered and how to access services from a Specialist.
VII. LIMITATIONS, EXCLUSIONS, EXCEPTIONS, REDUCTIONS
See Appendix 1 for limitations to covered procedures and Exclusions to Your plan Benefits.
A. GENERAL EXCLUSIONS
LIBERTY will not cover:
Care You get from a doctor who is not in the LIBERTY network, unless You have pre-approval from LIBERTY, or You need
Urgent Care and are outside the LIBERTY Service Area.
Care that is not medically necessary
Exams that You need only to get work, go to school, play a sport, or get a license or professional certification.
Services that are ordered for You by a court, unless they are medically necessary and covered by LIBERTY.
The cost of copying Your medical records. (This cost is usually a small fee per page)
Expenses for travel, such as taxis and bus fare, to see a doctor or get health care.
Other Exclusions are listed in Appendix 1.
B. MISSED APPOINTMENTS
LIBERTY strongly recommends that if You need to cancel or reschedule an appointment with Your Provider that You notify the Dental
Office as far in advance as possible. This will allow the LIBERTY and the Provider to accommodate another person in need of
attention. Providers may charge a fee for missed or broken appointments with less than the recommended notice.
EOC Individual
Revised 08/16
VIII. TERMINATION, RESCISSION AND CANCELLATION OF COVERAGE
A. TERMINATION OF BENEFITS
1. Termination Due to Loss of Eligibility
Your LIBERTY Plan coverage may end if You no longer live or work in the LIBERTY service area or if LIBERTY no longer
offers Your dental plan.
2. Termination Due to Non-Payment of Premium
If premiums are not paid according to the agreement, termination will be effective on midnight of the last day of the month for
which premiums were last received, subject to compliance with notice requirements accepted by LIBERTY Dental Plan.
Enrollees are given a grace period of at least 30 days extending from the last date of paid coverage. In the event premiums are
paid before the end of the grace period, coverage shall continue uninterrupted under the Plan contract. If premiums are not
paid, coverage shall terminate after the completion of the grace period.
Termination by LIBERTY will comply with Health and Safety Code, Section 1365(a) as amended and any associated guidance
or regulation in force at that time.
3. Completion of Treatment In Progress After Termination
If You terminate from the Plan while the contract between You and LIBERTY Dental Plan is in effect, Your Primary Care
Provider or Specialist must complete any procedure in progress that was started before Your termination, abiding by the terms
and conditions of the Plan.
If You terminate coverage from the Plan after the start of orthodontic treatment, You will be responsible for any Charges on
any remaining orthodontic treatment.
4. Termination Due to Fraud
If a Subscriber permits any other person to use their Member ID card to obtain services under this dental plan, or otherwise
engages in fraud or deception in the provision of incomplete or incorrect “material” information to LIBERTY or to the
Provider that would affect enrollment information, for use of the services or facilities of the plan or knowingly permits such
fraud or deception by another, termination will be effective immediately upon notice from LIBERTY Dental Plan.
5. Termination Due to Health Status
LIBERTY does not terminate based on any health status. If You believe that Your coverage has been terminated based on
Your health status or requirements for health care services, You may request a review to be performed by the Director of the
Department of Managed Health Care. If the Director determines that a proper complaint exists under the provisions of this
section, the Director shall notify the plan. Within 15 days after receipt of such notice, the plan shall either request a hearing or
reinstate the Enrollee or Subscriber. A reinstatement shall be retroactive to time of cancellation or failure to renew and the plan
shall be liable for the expenses incurred by the Subscriber or Enrollee for covered health care services from the date of
cancellation or non-renewal to and including the date of reinstatement. You can contact the Department of Managed Health
Care at (1-888-HMO-2219) or on a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s
Internet web site is http://www.hmohelp.ca.gov
.
B. EFFECTIVE DATE OF TERMINATION
Coverage may be terminated, cancelled or non-renewed following 15 days since the date of notification of termination, except for fraud
or deception as stated above, which is effective immediately upon notification.
C. DISENROLLMENT
You may disenroll from the plan by contacting LIBERTY by phone or in writing. Disenrollment is effective as of the end of the last
day of the period for which Premium was paid.
D. RESCISSION
Rescission means that LIBERTY may cancel Your coverage as if no coverage ever existed. Rescission may be elected by LIBERTY
only in the event of fraud or intentional misrepresentation of material fact such as if You intentionally submitted incomplete or incorrect
material information in Your enrollment application that would have affected our decision to accept You as a covered Member. You
have the right to appeal any decision to rescind Your membership. Appeal procedures will be provided to You in the notice of
rescission.
EOC Individual
Revised 08/16
IX. RENEWAL AND REINSTATEMENT OF COVERAGE
Your coverage will be automatically renewed at the same terms and conditions unless LIBERTY notifies You in writing at least 30 days
before the end of Your coverage term describing any changes in the Premium, coverage or other terms or conditions of Your coverage.
X. GRIEVANCE PROCEDURES
If You are dissatisfied with Your selected Primary Care Dentist, personnel, facilities, specialty referral, Pre-Authorization, claim, or the
dental care You receive, You have the right to complain to the dental plan. A Complaint is the same as a Grievance. Grievance Forms
may be requested by contacting LIBERTY Dental Plan’s Member Services Department at (888) 703-6999. Grievance Forms are also
available on our website, www.libertydentalplan.com
, or by calling LIBERTY Member Services or by asking Your Provider.
Grievance Forms are not necessary. LIBERTY will investigate a Grievance submitted in any format. Your complaint or Grievances
may be:
Sent in writing to: LIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA, 92799-6110, or
Sent by facsimile to: LIBERTY Dental Plan’s Member Services Department facsimile at (949) 223-0011, or
Submitted verbally: LIBERTY Dental Plan Member Services Representative at LIBERTY’s toll-free number: (888) 703-6999, or
Submitted using our website online Grievance filing process by visiting www.libertydentalplan.com
.
You may use a “patient advocate” to help You file a Grievance. For Grievances involving minors or incapacitated or incompetent
individuals, the parent, guardian, conservator, relative or other designee of the Member, as appropriate may submit the Grievance to
LIBERTY, or to the DMHC for urgent matters (see “Urgent Grievances” below)
If You have limited English proficiency, visual or other communication impairment, LIBERTY will assist You in filing a Grievance.
Assistance may include translation of Grievance procedures, forms and LIBERTY’s responses, and may also include access to
interpreters, telephone relay systems to aid disabled individuals to communicate.
You will not be discriminated against in any way by LIBERTY or Your Provider for filing a Grievance.
You may file a Grievance for at least 180 calendar days following any incident or action that is the subject of Your dissatisfaction.
LIBERTY Dental Plan’s representatives will review the problem with You and take appropriate steps for a quick resolution. You will
receive acknowledgement of Your Grievance within five (5) calendar days of receipt. Grievances will be resolved within 30 days.
Grievances Exempt from Written Acknowledgement and Response: In some cases Grievances that are received by telephone,
facsimile, e-mail or through a website that are not coverage disputes, or are not involving Dental Necessity and are resolved by the next
business day do not require a written acknowledgement or response. In these cases You will be contacted by the same method by which
You submitted the Grievance or otherwise discussed with You at the time You reported Your complaint.
The following information is required by the State of California pertaining to Your dental plan.
A. 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, or requests for review of cancellations, rescissions and non-renewals under Health and Safety Code section 1365(b) and related
guidance and rules. 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.
California Required Statement: The California Department of Managed Health Care is responsible for
regulating health care service plans. If you have a grievance against your Health Plan, you should first telephone
your Health Plan at 1-888-703-6999 and use your Health Plan’s grievance process before contacting the
Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may
be available to you. If you need help with a grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your Health Plan, or a grievance that remained unresolved for more than 30 days, you
EOC Individual
Revised 08/16
may call the Department for assistance. You may also be eligible for Independent Medical Review (IMR). If you
are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a Health
Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment disputes for emergency or urgent medical services. The
Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the
hearing and speech impaired. The Department’s Internet web site http://www.hmohelp.ca.gov has complaint
forms, IMR application forms and instructions online.
Grievance Resolutions and Responses: For Grievances related to requested services that were denied, delayed or modified based in
whole or in part on a finding that the proposed health care service is not a covered benefit, the response will indicated the exact
document, page and provision applicable to the Grievance response.
For Grievances related to requested health care services that were denied, delayed or modified in whole or in part based on a
determination that the service is not medically (dentally) necessary, the response will indicate the criteria, clinical guideline or policy
used in reaching the determination.
Urgent Grievances: For cases involving an imminent and serious threat to Your health including, but not limited to, severe pain,
potential loss of life, limb, or major bodily function, LIBERTY will expedite the processing of Your Grievance upon notification of this
urgent condition. LIBERTY will resolve to the urgent condition within 3 calendar days of receipt of the Grievance, or sooner, based on
the condition. In the case of urgent Grievances, You are not required to await the determination by LIBERTY before accessing the
DMHC as noted above.
If You are not satisfied with the resolution initially provided, You may contact the DMHC as noted above. You may also submit
additional materials for additional consideration to LIBERTY Dental Plan’s Quality Management Department. Your requests must be
in writing with a detailed summary and should be directed to:
LIBERTY Dental Plan, Inc.
Quality Management Department
P.O. Box 26110
Santa Ana, CA 92799-6110
Any additional information will be processed as a new Grievance.
B. MEDIATION
You may also request voluntary mediation with LIBERTY before exercising Your right to submit a Grievance to the DMHC. The use
of mediation does not preclude Your right to submit a Grievance to the DMHC upon completion of mediation. In order to initiate
mediation, You or Your agent must voluntarily agree to the mediation process. Expenses for mediation will be borne equally by You
and LIBERTY.
C. INDEPENDENT MEDICAL REVIEW (IMR)
In cases which result in the denial of the Pre-Authorization request for Covered Services by a LIBERTY Dental Plan Provider, and are
considered the practice of medicine or are provided pursuant to a contract between LIBERTY and a health plan (that covers hospital,
medical or surgical benefits) may be eligible for the DMHC Independent Medical Review (IMR) program. 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 26110, 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 1-888-HMO-2219 or by visiting their website at:
http://www.hmohelp.ca.gov
. Independent Medical Review is only available for certain medical services.
D. ARBITRATION
If You or one of Your eligible Dependents is not satisfied with the results of LIBERTY Dental Plan’s complaint resolution process, and
all the complaint resolution procedures have been exhausted, the matter can be submitted t