EOC – Individual
Revised 08/16
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.