Phone: (Monday – Friday from 7:00 a.m. until

:00 p.m., CST.

7

LIBERTY Dental Plan

I.888.902.0407

We encourage you to contact us with your

questions or concerns.

Also, you may directly contact the Missouri

Department of Insurance, Financial Institutions

and Professional Registration (“MDI”). MDI has

established a process to receive inquiries and

complaints from consumers of healthcare in

Missouri concerning healthcare plans.

Evidence of

Coverage

This Evidence of Coverage (EOC) describes the

dental care plan made available to Eligible

Employees of the Employer (referred to as

For More Information Contact MDI’s Consumer

Hotline:: 1- 800-726-7390

Inquiries and complaints may be filed online at:

“Group”) and their Eligible Family Members.

http://insurance.mo.gov/consumer/complaints/in

dex.htm

LIBERTY Dental Plan of Missouri, Inc. (LIBERTY),

and the Group have agreed to all of the terms of

this EOC. It is part of the contract (Group

Enrollment Agreement or “GEA”) between

LIBERTY and Group. This EOC may be

terminated by LIBERTY or the Group upon

appropriate written notice in accordance with the

GEA. The Group is responsible for giving

Members notice of termination.

or by mailing or faxing your inquiry or complaint

to:

Missouri DIFP

Attn: Consumer Affairs

P.O. Box 690

Jefferson City, MO 65102-0690

Fax Number: 573-526-4898

This EOC and your attached Benefit Schedule tell

you about your benefits, rights and duties as a

LIBERTY Member. They also tell you about

LIBERTY’s duties to you.

Evidence of Coverage

SECTION 1.

Eligibility, Enrollment and

Effective Date

You may contact LIBERTY’s Member Services

Department at:

Subscribers and Dependents who meet the

following criteria are eligible for coverage under

this EOC.

Address:

LIBERTY Dental Plan

P.O. Box 26110

Santa Ana, CA 92799-6110]

LDPMO2011

- 1 -

1

.1

Who Is Eligible



A child by birth. Adopted child. Stepchild.

Minor child for whom a court has ordered

coverage. Child being placed for Adoption

with the Subscriber. A child for whom a

court has appointed the Subscriber or the

Subscriber’s spouse the legal guardian.

You and your eligible dependents are eligible to

enroll in LIBERTY Dental Plan so long as you

meet the eligibility requirements imposed by

your employer.

A.

B.

Be a bona fide employee of the Group; and

Meet the following criteria:

Be employed full-time;

The DEPENDENT CHILD of a SUBSCRIBER up to

the child’s twenty-sixth (26th) birthday unless

such child is eligible for employer-sponsored

coverage (other than coverage through the

SUBSCRIBER). The children and spouse of a

DEPENDENT CHILD are excluded from

coverage.



Be actively at work;

Work at least the minimum number of

hours per week indicated by the Group in

its Application;



Any unmarried child who is incapable of self-

sustaining employment due to mental or

physical handicap, chiefly dependent upon

the Subscriber for economic support and

maintenance, and who has satisfied all of the

requirements of (a) or (b) below.



Meet the applicable waiting period

indicated by the Group in its Application;



Enroll during an enrollment period;

Live or work in the service area; and

(

a) The child must be a Dependent enrolled

under this EOC before reaching the

limiting age, and proof of incapacity and

dependency must be given to LIBERTY by

the Subscriber within thirty-one (31) days

of the child reaching the limiting age; or

Work for an employer that meets the

Minimum Employer Contribution

Percentage for the applicable coverage.

(

b) The handicap started before the child

reached the limiting age, but the Group

was enrolled with another health

The actively at work requirement will not apply to

Individuals covered under Group’s prior welfare

benefit plan on the date of that plan’s

discontinuance, provided that this EOC is initially

effective no more than sixty (60) days after the

prior plan’s discontinuance. All other

insurance carrier that covered the child as

a handicapped Dependent prior to the

Group enrolling with LIBERTY.

LIBERTY may require proof of continuing

requirements will apply to such Individuals.

incapacity and dependency, but not more often

than once a year after the first two (2) years

beyond when the child reaches the limiting age.

LIBERTY’s determination of eligibility is final.

Dependent. To be eligible to enroll as a

Dependent, a person must be one of the

following:

Evidence of any court order needed to prove

eligibility must be given to LIBERTY.



A Subscriber's legal spouse or a legal spouse

for whom a court has ordered coverage.



Registered domestic partner

LDPMO2011

- 2 -

If a policy provides that coverage of a dependent

child terminates upon attainment of the limiting

age for dependent children specified in the policy,

such policy, so long as it remains in force, until the

dependent child attains the limiting age, shall

remain in force at the option of the certificate

holder. Eligibility for continued coverage shall be

established where the dependent child is:



Or transfer of residence or work outside

LIBERTY’s Service Area.

1

.4

Enrollment

Eligible Employees and Eligible Family Members

must enroll during one of the Enrollment Periods

described below or within thirty-one (31) days of

first becoming eligible in order to have coverage

under this Plan.

(

a) Unmarried and no more than that twenty-five

years of age; and

(

b) A resident of this state; and

1

.

Initial Enrollment Period. An Initial

Enrollment Period is the period of time

during which an Eligible Employee may enroll

under this Plan, as shown in the GEA signed

by the Group.

c) Not provided coverage as a named subscriber,

insured, enrollee, or covered person under any

group or individual health benefit plan, or entitled

to benefits under Title XVIII of the Social Security

Act, P.L. 89-97, 42 U.S.C. Section 1395, et seq.;

2.

Group Open Enrollment Period. An Open

Enrollment Period of at least thirty-one (31)

days may be held at least once a year

allowing Eligible Employees and Eligible

Family Members to enroll under this Plan

without giving evidence of good health.

1

.2

Who Is Not Eligible

Eligible Dependents may not include:



A foster child.

3

.

Special Enrollment Period. A Special

A child placed in the Subscriber's home other

than for adoption.

Enrollment Period allows a Special Enrollee to

enroll for coverage under this Plan upon a

Special Enrollment Event as defined herein

during a period of at least thirty-one (31)

days following the Special Enrollment Event.



A grandchild.

Any other person not defined in Section 1.1.

4

Right to Deny Application. LIBERTY can deny

1

.3

Changes In Eligibility Status

membership to any person who:

It is the Subscriber's responsibility to give his/her

employer notice within thirty-one (31) days of

changes, which affect his Dependents’ eligibility.

Changes include:

Violates or has violated any provision of a

LIBERTY EOC.

Misrepresents or fails to disclose a material

fact which would affect coverage under this

Plan.



Reaching the limiting age.

Death.

Fails to follow LIBERTY rules.

Divorce.

5.

Right to Deny Application for Renewal. As a

condition of Group’s renewal under this Plan,

LIBERTY may require Group to exclude a

Marriage.

LDPMO2011

- 3 -

Subscriber or Dependent who committed

fraud upon LIBERTY or misrepresented and/or

failed to disclose a material fact, which

affected his coverage under this Plan.

1. Nonpayment of premiums.

2.

Failure to meet minimum enrollment

requirements.

3.

LIBERTY amends this EOC and the Group

does not accept the amendment.

SECTION 2.

Termination

2

.2

Termination by the Subscriber

LIBERTY may terminate coverage under this Plan

at the times shown for any one or more of the

following reasons:

Subscriber has the right to terminate his coverage

under the Plan by notice to his/her employer. .

Such termination is effective on the last day of the

month when the notice is received by LIBERTY,

unless stated otherwise in the GEA.

2.1

Termination by LIBERTY



Failure to maintain eligibility requirements as

set forth in Section 1.

2.3

Reinstatement



On the first day of the month that a

contribution was due and not received by

LIBERTY.

Any member, who has been terminated in any

manner, may be reinstated by LIBERTY at its sole

discretion.

With thirty (30) days written notice, if the

Member allows his or any other Member's

LIBERTY ID card to be used by any other

person, or uses another person's card. The

Member will be liable to LIBERTY for all costs

incurred as a result of the misuse of the

LIBERTY Member card.

2.4

Retroactive Termination

A request for retroactive termination by Group

may be granted as shown in the GEA.

2.5

Effect of Termination

No benefits will be paid under this Plan by

LIBERTY for services provided after termination of

a Member's coverage under this Plan. You will be

responsible for payment of services and supplies

incurred after the effective date of the



If information given to LIBERTY by the

Member in his Enrollment Form is untrue,

inaccurate, or incomplete, LIBERTY has the

right to declare the coverage under the Plan

null and void as of the original Effective Date

of coverage.

termination of this EOC and/or the GEA.

When a Subscriber moves his primary

SECTION 3.

Using this Plan

residence outside the Service Area and/or no

longer has his place of work within the Service

Area or when a Dependent moves his primary

residence outside LIBERTY's Service Area,

Subscriber must notify his/her employer

within thirty-one (31) days of the change.

This Plan offers you a choice of Plan Providers

where you receive your dental care. You must

receive services from a Plan Provider to utilize

benefits covered by this Plan. Your out-of-pocket

costs are identified in the Schedule of Benefits.

You will also not need to submit any claim forms

when you receive your care from a Plan Provider.

To receive benefits for care provided by a



On the date the GEA terminates for any

reason, including but not limited to:

LDPMO2011

- 4 -

Specialist you must be referred to the Specialist

by a Plan Provider and have your care pre-

authorized by the Plan.

Written notice of claim must be given to LIBERTY

within twenty days after the occurrence or

commencement of any loss covered by the policy.

Failure to give notice within such time shall not

invalidate nor reduce any claim if it shall be

shown not to have been reasonably possible to

give such notice and that notice was given as soon

as was reasonably possible;

You and your dependents must choose a Plan

Provider from a network of private practice dental

offices. A list of Plan Providers is available

through the Plan.

LIBERTY shall furnish to the person making claim,

or to the policyholder for delivery to such person,

such forms as are usually furnished by it for filing

proof of loss. If such forms are not furnished

before the expiration of fifteen days after the

insurer receives notice of any claim under the

policy, the person making such claim shall be

deemed to have complied with the requirements

of the policy as to proof of loss upon submitting,

within the time fixed in the policy for filing proof

of loss, written proof covering the occurrence,

character, and extent of the loss for which claim is

made

SECTION 4.

Covered Services

This section tells you what services are covered

under this Plan. Only services and supplies, which

meet LIBERTY’s definition of Dentally Necessary

will be considered to be Covered Services. The

Benefit Schedule shows applicable Copayments

and benefit limitations for Covered Services.

4.1

Benefits Available

Subject to the Exclusions listed herein, dental

services related to a Member's dental health as

identified in the Benefits Schedule are available to

Members.

4

.3

Emergency Services

In the event of a dental emergency outside the

service area of the Plan, the Member should

contact LIBERTY at 888.902.0407. The Plan will

direct you to an available dentist or Specialist.

Should no Plan Provider be available in a fifty (50)

mile radius you can seek treatment from an out-

of-network provider. In such an event, the Plan

will reimburse you for the cost of Emergency

Services received from an out-of-network

provider as if you had visited a Plan Provider, up

to a maximum of seventy-five dollars ($75) less

applicable co-payments.

Benefits must be obtained from Plan Providers.

The Benefit Schedule Identifies the copayments

that are to be paid to Plan Providers.

4.2

Claim Payments

Plan Providers are paid an amount agreed upon

between the Plan and the Plan Provider plus any

copayment from the Member required by the

Benefit Schedule.

LDPMO2011

- 5 -

Emergency Services and care include (and are

covered by LIBERTY) dental screening,

medical professional except for dental

services otherwise covered herein.

a

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 if the services are

rendered in a hospital setting which are covered

by a Medical Plan, or if LIBERTY determines the

services were not dental in nature.



Treatment of fractures or dislocations.

Loss or theft or dentures, partials or other

appliances (e.g. crowns, bridges, full or

partial dentures).



Services which are normally reimbursed

by a third part or liability insurance

and/or under the medical portion of a

group health plan.



Dental procedures for which treatment

started prior to the time Member became

eligible for benefits.

Procedures, appliances, restorations or

other treatment to correct congenital or

developmental malformations.

Treatment and/or removal of: (a)

malignancies; (b) cysts or benign tumors

not within the scope of usual dental care;

(c) odontogenic cysts exceeding 1.25 cm

in diameter.

SECTION 5.

Exclusions and Limitations

5.1

Exclusions

This section tells you what services or supplies are

excluded from coverage under this Plan.



Drugs/ medications not normally supplied

or prescribed by a dental office.



Dental services for aesthetics only and/or

cosmetic dental care.

Any treatment which, on the opinion of

LIBERTY’s Dental Director, is not

necessary for the Member's dental

health.



General anesthesia, intravenous and

inhalation sedation, prescription drugs for

anesthesia, and the services of a special

anesthesiologist.



Replacement of an existing bridge, partial

or denture which, in the opinion of

LIBERTY's Dental Director, is satisfactory

or that can be made satisfactory.



Dental conditions arising out of and due

to a Member's employment or for which

the Member is entitled to Workers'

Compensation benefits.



Orthognathic surgery.



Hospital and medical facility charges of

any kind.

Implants or any prosthesis attached to or

dependent upon an implant.

Charges from a medical doctor, doctor of

osteopathic medicine and/or other



Any experimental, investigational or

exotic procedure not approved by the

ADA Council on Dental Therapeutics.

LDPMO2011

- 6 -



Treatment to alter vertical dimension or

to restore occlusion, unless dentures are

involved.

- War.

-

Riot.

Civil insurrection.

Epidemic.

Major therapy for Temporomandibular

Joint (TMJ) problems including, but not

limited to, assessment beyond that

customarily provided in a general dental

practice.

- Or any other emergency beyond

LIBERTY’s control.



Prophylaxis is limited to one treatment

each (6) month period (includes

periodontal maintenance following active

therapy).



Expense or charge incurred by a Member

confined to an institution of any kind.

Cases in which, in the reasonable

professional judgment LIBERTY’s Dental

Director, a satisfactory result cannot be

obtained.



Oral evaluation is limited to one each (6)

month period.

Oral hygiene instruction is limited to one

per twenty-four (24) month period.



Replacement of long-standing missing

tooth/teeth in an otherwise stable

dentition.

Fluoride treatment is limited to one per

twelve (12) month period.

Orthodontic services unless otherwise

noted as a covered benefit in the

member’s Benefit Schedule.

Crowns, bridges and dentures may not be

replaced within five (5) years from the

initial placement.



Care related to the bite, alignment of

teeth, or bite correction.



Partial dentures are not to be replaced

within five (5) years of the initial

placement, unless necessary due to

natural tooth loss where the addition or

replacement of teeth to the existing

partial is not feasible.

Charges for specialized techniques

involving precision attachments,

personalization or characterization of a

temporary or permanent prosthesis.



Charges related to the Member's failure

to appear at a scheduled appointment.



Denture relines are limited to one per

denture during any twelve (12)

consecutive months.

5.2

Limitations

Covered charge for both a temporary and

a permanent prosthesis will be limited to

the charge for a permanent prosthesis

only.

This section tells you when LIBERTY's duty to

provide or arrange for services is limited.



LIBERTY will not be liable for any delay or

failure to provide or arrange for Covered

Services if the delay or failure is caused by

the following:



Charges for adjustment of a prosthesis

will be limited to one in a six (6) month

period.

-

Natural disaster.

LDPMO2011

- 7 -



Periodontal treatments, including root

planing and scaling, are limited to four

quadrants during any twenty-four (24)

consecutive months.

LIBERTY is not bound by statements or promises

made by its Plan Providers.

6.2

Entire Agreement

Full mouth debridement (gross scale) is

limited to one treatment in any thirty-six

This EOC along with the Group Enrollment

Agreement, Enrollment Forms/Application

constitute the entire agreement between the

Member and LIBERTY and as of its Effective Date,

replaces all other agreements between the

parties.

(

36) consecutive month period.



Osseous surgery is limited to one

treatment in any five (5) year period.

Crowns will be covered only if, in the

opinion of LIBERTY’s Dental Director,

there is not enough retentive quality left

in the tooth to hold a filing.

6.3

Contestability

Any and all statements made to LIBERTY by Group

and any Subscriber or Dependent, will, in the

absence of fraud, be considered representations

and not warranties. Also, no statement, unless it

is contained in a written application for coverage,

shall be used in defense to a claim under this

agreement.



Bitewing x-rays are limited to not more

than one series in any six (6) month

period.

Full mouth x-rays and/or panographic

type films are limited to one set every

twenty-four (24) consecutive months.

6.4

Authority to Change the Form or Content

of EOC

Sealant benefits include the application of

sealants only to permanent first and

second molars with no decay up to the

age of fifteen (15). Sealants are limited to

once per thirty-six (36) month period per

tooth.

No agent or employee of LIBERTY is authorized to

change the agreement or waive any of its

provisions. Such changes can be made only

through an amendment authorized and signed by

an officer of LIBERTY.

SECTION 6.

General Provisions

6.5

Identification Card

Cards issued by LIBERTY to Members are for

identification only. Possession of the LIBERTY

identification card does not give right to services

or other benefits under this Plan.

6

.1

Relationship of Parties

The relationship between LIBERTY and Plan

Providers is an independent contractor

relationship. Plan Providers are not agents or

employees of LIBERTY; nor is LIBERTY or any

employee of LIBERTY an employee or agent of a

Plan Provider. LIBERTY is not liable for any claim

or demand on account of damages as a result of,

or in any manner connected with, any Injury

suffered by a Member while receiving care from

any Plan Provider or in any Plan Provider's facility.

To be entitled to such services or benefits, the

holder of the card must in fact be a Member and

all applicable premiums actually have been paid.

Any person not entitled to receive services or

other benefits will be liable for the actual cost of

such services or benefits.

LDPMO2011

- 8 -

the orderly and efficient administration of this

EOC with which Members shall comply. These

policies and procedures are maintained by

LIBERTY at its offices. Such policies and

procedures may have bearing on whether a

dental service and/or supply is covered.

6

.6

Notice

Any notice under this Plan may be given by United

States mail, first class, postage paid, addressed as

follows:

LIBERTY Dental Plan

P.O. Box 26110

6.11 Overpayments

Santa Ana, CA 92799-6110

LIBERTY has the right to collect payments for

services made in error. Dentists, Specialists and

other providers have the responsibility to return

any overpayments or incorrect payments to

LIBERTY. LIBERTY has the right to offset any

overpayment against any future payments.

Notice to a Member will be sent to the Member's

last known address.

6.7

Assignment

This EOC is not assignable by Group without the

written consent of LIBERTY. The coverage and

any benefits under this Plan are not assignable by

any Member without the written consent of

LIBERTY.

6.12 Release of Records

Each Member authorizes their providers to permit

the examination and copying of the Member's

dental records, as requested by LIBERTY.

6.8

Modifications

6

.13 Gender References

The Group makes LIBERTY coverage available to

individuals who are eligible under Section 1.

However, this EOC is subject to amendment,

modification and termination with sixty (60) days

written notice to the Group without the consent

of Members.

Whenever a masculine pronoun is used in this

EOC, it also includes the feminine pronoun.

6.14 Availability of Providers

LIBERTY does not guarantee the continued

availability of any Plan Provider.

By electing dental coverage with LIBERTY or

accepting benefits under this Plan, all Members

legally capable of contracting, and the legal

representatives of all Members incapable of

contracting, agree to all terms and provisions.

6.15 Legal Action

No action at law or in equity shall be brought to

recover on the policy prior to the expiration of

sixty days after proof of loss has been filed in

accordance with the requirements of the policy

and that no such action shall be brought at all

unless brought within three years from the

expiration of the time within which proof of loss is

required by the policy.

6.9

Clerical Error

Clerical error in keeping any record pertaining to

the coverage will not invalidate coverage in force

or continue coverage terminated.

6.10 Policies and Procedures

LIBERTY may adopt reasonable policies,

procedures, rules and interpretations to promote

LDPMO2011

- 9 -

solve the problem there, if the issue is not a Claim

for Benefits.

6

.16 Incontestability

The validity of the policy shall not be contested,

except for nonpayment of premiums, after it has

been in force for two years from its date of issue,

and that no statement made by any person

covered under the policy relating to insurability

shall be used in contesting the validity of the

insurance with respect to which such statement

was made after such insurance has been in force

prior to the contest for a period of two years

during such person's lifetime nor unless it is

contained in a written instrument signed by the

person making such statement; except that, no

such provision shall preclude the assertion at any

time of defenses based upon the person's

ineligibility for coverage under the policy or upon

other provisions in the policy.

A Member may contact MDI for assistance at any

time using the contact information provided on

the cover page of this EOC. A Member that

receives an Adverse Benefit Determination may

file a grievance with MDI without exhausting the

Appeals Procedures.

Please see the Glossary terms for a description of

the terms used in this section.

The following Appeals Procedures will be followed

for all Grievances.

SECTION 7.

Appeals and Grievances

The LIBERTY Appeals Procedures are available to

you in the event you are dissatisfied with some

aspect of the Plan administration, you wish to

appeal an Adverse Benefit Determination or there

is another concern you wish to bring to LIBERTY’s

attention. This procedure does not apply to any

problem of misunderstanding or misinformation

that can be promptly resolved by the Plan

supplying the Member with the appropriate

information.



Informal Review: Available for all Grievances,

including a complaint regarding an Adverse

Benefit Determination, which are directed to

the LIBERTY Member Services Department via

phone or in person. If the Informal Review

resolves the Grievance to the satisfaction of

the Member, the matter ends. The Informal

Review is voluntary.

If a Member’s Plan is governed by ERISA, a

Member must exhaust all mandatory levels of

mandatory appeal before bringing a claim in court

for a Claim of Benefits.

st



1

Level Formal Appeal: Available for all

Grievances, including a complaint regarding

an Adverse Benefit Determination, which

LIBERTY’s Customer Response and Resolution

Department investigates. If a 1 Level Formal

Appeal resolves the Grievance to the

satisfaction of the Member, the appeal is

st

Concerns about dental services are best handled

at the service site level before being brought to

LIBERTY. If a Member contacts LIBERTY regarding

an issue related to the dental service site and has

not attempted to work with the site staff, the

Member may be directed to that site to try to

st

closed. The 1 Level Formal Appeal is

mandatory if the Member is not satisfied with

the initial determination and the Member

wishes to appeal such determination.

LDPMO2011

- 10 -

Determination of a Claim for Benefits, may

request an Informal Review. All Informal Reviews

regarding an Adverse Benefit Determination must

be made to LIBERTY’s Member Services

Department within sixty (60) days of the Adverse

Benefit Determination. Informal Reviews of

Adverse Benefit Determinations not filed in a

timely manner will be deemed waived. The

Informal Review is a voluntary level of appeal.

nd

st



2

Level Formal Appeal: If a 1 Level Formal

Appeal is not resolved to the Member’s

satisfaction, a Member may then file a 2

Level Formal Appeal. A 2 Level Formal

Appeal is submitted in writing and reviewed

by the Grievance Advisory Panel. The 2

Level Formal Appeal is voluntary for all

Adverse Benefit Determinations.

nd

Upon the initiation of an Informal Review, a

Member must provide Member Services with at

least the following information:



Grievance Advisory Panel: A committee

consisting of other Members, representatives

of LIBERTY that were not involved in the

circumstances giving rise to the Grievance or

any

subsequent

investigation

or

.

The Member’s name (or name of Member

and Member’s Authorized Representative),

address, and telephone number;

determination, and, where the Grievance

involves an Adverse Benefit Determination, a

majority of persons that are appropriate

clinical peers in the same or similar specialty

as would typically manage the case being

reviewed who were not involved in the

circumstances giving rise to the Grievance or

.

The Member’s LIBERTY membership number

and Group name; and

A brief statement of the nature of the matter,

the reason(s) for the appeal, and, if

applicable, why the Member feels that the

Adverse Benefit Determination was wrong.

any

subsequent

investigation

or

determination.



Member Services Representative:

An

The Member Services Representative will inform

the Member that upon review and investigation

of the relevant information, LIBERTY will make a

determination of the Informal Review. The

determination will be made as soon as reasonably

possible but will not exceed thirty (30) days unless

more time is required for fact-finding. If the

determination of the Informal Review is not

acceptable to the Member and the Member

wishes to pursue the matter further, the Member

employee of LIBERTY that is assigned to assist

the Member or the Member's authorized

representative in filing a Grievance with

LIBERTY or appealing an Adverse Benefit

Determination.

7

.1 Informal Review

st

may file a 1 Level Formal Appeal.

A Member who has a Grievance, including a

complaint regarding an Adverse Benefit

LDPMO2011

- 11 -

st

7

.2 1 Level Formal Appeal

Additionally, the Member may submit any

supporting medical records, Dentist’s letters, or

other information that explains why LIBERTY

should approve the Claim for Benefits. The

Member can request the assistance of a Member

Services Representative at any time during this

process. The Member has the right to have any

other person help them with the Grievance

When an Informal Review does not resolve the

Grievance in a manner that is satisfactory to the

Member or when the Member chooses not to file

an Informal Review and the Member wishes to

pursue the matter further, the Member must file

st

a Grievance requesting a 1 Level Formal Appeal.

st

A Grievance requesting a 1 Level Formal Appeal

requesting a 1 Level Formal Appeal of the

regarding an Adverse Benefit Determination must

be submitted in writing to LIBERTY’s Customer

Response and Resolution Department within 180

Grievance.

days of the Adverse Benefit Determination.

A

st

The Grievance requesting a 1 Level Formal

st

Grievance requesting a 1 Level Formal Appeal

regarding any other type of Grievance must be

submitted in writing to LIBERTY’s Customer

Response and Resolution Department within 180

days of the event giving rise to the Grievance.

Appeal should be sent or faxed to the following:

Address: LIBERTY Dental

Attn: Customer Response and Resolution Dept.

LIBERTY Dental Plan

st

Grievances requesting 1 Level Formal Appeals

not filed in a timely manner will be deemed

waived with respect to the Grievance, including

the Adverse Benefit Determination, to which they

relate.

P.O. Box 26110

Santa Ana, CA 92799-6110

Fax: (888) 223-0011

st

The Grievance requesting a 1 Level Formal

Appeal shall contain at least the following

information:

LIBERTY will acknowledge receipt of the

st

Grievance requesting a 1 Level Formal Appeal

from a Member within ten (10) working days of

its receipt by LIBERTY. LIBERTY will conduct a

complete investigation within twenty (20)

working days after receipt of the Grievance

.

The Member’s name (or name of Member

and Member’s Authorized Representative),

address, and telephone number;

st

.

The Member’s LIBERTY membership number

and Group name; and

requesting a 1 Level Formal Appeal, unless the

investigation cannot be completed within this

time. If the investigation cannot be completed

within twenty (20) working days after receipt of

A brief statement of the nature of the matter,

the reason(s) for the appeal, and, if applicable,

why the Member feels that the Adverse

Benefit Determination was wrong.

st

the Grievance requesting a 1 Level Formal

Appeal, LIBERTY shall notify the Member in

LDPMO2011

- 12 -

th

writing on or before the twentieth (20 ) working

relied on in making the determination is

available free of charge upon the Member’s

request; and

day and the investigation shall be completed

within thirty (30) working days thereafter. The

notice will set forth with specificity the reasons

.

If the Adverse Benefit Determination is based

on Medical Necessity or experimental

treatment or similar exclusion or limit, either

an explanation of the scientific or clinical

for which additional time is needed for the

st

investigation.

decided by

1

a

Level Formal Appeals will be

grievance review committee

established by LIBERTY.

judgment or statement that such

a

explanation will be provided free of charge.

Within five (5) working days of the completion of

the investigation, the Member will be informed in

writing of the resolution. If the 1 Level Formal

Appeal results in an Adverse Benefit

Determination, the Member will be informed in

writing of the following:

st

If the resolution to the Grievance requesting a 1

st

Level Formal Appeal is not acceptable to the

Member and the Member wishes to pursue the

nd

matter further, the Member is entitled to file a 2

Level Formal Appeal. The Member will be

informed of this right at the time the Member is

st

informed of the resolution of his 1 Level Formal

.

The specific reason or reasons for upholding

the Adverse Benefit Determination;

Appeal.

Reference to the specific Plan provisions on

which the determination is based;

If the person who submitted the Grievance

st

requesting a 1 level Formal Appeal was not the

A statement that the Member is entitled to

receive, upon request and free of charge,

reasonable access to, and copies of, all

documents, records, and other information

relevant to the Member’s Claim for Benefits;

Member, LIBERTY will notify the person

submitting the request of the resolution within

fifteen (15) working days after the investigation is

completed.

.

A statement describing any voluntary appeal

procedures offered by LIBERTY and the

Member’s right to receive additional

information describing such procedures;

7

.3

Expedited Appeal

The Member can ask (either orally or in writing)

for an Expedited Appeal of an Adverse Benefit

Determination for a Pre-Service Claim for which

the Member or his Dentist believe that the health

of the Member could be seriously harmed by

waiting for a routine appeal decision. Expedited

Appeals are not available for appeals regarding

denied claims for benefit payment (Post-Service

Claim). Expedited Appeals must be decided no

later than seventy-two (72) hours after receipt of

For Member’s whose coverage is subject to

ERISA, a statement of the Member’s right to

bring a civil action under ERISA Section 502(a)

following an Adverse Benefit Determination,

if applicable;

.

A statement that any internal rule, guideline,

protocol or other similar criteria that was

LDPMO2011

- 13 -

the appeal, provided all necessary information

has been submitted to LIBERTY. If the initial

notification was oral, LIBERTY shall provide a

written or electronic explanation to the Member

within three (3) days of the oral notification.

If a request for an Expedited Appeal is submitted

without support of the Member’s Dentist,

LIBERTY shall decide whether the Member’s

health requires an Expedited Appeal. If an

Expedited Appeal is not granted, LIBERTY will

provide a decision within thirty (30) days, subject

to the routine appeals process for Pre-Service

Claims.

If insufficient information is received, LIBERTY

shall notify the Member as soon as possible, but

no later than twenty-four (24) hours after receipt

of the claim of the specific information necessary

to complete the claim. The Member will be

afforded a reasonable amount of time, taking into

account the circumstances, but not less than

forty-eight (48) hours, to provide the specified

information. LIBERTY shall notify the Member of

the benefit determination as soon as possible, but

in no case later than forty-eight (48) hours after

the earlier of:

nd

7.4

2

Level Formal Appeal

st

When a 1 Level Formal Appeal is not resolved in

a manner that is satisfactory to the Member, the

nd

Member may initiate a 2 Level Formal Appeal.

This appeal must be submitted in writing within

one hundred eighty (180) days after the Member

st

has been informed of the resolution of the 1

Level Formal Appeal.

.

LIBERTY’s receipt of the specified information,

or

st

Exhaustion of the 1 Level Formal Appeal

nd

procedure is a precondition to filling a 2 Level

Formal Appeal. A 2 Level Formal Appeal not

filed in a timely manner will be deemed waived

with respect to the Grievance, including the

Adverse Benefit Determination, to which it

The end of the period afforded the Member

to provide the specified information.

nd

If the Member’s Dentist requests an Expedited

Appeal, or supports a Member’s request for an

Expedited Appeal, and indicates that waiting for a

routine appeal could seriously harm the health of

the Member or subject the Member to

unmanageable severe pain that cannot be

adequately managed without care or treatment

that is the subject of the Claim for Benefits,

LIBERTY will automatically grant an Expedited

Appeal.

relates. The 2 Level Formal Appeal is voluntary

for all Pre-Service and Post-Service Claims for

Benefits.

The Member shall be entitled to the same

reasonable access to copies of documents

referenced above under the 1 Level Formal

st

Appeal.

LDPMO2011

- 14 -

nd

acknowledge receipt of the request for a 2

Level Formal Appeal within ten (10) working

days of its receipt by LIBERTY;

The Member can request the assistance of a

Member Services Representative at any time

during this process.

.

nd

.

consider the 2 Level of Appeal;

Upon request a Member is entitled to attend and

nd

schedule and conduct a formal presentation if

applicable;

provide a formal presentation on a 2 Level

Formal Appeal. If such a hearing is requested

LIBERTY shall make every reasonable effort to

schedule one at a time mutually convenient to

the parties involved. Repeated refusal on the part

of the Member to cooperate in the scheduling of

the formal presentation shall relieve the

Grievance Advisory Panel of the responsibility of

hearing a formal presentation, but not of

.

obtain additional information from the

Member and/or staff as it deems appropriate;

conduct a complete investigation within

twenty (20) working days after receipt of the

nd

request for a 2 Level Formal Appeal, unless

nd

the investigation cannot be completed within

this time. If the investigation cannot be

completed within twenty (20) working days

after receipt of the request for a 2nd Level

Formal Appeal, LIBERTY shall notify the

reviewing the 2 Level Formal Appeal. If a formal

presentation is held, the Member will be

permitted to provide documents to the Grievance

Advisory Panel and to have assistance in

presenting the matter to the Grievance Advisory

Panel, including representation by counsel.

However, LIBERTY must be notified at least five

Member in writing on or before the twentieth

th

(

20 ) working day and the investigation shall

be completed within thirty (30) working days

thereafter. The notice will set forth with

specificity the reasons for which additional

time is needed for the investigation; and

(

5) business days before the date of the

scheduled formal presentation of the Member’s

intent to be represented by counsel and/or to

have others present during the formal

presentation. Additionally, the Member must

provide LIBERTY with copies of all documents the

Member may use at the formal presentation (5)

business days before the date of the scheduled

formal presentation.

.

make a decision and communicate its decision

to the Member within five (5) working days of

the completion of the investigation. This

notice of the Grievance Advisory Panel’s

decision will also include notice of the

Member’s right to file an appeal with MDI of

the Grievance Advisory Panel’s decision and

the toll-free telephone number and address

of MDI.

Upon LIBERTY’s receipt of the written request for

a 2 Level Formal Appeal, the request will be

forwarded to the Grievance Advisory Panel along

with all available documentation relating to the

appeal.

nd

If the resolution of the 2 Level Formal Appeal

results in an Adverse Benefit Determination, the

Member will be informed in writing of the

following:

The Grievance Advisory Panel shall:

LDPMO2011

- 15 -

“

Authorized Representative” means a person

.

The specific reason or reasons for upholding

the Adverse Benefit Determination;

designated by the Member to act on his behalf in

pursuing a Claim for Benefits, to file an appeal of

an Adverse Benefit Determination, or in obtaining

an External Review of a final Adverse Benefit

Determination.

Reference to the specific Plan provisions on

which the benefit determination is based;

A

statement describing any additional

voluntary levels of appeal; and

“Benefit Schedule” means the brief summary of

benefits, limitations and Copayments given to the

Subscriber by LIBERTY. It is Attachment A to this

EOC.

For Member’s whose coverage is subject to

ERISA, a statement of the Member’s right to

bring a civil action under ERISA Section 502(a)

following an Adverse Benefit Determination,

if applicable.

“Calendar Year” means January 1 through

December 31 of the same year.

SECTION 8.

Glossary

“Claim for Benefits” means a request for a Plan

benefit or benefits made by a Member in

accordance with the Plan’s Appeals Procedures,

including any Pre-Service Claims (requests for

Prior Authorization) and Post-Service Claims

(requests for benefit payment).

“Adverse Benefit Determination” means

a

decision by the Plan to deny, in whole or in part, a

Member’s Claim for Benefits. Receipt of an

Adverse Benefit Determination entitles the

Member or his Authorized Representative to

appeal the decision, utilizing LIBERTY’s Appeals

Procedures set forth in section 8.

“Contract Year” means the twelve (12) months

beginning with and following the Effective Date of

the Group Enrollment Agreement (GEA).

An Adverse Benefit Determination is final if the

Member has exhausted all complaint and Appeal

Procedures set forth herein for the review of such

Adverse Benefit Determination.

“

Copayment” means the amount the Member

pays when a Covered Service is received.

"

Aesthetic Dentistry" means any dental

“

Covered Services” means the dental services,

procedure performed for cosmetic purposes and

where there is not restorative value.

supplies and accommodations for which the plan

pays benefits under this Plan.

LDPMO2011

- 16 -



Is actively at work;

“Dental Director" means a Missouri licensed

Work at least the

dentist who is contracted with LIBERTY to provide

professional advice concerning dental care to

Members under the applicable EOC.

minimum number of

hours per week indicated

by the Group in this

Application;



Meet the applicable

waiting period

"

Dentist" means an individual who is licensed as a

Doctor of Dental Surgery (D.D.S.) or a Doctor of

Dental Medicine (D.M.D.) in accordance with the

applicable state laws and regulations in which

he/she practices and who is practicing within the

scope of such license.

Enroll during an

enrollment period

Live or work in the service

area; and

Works for an employer

that meets the Minimum

Employer Contribution

Percentage for the

“Dependent” means an Eligible Family Member

of the Subscriber's family who:



meets the eligibility requirements of

applicable coverage

the Plan as set forth in Section 1 of

this EOC;



is enrolled under this Plan; and

“

Eligible Family Member” means a member of a

for whom premiums have been

received and accepted by LIBERTY.

Subscriber’s family that is or becomes eligible to

enroll for coverage under this Plan.

“

Effective Date” means the initial date on which

“Eligible Dental Expenses” or “EDE” means

charges up to the LIBERTY Reimbursement

Schedule amount, incurred by a Member while

he/she is covered under this EOC for Covered

Services.

Members are covered for services under the

LIBERTY Plan provided any applicable premiums

have been received and accepted by LIBERTY.

"

Elective Dentistry" means any dental procedures

that are unnecessary to the dental health of the

patient as determined by LIBERTY's Dental

Director.

“Emergency Services” means Covered Services (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

“Eligible Employee” means a natural person that:

A.

Is a bona fide employees of the

Group; and

professionally recognized standards of care and in

order to alleviate any emergency symptoms in a

dental office ) provided after the sudden onset of

a dental condition with symptoms severe enough

to cause a prudent person to believe that lack of

B.

Meet the following criteria:



Is employed full-time;

LDPMO2011

- 17 -

immediate medical attention could result in

serious:

Group Enrollment Agreement with LIBERTY for

LIBERTY to provide Covered Services.



jeopardy to his health;

“Group Enrollment Agreement” or “GEA” means

the agreement signed by LIBERTY and Group that

states the conditions for coverage, eligibility and

enrollment requirements and premiums.

jeopardy to the health of an unborn

child;



if an enrollee reasonably believes

that the condition, if not diagnosed

or treated, may lead to disability,

dysfunction or death.

“

Initial Enrollment Period” means the period of

time during which an eligible person may enroll

under this Plan, as shown in the GEA signed by

the Group.

“Dentally Necessary” of "Necessary" means a

service or supply needed to improve a specific

dental condition or to preserve the Member’s

dental health and which, as determined by

LIBERTY is:

“

Enrollment Date” means the first day of

coverage under this Plan or, if there is a Waiting

Period, the first day of the Waiting Period.

“ERISA” means Employee Retirement Income



consistent with the diagnosis and

treatment of the Member

Security Act of 1974, as amended, including

regulations implementing the Act.



the most appropriate level of service

which can be safely provided to the

Member; and

“

Evidence of Coverage” or “EOC” means this

document, including any attachments or

endorsements, the Member identification card,

health statements and all applications received by

LIBERTY.



not solely for the convenience of the

Member or the Provider(s).

“

Grievance” means a written complaint

In determining whether a service or

supply is Necessary, LIBERTY may give

consideration to any or all of the

following:

submitted by or on behalf of a Member regarding

the:



availability, delivery or quality of

Covered Services, including a

complaint regarding an Adverse

Benefit Determination;



the likelihood of a certain service or

supply producing a significant

positive outcome;



claims payment, handling or

reimbursement for Covered Services;

or



reports in peer-review literature;

evidence based reports and

guidelines published by nationally

recognized professional organizations

that include supporting scientific

data;

matters pertaining to the contractual

relationship between LIBERTY and a

Member.

“

Group” means an employer or legal entity that



professional standards of safety and

effectiveness that are generally

has completed a Group Application and signed a

LDPMO2011

- 18 -

recognized in the United States for

diagnosis, care or treatment;

prescription order or that is restricted to

prescription dispensing by state law. It also

includes insulin and glucagon.



the opinions of independent expert

Dentists in the health specialty

involved when such opinions are

based on broad professional

consensus; or

“Pre-Service Claim” means any Claim for Benefits

under a Group Health Plan with respect to which

the terms of the Plan condition receipt of the

benefit, in whole or in part, on approval of the

benefit in advance of obtaining medical care.

other relevant information obtained

by LIBERTY.

“Prior Authorization” or “Prior Authorized”

means a system that requires a Provider to get

approval from LIBERTY before providing non-

emergency health care services to a Member for

those services to be considered Covered Services.

Prior authorization is not an agreement to pay for

a service.

Services will not automatically be

considered Dentally Necessary simply

because they were prescribed by a

Dentist.

“

Member” means a person who meets the

eligibility requirements of Section 1, who has

enrolled under this Plan and for whom premiums

have been received by LIBERTY.

“

Referral” means a recommendation for a

Member to receive a service or care from another

Provider or facility.

“

Non-Plan Provider” or "Out-of-network

“

Retrospective” or “Retrospectively” means a

Provider" means a Provider who does not have

an independent contractor agreement with

LIBERTY.

review of an event after it has taken place.

“Rider” means a provision added to the

agreement or the EOC to expand benefits or

coverage.

“Open Enrollment Period” means an annual

thirty-one (31) day period of time during which

Eligible Employees and their Eligible Family

Members may enroll under this Plan.

“Service Area” means the geographical area

where LIBERTY is licensed to operate. It is shown

in Attachment B. Subscribers must live or work in

the Service Area to be covered under this Plan.

Dependent children that are covered under this

Plan, due to a court order, do not have to reside

within the Service Area.

"

Plan” means LIBERTY Dental Plan.

“Plan Provider” means a Provider who has an

independent contractor agreement with LIBERTY

to provide certain Covered Services to Members.

A Plan Provider’s agreement with LIBERTY may

terminate, and a Member will be required to

select another Plan Provider.

“Specialist” means a Plan Provider who has an

independent contractor agreement with LIBERTY

to assume responsibility for the delivery of

specialty dental services to Members. These

specialty dental services include any services not

related to the ongoing primary or regular dental

care of a patient. Specialty dental services

include specific fields of dentistry such as

endodontics, periodontics, oral surgery, or

orthodontics.

“Post-Service Claim” means any Claim for

Benefits under a Group Health Plan regarding

payment of benefits that is not considered a Pre-

Service Claim.

“Prescription Drug” means a Federal Legend drug

or medicine that can only be obtained by a

LDPMO2011

- 19 -

“Subscriber” means an employee of the Group

who meets the eligibility requirements, who has

enrolled under the Plan, and for whom premiums

have been received.

“Waiting Period” means the period of time as

established by the Group that must pass before

coverage for an Eligible Employee or Eligible

Family Member can become effective. If an

Eligible Employee or Eligible Family Member

enrolls as a Special Enrollee, any period before

such Special Enrollment is not a Waiting Period.

LDPMO2011

- 20 -