Phone: (Monday – Friday from 7:00 a.m. until  
:00 p.m., CST.  
LIBERTY Dental Plan  
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  
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.  
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  
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  
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.  
LIBERTY Dental Plan  
P.O. Box 26110  
Santa Ana, CA 92799-6110]  
- 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.  
Be a bona fide employee of the Group; and  
Meet the following criteria:  
Be employed full-time;  
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  
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  
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  
- 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.  
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  
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.;  
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.  
Who Is Not Eligible  
Eligible Dependents may not include:  
A foster child.  
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.  
Right to Deny Application. LIBERTY can deny  
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  
Misrepresents or fails to disclose a material  
fact which would affect coverage under this  
Reaching the limiting age.  
Fails to follow LIBERTY rules.  
Right to Deny Application for Renewal. As a  
condition of Group’s renewal under this Plan,  
LIBERTY may require Group to exclude a  
- 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.  
Failure to meet minimum enrollment  
LIBERTY amends this EOC and the Group  
does not accept the amendment.  
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.  
Termination by LIBERTY  
Failure to maintain eligibility requirements as  
set forth in Section 1.  
On the first day of the month that a  
contribution was due and not received by  
Any member, who has been terminated in any  
manner, may be reinstated by LIBERTY at its sole  
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.  
Retroactive Termination  
A request for retroactive termination by Group  
may be granted as shown in the GEA.  
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  
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:  
- 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  
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.  
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  
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.  
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.  
- 5 -  
Emergency Services and care include (and are  
covered by LIBERTY) dental screening,  
medical professional except for dental  
services otherwise covered herein.  
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.  
Exclusions and Limitations  
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  
General anesthesia, intravenous and  
inhalation sedation, prescription drugs for  
anesthesia, and the services of a special  
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.  
- 6 -  
Treatment to alter vertical dimension or  
to restore occlusion, unless dentures are  
- War.  
Civil insurrection.  
Major therapy for Temporomandibular  
Joint (TMJ) problems including, but not  
limited to, assessment beyond that  
customarily provided in a general dental  
- Or any other emergency beyond  
LIBERTY’s control.  
Prophylaxis is limited to one treatment  
each (6) month period (includes  
periodontal maintenance following active  
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  
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  
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.  
Covered charge for both a temporary and  
a permanent prosthesis will be limited to  
the charge for a permanent prosthesis  
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  
Natural disaster.  
- 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.  
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  
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.  
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  
Bitewing x-rays are limited to not more  
than one series in any six (6) month  
Full mouth x-rays and/or panographic  
type films are limited to one set every  
twenty-four (24) consecutive months.  
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  
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.  
General Provisions  
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.  
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.  
- 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.  
Any notice under this Plan may be given by United  
States mail, first class, postage paid, addressed as  
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.  
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  
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.  
.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.  
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  
- 9 -  
solve the problem there, if the issue is not a Claim  
for Benefits.  
.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.  
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  
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.  
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  
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  
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.  
- 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.  
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.  
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  
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.  
Member Services Representative:  
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  
.1 Informal Review  
may file a 1 Level Formal Appeal.  
A Member who has a Grievance, including a  
complaint regarding an Adverse Benefit  
- 11 -  
.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  
a Grievance requesting a 1 Level Formal Appeal.  
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  
days of the Adverse Benefit Determination.  
The Grievance requesting a 1 Level Formal  
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  
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  
P.O. Box 26110  
Santa Ana, CA 92799-6110  
Fax: (888) 223-0011  
The Grievance requesting a 1 Level Formal  
Appeal shall contain at least the following  
LIBERTY will acknowledge receipt of the  
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;  
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.  
the Grievance requesting a 1 Level Formal  
Appeal, LIBERTY shall notify the Member in  
- 12 -  
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  
decided by  
Level Formal Appeals will be  
grievance review committee  
established by LIBERTY.  
judgment or statement that such  
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:  
If the resolution to the Grievance requesting a 1  
Level Formal Appeal is not acceptable to the  
Member and the Member wishes to pursue the  
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  
informed of the resolution of his 1 Level Formal  
The specific reason or reasons for upholding  
the Adverse Benefit Determination;  
Reference to the specific Plan provisions on  
which the determination is based;  
If the person who submitted the Grievance  
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  
A statement describing any voluntary appeal  
procedures offered by LIBERTY and the  
Member’s right to receive additional  
information describing such procedures;  
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  
- 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  
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:  
Level Formal Appeal  
When a 1 Level Formal Appeal is not resolved in  
a manner that is satisfactory to the Member, the  
Member may initiate a 2 Level Formal Appeal.  
This appeal must be submitted in writing within  
one hundred eighty (180) days after the Member  
has been informed of the resolution of the 1  
Level Formal Appeal.  
LIBERTY’s receipt of the specified information,  
Exhaustion of the 1 Level Formal Appeal  
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.  
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  
relates. The 2 Level Formal Appeal is voluntary  
for all Pre-Service and Post-Service Claims for  
The Member shall be entitled to the same  
reasonable access to copies of documents  
referenced above under the 1 Level Formal  
- 14 -  
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.  
consider the 2 Level of Appeal;  
Upon request a Member is entitled to attend and  
schedule and conduct a formal presentation if  
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  
request for a 2 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 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  
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  
If the resolution of the 2 Level Formal Appeal  
results in an Adverse Benefit Determination, the  
Member will be informed in writing of the  
The Grievance Advisory Panel shall:  
- 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  
Reference to the specific Plan provisions on  
which the benefit determination is based;  
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  
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.  
“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  
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.  
- 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  
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  
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  
“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:  
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  
Meet the following criteria:  
Is employed full-time;  
- 17 -  
immediate medical attention could result in  
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  
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  
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  
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  
submitted by or on behalf of a Member regarding  
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;  
reports in peer-review literature;  
evidence based reports and  
guidelines published by nationally  
recognized professional organizations  
that include supporting scientific  
matters pertaining to the contractual  
relationship between LIBERTY and a  
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  
- 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  
“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  
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  
review of an event after it has taken place.  
“Rider” means a provision added to the  
agreement or the EOC to expand benefits or  
“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  
“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  
- 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.  
- 20 -