LIBERTY Dental Plan of Nevada, Inc.
Evidence of Coverage
This Evidence of Coverage (EOC) describes the dental care plan
made available to Eligible Employees of the Employer (referred to as
“Group”) and their Eligible Family Members.
LIBERTY Dental Plan of Nevada, Inc. (LIBERTY), and the Group
have agreed to all of the terms of this EOC. It is part of the contract
(Group Enrollment Agreement “GEA”) between LIBERTY and Group.
This plan is guaranteed renewable. 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
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.
LIBERTY Dental Plan Member Services Department
(888) 401-1128
LIBERTY provides toll-free customer services support Monday
through Friday from 5:00 a.m. through 5:00 p.m. to assist
Members may also log onto our internet site,, to view plan information, view
claim status, print ID cards, search for Plan Providers, and send
an e-mail notice to our Member Services Department.
NV_EOC_11/11 - 2 -
The Department of Business and Industry
State of Nevada
Division of Insurance
Telephone Numbers
Consumers of Healthcare
The Division of Insurance (“Division”) has established a telephone
service to receive inquiries and complaints from consumers of
healthcare in Nevada concerning healthcare plans.
The hours of operation of the Division are:
Monday through Friday from 8:00 a.m. until 5:00 p.m., Pacific
Standard Time (PST)
The Division local telephone numbers are:
Carson City (775) 687-4270
Las Vegas (702) 486-4009
The Division also provides a toll-free number for consumers
residing outside of the above areas:
1-(888) 872-3234
All questions about Preexisting Condition Limitation should be
directed to LIBERTY’s Member Services Department:
Address: LIBERTY Dental Plan of Nevada, Inc.
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
Phone (Monday Friday from 5:00 a.m. until 5:00 p.m., Pacific
Standard Time):
(888) 401-1128
NV_EOC_11/11 - 3 -
Evidence of Coverage
Subscribers and Dependents who meet the following criteria are
eligible for coverage under this EOC.
Subscriber. To be eligible to enroll as a Subscriber, an employee
A. Be a bona fide employee of the Group; and
B. meets the following criteria:
Be employed full-time;
Be actively at work;
Work at least the minimum number of hours per week indicated
by the Group in its Application;
Meet the applicable waiting period indicated by the Group in its
Enroll during an enrollment period;
Live or work in the service area; and
Work for an employer that meets the Minimum Employer
Contribution Percentage for the applicable coverage.
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
requirements will apply to such Individuals.
Dependent. To be eligible to enroll as a Dependent, a person must
be one of the following:
A Subscriber's legal spouse or a legal spouse for whom a court
has ordered coverage.
Subscriber's Domestic Partner meeting all of the criteria for a
Qualified Domestic Partnership set forth in LIBERTY's Affidavit of
Domestic Partnership.
An unmarried 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
The child must be under the limiting age of 19 years, and except
in the case of a child for whom a court has ordered coverage, the
NV_EOC_11/11 - 4 -
child must qualify as a Dependent of the Subscriber under the
Internal Revenue Code and Regulations.
Any unmarried child, under the age of 23 (or age 24 if your
employer is considered to be a "small employer", 2-50
employees, as defined by Nevada law), who is a full-time student
in an accredited educational institution which is eligible for
payment of benefits under the Veterans Administration Program,
and who is financially dependent on the Subscriber. Proof of full-
time student status must be given to LIBERTY each semester.
Any unmarried child, under the age of 24, who is on a religious
mission and who is financially dependent on the Subscriber. The
religious organization must give LIBERTY a letter, which states
the Dependent is on a religious mission. Proof of the continuation
of the religious mission status must be given to LIBERTY at least
twice a year.
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.
(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
(b) The handicap started before the child reached the limiting
age, but the Group was enrolled with another health
insurance carrier that covered the child as a handicapped
Dependent prior to the Group enrolling with LIBERTY.
LIBERTY may require proof of continuing 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.
Evidence of any court order needed to prove eligibility must be given
Group’s eligibility rules may supersede the Dependent guidelines
noted above. Please contact the sponsor of this program to
determine eligibility requirements.
Eligible Dependents do not include:
NV_EOC_11/11 - 5 -
A foster child.
A child placed in the Subscriber's home other than for the
purpose of adoption.
A grandchild other than a grandchild that has been adopted by
the grandparents and/or has not been place in the home of the
grandparents for the purposes of adoption.
Any other person not defined in Section 1.1.
It is the Subscriber's responsibility to give LIBERTY written notice
within thirty-one (31) days of changes, which affect his Dependents’
eligibility. Changes include:
Reaching the limiting age.
Termination of a Domestic Partnership that qualifies for coverage
under LIBERTY's Affidavit of Domestic Partnership.
Or transfer of residence or work outside LIBERTY’s Service Area.
If Subscriber fails to give notice, which would have resulted in
termination of coverage, LIBERTY shall have the right to terminate
coverage retroactively.
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.
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.
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.
3. Special Enrollment Period. A Special 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.
NV_EOC_11/11 - 6 -
4. Right to Deny Application. LIBERTY can deny membership to
any person who:
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.
Fails to follow LIBERTY rules.
Fails to make a premium payment.
5. Right to Deny Application for Renewal. As a condition of
Group’s renewal under this Plan, LIBERTY may require Group to
exclude a 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.
Before coverage can become effective, LIBERTY must receive and
accept premium payments and an Enrollment Form for the person
applying to be a Member.
When a person applies to be a Member on or before the date he is
eligible, coverage starts as shown in the GEA signed by Group.
1. If a person applies to be a Member within thirty-one (31) days of
the date he is first eligible to apply, coverage starts on the first
day of the calendar month following the month when the
Enrollment Form is received by LIBERTY.
2. Subscriber's newborn natural child is covered for the first thirty-
one (31) days from birth. Coverage continues after thirty-one
(31) days only if the Subscriber enrolls the child as a Dependent
the premium is paid within thirty-one (31) days of the date of
3. An adopted child is covered for the first thirty-one (31) days from
birth only if the adoption has been legally completed before the
child’s birth. A child Placed for Adoption at any other age is
covered for the first thirty-one (31) days after the placement for
Coverage continues after thirty-one (31) days only if the
Subscriber enrolls the child as a Dependent and the premium is
paid within thirty-one (31) days following the placement of the
child in the Subscriber’s home. In the event adoption
proceedings are terminated, coverage of a child Placed for
Adoption ends on the date the adoption proceedings are
NV_EOC_11/11 - 7 -
4. If a court has ordered Subscriber to cover his or her legal spouse
or unmarried minor child, that person will be covered for the first
thirty-one (31) days following the date of the court order.
Coverage continues after thirty-one (31) days if the Subscriber
enrolls the Dependent and the Dependent’s premium is paid. A
copy of the court order must be given to LIBERTY.
5. For a Special Enrollee, the Effective Date of coverage is as
In the case of marriage, on the first day of the calendar month
after the marriage date; or
In the case of birth, adoption or Placement for Adoption, upon
the Dependent’s date of birth, or upon the Dependent’s date
of adoption or Placement for Adoption; or
In the case of all other Special Enrollment Events, on the first
day of the calendar month after an Enrollment Form is
received, unless otherwise specified in the GEA.
6. When a person applies to be a Member during the Open
Enrollment Period, coverage starts on the first day of the
calendar month following the Open Enrollment Period.
Subscriber must give LIBERTY a copy of the certified birth
certificate, decree of adoption, or certificate of placement for
adoption for coverage to continue after thirty-one (31) days for
newborn and adopted children.
Subscriber must give LIBERTY a copy of the certified marriage
certificate, complete affidavit of domestic partnership (LIBERTY's
form only), proof of student status or any other required
documents before coverage can be effective for other Eligible
Family Members.
LIBERTY may terminate coverage under this Plan at the times shown
for any one or more of the following reasons:
Failure to maintain eligibility requirements as set forth in Section
Payment is due on 1st the day of each month that you are
insured by LIBERTY. There is a 30 day grace period for payment
to be received by LIBERTY. The member will be terminated on
the 31
day if payment has not been received by LIBERTY.
NV_EOC_11/11 - 8 -
On the first day of the month that a contribution was due and not
received by LIBERTY.
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.
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 if the discovery is made within
two years of the document being received by LIBERTY.
When a Subscriber moves his primary 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
LIBERTY within thirty-one (31) days of the change. LIBERTY will
request proof of the change of residence and/or place of work.
On the date the GEA terminates for any reason, including but not
limited to:
1. Nonpayment of premiums.
2. Failure to meet minimum enrollment requirements.
3. LIBERTY amends this EOC and the Group does not accept
the amendment.
Subscriber has the right to terminate his coverage under the Plan.
Termination notice must be reported to LIBERTY by the sponsor of
this program. Such termination is effective on the last day of the
month when the notice is received by LIBERTY, unless stated
otherwise in the GEA.
Any coverage which has been terminated in any manner, may be
reinstated by LIBERTY at its sole discretion.
2.4 Retroactive Termination
A request for retroactive termination by Group may be granted as
shown in the GEA.
NV_EOC_11/11 - 9 -
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 all services and supplies
incurred after the effective date of the termination of this EOC and/or
the GEA.
This Plan offers you a choice of where you receive your dental care.
However, to receive benefits under this plan, you must receive care
from a Plan Provider. When you choose to receive your care from
any dentist that is a Plan Provider, your costs will be limited by the
costs 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 Specialist your
Plan Provider must initiate the referral process with LIBERTY.
LIBERTY will then refer you to a Specialist who is a Plan Specialty
Provider for approved Specialty services.
Care by a Specialist that was not approved by LIBERTY following the
Specialty Referral process noted above will not be considered a
covered benefit.
You and your dependents can choose a Plan Provider from a network
of private practice dental offices. A list of Plan Providers is available
through the Plan.
This section tells you what services are covered under this Plan.
Only services and supplies, which meet LIBERTY’s definition of
Dentally Necessary and are identified as covered benefits on the
Benefits Schedule will be considered to be Covered Services. The
Benefit Schedule shows applicable Copayments and benefit
limitations for Covered Services.
Subject to the Exclusions listed herein, dental services related to a
Member's dental health as identified in the Benefits Schedule and that
are dentally necessary are available to Members.
Benefits must be obtained from Plan Providers. The Benefit
Schedule identifies the member copayments that are to be paid to
Plan Providers at the time of service.
NV_EOC_11/11 - 10 -
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.
All claims shall be approved or denied within thirty (30) days after
receipt by the Plan, unless additional information is requested. If the
claim is approved, the claim will be paid within thirty (30) days after it
is approved. If the Plan requires additional information, the Member
shall be notified within twenty (20) days after the Plan actually
receives the claim. The claim will be paid or denied within thirty (30)
days of the Plan's receipt of all of the additional information it
All claims must be submitted to LIBERTY within sixty (60) days from
the date expenses were incurred, unless it shall be shown not to have
been reasonably possible to give notice within the time limit, and that
notice was furnished as soon as was reasonably possible.
No payments shall be made under this EOC with respect to any
claim, including additions or corrections to a claim which has already
been submitted, that is not received by LIBERTY within twelve (12)
months after the date Covered Services were provided.
Denials of claims can be submitted to the Plan's Grievance
procedures described in this EOC.
In the event of an emergency outside the service area of the Plan, the
Member should contact LIBERTY at (888) 401-1128 The Plan will
direct you to an available Plan Provider if possible. Should no Plan
Provider be available in a fifty (50) mile radius you can seek treatment
from any licensed dentist. In such an event, the Plan will reimburse
you for the cost of qualified emergency services received from an out-
of-network provider up to a maximum of seventy-five dollars ($75),
less any applicable member co-payments based on the Plan Benefits.
Any non-qualified emergency services will not be considered as
reimbursable emergency services.
The Plan provides coverage for emergency dental services only if the
services are required to alleviate severe pain or bleeding or if an
enrollee reasonably believes that the condition, if not diagnosed or
treated, may lead to disability, dysfunction or death.
NV_EOC_11/11 - 11 -
Qualified emergency dental service and care include a dental
screening, examination, evaluation by a dentist or dental specialist to
determine if an emergency dental condition exists, and to provide
care that would be acknowledged as within professionally recognized
standards of care an in order to alleviate any emergency symptoms in
a dental office.
1. Any procedure not specifically listed as a covered benefit
2. Replacement of lost or stolen prosthetics or appliances
including partial dentures, full dentures, and orthodontic
3. General anesthesia, analgesia, intravenous/intramuscular
sedation or the services of an anesthesiologist other than
those situations described below the covered benefits***
4. Treatment started prior to coverage or after termination of
5. Procedures, appliances, or restorations to treat
temporomandibular joint dysfunctions (e.g.
adjustments/corrections to the facial bones), congenital or
developmental situations (including supernumerary teeth) or
medically induced dental disorders, including but not limited
to: myofunctional treatment (e.g. speech therapy), or
myoskeletal dysfunctions, unless otherwise covered as an
orthodontic benefit
6. Services for cosmetic purposes or for conditions that are a
result of hereditary of developmental defects, such as cleft
palate, upper and lower jaw malformations, congenitally
missing teeth and teeth that are discolored or lacking enamel.
7. Procedures which are determined not to be dentally
necessary consistent with professionally recognized
standards of dental practice
8. Procedures performed on natural teeth solely to increase
vertical dimension or restore occlusion
9. Any services performed outside of a contracted LIBERTY
dental office, unless expressly authorized by LIBERTY Dental
Plan, or unless as outlined and covered in “Emergency
Dental Care” section.
10. The removal of asymptomatic, unerupted third molars (or
other teeth) that appear to have an unimpeded pathway to
eruption and no active pathology.
11. Procedures or appliances that are provided by a Dentist who
specializes in prosthodontics services.
NV_EOC_11/11 - 12 -
12. Services for restoring tooth structure lost from wear
(abrasion, erosion, attrition or abfraction), for rebuilding
occlusion or maintaining chewing surfaces of teeth that are
out of alignment or for stabilizing teeth. Examples of such
treatment are equilibration and periodontal splinting.
13. Any routine dental services performed by a primary care
dentist or specialist in an inpatient/outpatient hospital setting.
14. Consultations for non-covered services.
1. Prophylaxis procedures are covered once every 6
consecutive months.
2. Complete series of x-rays (full mouth x-rays) or panoramic
films are covered once every 36 consecutive months.
3. Fluoride treatments are covered once every 6 consecutive
4. Sealants are covered only on the first and second permanent
molars with no caries (decay) for dependent children up to
the 14
birth date. Limited to once per tooth per thirty-six
(36) month period.
5. Scaling and root planning per quadrant is covered once every
24 consecutive months.
6. Replacement of crowns, labial veneers or fixed partial
dentures (bridgework), per unit, are limited to once every five
(5) year period.
7. Replacement of an existing full and partial denture is covered
once per arch every 5 years if the appliance cannot be made
functional through reline or repair.
8. Denture Relines are covered twice every 12 consecutive
9. Fabricated crowns, onlays and inlays may be covered when a
tooth with a good prognosis requires restoration but has
insufficient remaining structure to reliably retain a filling.
Coverage for these procedures limited to members age 16
and over.
10. The replacement of an amalgam or resin restoration in less
than twelve months by the same contracted dentist or office is
not chargeable to the plan or the member.
11. Procedure(s) that appear to have a poor prognosis as
determined by a licensed LIBERTY dentist consultant are not
12. Localized delivery of antimicrobial agents may be covered 4-6
weeks after the completion of scaling and root planning as an
adjunctive procedure for two non-responsive sites in a
quadrant with 5 mm pockets or deeper plus inflammation.
NV_EOC_11/11 - 13 -
13. For treatment plans involving seven (7) or more units of
crowns and/or fixed partial dentures (bridges), contracted
providers may charge an additional $200 co-payment per
unit. In such cases, the first six (6) units as described in
limitation #6 above are covered at the specified member co-
payment amount only, as documented on the Plan’s
Schedule of Benefits;
14. Fixed Partial Dentures (bridges) are covered when: replacing
a “like-for-like” existing fixed partial denture with identical
pontics and abutment teeth with a good prognosis; abutment
teeth qualify for crowns on their own merit as described in
limitation #6 above; there is only one missing permanent
tooth in a full arch and the bridge would have opposing teeth
in the opposite arch.
15. Surgical periodontal services are limited to once every thirty-
six (36) month period.
16. Full mouth debridement is limited to once in a twenty-four
(24) month period.
17. Pediatric referrals, if authorized by LIBERTY Dental Plan, are
covered only for dependent children through the age of six (6)
unless the child qualifies under the American with Disabilities
Act (ADA).
Orthodontic Exclusions & Limitations
1. Replacement of lost or stolen orthodontic appliances
2. Lost, stolen or broken appliances
3. Orthodontic treatment started prior to member’s effective date
of coverage unless covered through an orthodontic takeover
4. Extractions for orthodontic purposes, (will not be applied if
extraction is consistent with professionally recognized
standards of dental practice or arises in the context of an
emergency dental condition)
5. Treatment in progress at the time of eligibility, unless included
as an orthodontic rider to the groups benefits.
6. Temporomandibular joint syndrome (TMJ) surgical
7. Myofunctional therapy
8. Treatment of cleft palate
9. Treatment of micrognathia
10. Treatment of macroglossia
11. Changes in orthodontic treatment necessitated by accident of
any kind
12. Orthodontic coverage is limited to 24 months of treatment,
followed by 24 months of retention office visits.
NV_EOC_11/11 - 14 -
13. Services provided after the 24
month of treatment and/or
retention is the responsibility of the patient
14. In the event of termination the patient is responsible for the
usual fee of the treating dentist pro-rated over the remainder
of treatment and/or retention
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. LIBERTY is not bound by statements or promises made by its
Plan Providers.
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.
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.
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.
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.
NV_EOC_11/11 - 15 -
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.
Any notice under this Plan may be given by United States mail, first
class, postage paid, addressed as follows:
LIBERTY Dental Plan of Nevada, Inc.
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
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 LIBERTY.
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.
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.
Clerical error in keeping any record pertaining to the coverage will not
invalidate coverage in force or continue coverage terminated.
LIBERTY may adopt reasonable policies, procedures, rules and
interpretations to promote 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 dental service and/or
supply are covered.
LIBERTY has the right to collect payments for healthcare services
made in error. Dentists, Specialists and other providers have the
NV_EOC_11/11 - 16 -
responsibility to return any overpayments or incorrect payments to
LIBERTY. LIBERTY has the right to offset any overpayment against
any future payments.
Each Member authorizes their providers to permit the examination
and copying of the Member's medical records, as requested by
Whenever a masculine pronoun is used in this EOC, it also includes
the feminine pronoun.
LIBERTY does not guarantee the continued availability of any Plan
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.
If a Member’s Plan is governed by ERISA, a Member must exhaust all
mandatory levels of appeal before bringing a claim in court for a
Claim of Benefits.
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 solve the problem there, if the issue is not a Claim
for Benefits.
Please see the Glossary terms for a description of the terms used in
this section.
The following Appeals Procedures will be followed if the dental
service site matter cannot be resolved at the site or if the concern
involves the Adverse Benefit Determination of a Claim for Benefits.
Informal Review: An Adverse Benefit Determination or other
complaint/concern which is directed to the LIBERTY Member
NV_EOC_11/11 - 17 -
Services Department via phone or in person. If an Informal
Review is resolved to the satisfaction of the Member, the matter
ends. The Informal Review is voluntary.
Level Formal Appeal: An appeal of an Adverse Benefit
Determination filed either orally or in writing which LIBERTY’s
Customer Response and Resolution Department investigates. If
a 1
Level Formal Appeal is resolved to the satisfaction of the
Member, the appeal is 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
Level Formal Appeal: If a 1
Level Formal Appeal is not
resolved to the Member’s satisfaction, a Member may then file a
Level Formal Appeal. A 2
Level Formal Appeal is submitted
in writing and reviewed by the Grievance Review Committee.
The 2
Level Formal Appeal is voluntary for all Adverse Benefit
Grievance Review Committee: A committee of three (3) or
more individuals, the majority of which must be Members of
Member Services Representative: An 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.
A Member who has received an Adverse Benefit Determination of a
Claim for Benefits may request an Informal Review. All Informal
Reviews must be made to LIBERTY’s Member Services Department
within sixty (60) days of the Adverse Benefit Determination. Informal
Reviews not filed in a timely manner will be deemed waived. The
Informal Review is a voluntary level of appeal.
Upon the initiation of an Informal Review, a Member must provide
Member Services with at least the following information:
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;
NV_EOC_11/11 - 18 -
A brief statement of the nature of the matter, the reason(s) for the
appeal, and why the Member feels that the Adverse Benefit
Determination was wrong.
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
may file a 1
Level Formal Appeal.
When an Informal Review is not resolved 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 1
Level Formal Appeal. The 1
Level Formal
Appeal must be submitted in writing to LIBERTY’s Customer
Response and Resolution Department within 180 days of an Adverse
Benefit Determination. 1
Level Formal Appeals not filed in a timely
manner will be deemed waived with respect to the Adverse Benefit
Determination to which they relate.
The 1
Level Formal Appeal shall contain at least the following
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;
A brief statement of the nature of the matter, the reason(s) for
the appeal, and why the Member feels that the Adverse Benefit
Determination was wrong.
Additionally, the Member may submit any supporting medical/dental
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 1
Level Formal Appeals should be sent or faxed to the following:
Address: LIBERTY Dental Plan of Nevada, Inc.
Attn: Customer Response and Resolution Dept.
NV_EOC_11/11 - 19 -
6385 S. Rainbow Blvd., Suite 200
Las Vegas, NV 89118
Fax: (888) 401-1129
LIBERTY will investigate the appeal. When the investigation is
complete, the Member will be informed in writing of the resolution
within thirty (30) days of receipt of the request for the 1
Level Formal
Appeal. This period may be extended one (1) time by LIBERTY for up
to fifteen (15) days, provided that the extension is necessary due to
matters beyond the control of LIBERTY and LIBERTY notifies the
Member prior to the expiration of the initial thirty (30) day period of the
circumstances requiring the extension and the date by which
LIBERTY expects to render a decision. If the extension is necessary
due to a failure of the Member to submit the information necessary to
decide the claim, the notice of extension shall specifically describe
the required information and the Member shall be afforded at least
forty-five (45) days from receipt of the notice to provide the
Level Formal Appeals will be decided by a Grievance Review
If the 1
Level Formal Appeal results in an Adverse Benefit
Determination, the Member will be informed in writing of the following:
The specific reason or reasons for upholding the Adverse Benefit
Reference to the specific Plan provisions on which the
determination is based;
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;
A statement describing any voluntary appeal procedures offered
by LIBERTY and the Member’s right to receive additional
information describing such procedures;
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 relied on in making the determination is
available free of charge upon the Member’s request; and
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 judgment or a
statement that such explanation will be provided free of charge.
NV_EOC_11/11 - 20 -
Limited extensions may be required if additional information is
required in order for LIBERTY to reach a resolution.
If the resolution to the 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 Appeal.
The Member can ask (either orally or in writing) for an Expedited
Appeal of an Adverse Benefit Determination for a Pre-Service Claim
that 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
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 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:
LIBERTY’s receipt of the specified information, or
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
NV_EOC_11/11 - 21 -
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.