How Your Florida Exchange Dental Plan Works

We thank you for considering LIBERTY as your dental plan provider of choice.  The following provides important information about how your plan works.  For further assistance, please contact LIBERTY at
(877) 877-1893, Monday through Friday 8:00 am to 5:00 pm.

Access to Care

On your LIBERTY Dental plan, benefits are provided for in-network services only. If you go to Providers outside the network, you will have to pay all the cost, unless you received pre-approval from LIBERTY or you had Emergency Dental Care and are unable to reach your Primary Care Dentist.

Your Primary Care Dentist will provide for all of your dental care needs, including referring you to a specialist should it be necessary. When you join LIBERTY Dental plan, you must choose a Primary Care Dentist and will be auto-assigned to a dentist nearest you at the time you enroll.  If you desire to make a change, you may do so at any time.  Simply contact our Member Services Department toll-free at (877) 877-1893.  Your requested change to a Primary Care Dentist will be in effect on the first (1st) day of the following month if the change is received by LIBERTY Dental Plan prior to the twentieth (20th) of the current month.

A listing of providers in the LIBERTY network is available at https://www.libertydentalplan.com/Healthcare-Exchange/Florida-Exchange/Find-a-Dentist.aspx.

Balance Billing

Balance billing is when a provider bills you for the difference between what they bill and the amount covered by the plan. 

There is no balance billing on your LIBERTY DHMO plan. LIBERTY has contracted with network providers to accept member copayments as payment in full.  Member copayments are payable to the dental office at the time you receive services, and are subject to Out-of-Pocket Maximums if the services are covered as a Pediatric benefit.

Pediatric benefits apply for Enrollees ages 0 to the age of 19. Adult benefits are not subject to Out-of-Pocket Maximums. There may be other costs incurred for optional and non-covered services that do not apply toward Out-of-Pocket Maximums. For more details, please review your Schedule of Benefits.

Submitting Claims

LIBERTY contracts with in-network providers to accept member copayments as payment in full and to bill LIBERTY directly for services rendered. If you pay a bill for covered Emergency Dental Care, you may submit a copy of the paid bill to LIBERTY Dental Plan, Claims Department, P.O. Box 26110, Santa Ana, CA 92799-6110. Include a copy of the claim from the Provider’s office or a legible statement of services/invoice.  Please forward to LIBERTY the following information along with your claim:

• Your membership information
• Individual’s name that received the Emergency Dental Services
• Name and address of the dentist providing the Emergency Dental Service.
• A statement explaining the circumstances surrounding the emergency visit.

If additional information is needed, you will be notified in writing. If any part of your claim is denied you will receive a written explanation of benefits (EOB) within 30 days of LIBERTY Dental Plan’s receipt of the claim.

Claims for Emergency Dental Care must be submitted to LIBERTY six (6) months from the date you received services. For further assistance, please contact LIBERTY at (877) 877-1893, Monday through Friday 8:00 am to 5:00 pm.

Advance Premium Tax Credit Recipients and Grace Periods for Individual Dental Plan Enrollees

LIBERTY’s Family Value Plan has a grace period, which is a period of days you have to make the necessary premium payment before your coverage is termed.  The number of days will depend on whether you receive an Advance Premium Tax Credit.

An Advance Premium Tax Credit (APTC) is a refundable tax credit designed to help eligible individuals and families with low or moderate income purchase individual health insurance through the Health Insurance Marketplace (Healthcare.gov).  When you enroll for coverage through the Marketplace, you can choose to have the Marketplace compute an estimated credit that is paid to your insurance company to lower what you pay for your monthly premiums. If you choose to apply your APTC to LIBERTY’s Family Value Plan, your Grace Period will be extended to three months.

For members not receiving an Advance Premium Tax Credit

This plan has a one month grace period for members not receiving an Advance Premium Tax Credit.  This means that if any required premium is not paid on or before the date it is due, it may be paid during the period immediately following the premium due date.  Your coverage will stay in effect during the grace period.  If payment is not received by the end of the grace period, termination for non-payment will be effective on midnight of the last day of the month for which premiums were last received.

For members receiving an Advance Premium Tax Credit

Members receiving an advanced premium tax credit will be extended a three-month grace period. LIBERTY will cover all allowable claims for the first month of the three-month grace period and may pend claims submitted during the second and third months of the grace period. These claims will be put on hold until all outstanding payment has been received or until the three-month grace period ends.

During the grace period, LIBERTY will continue to collect subsidy payments on the delinquent member’s behalf and return such payments of the premium tax credit for the second and third months of the grace period if the member exhausts the grace period without paying premium. If your premium is not received by the end of the third month of the grace period, termination will be effective on the last day of the first month of the grace period.

Any claims submitted during the second and third month grace period will be denied, and your provider may bill you for the costs of services.

Grace Periods for Enrollees on the Small Business Exchange Dental Plan

LIBERTY’s FL Pediatric Low with Adult Option plan (offered on the Small Business Exchange) has a one month grace period, which is a period of days your employer has to make the necessary premium payment before coverage is termed.   This means that if any required premium is not paid on or before the date it is due, it may be paid during the period immediately following the premium due date.  Your coverage will stay in effect during the grace period.  If payment is not received by the end of the grace period, termination will be effective on midnight of the last day of the month for which premiums were last received.  If your coverage is termed due to non-payment, you and your employer will be provided a notice of termination of coverage.

Retroactive Denials of Claims

LIBERTY may deny a previously paid claim if your coverage has been retroactively terminated.  In this situation, only claims paid for services performed after your termination date will be denied due to not being eligible for services; and your provider may directly bill you for the costs of services. You and your provider will be notified of a retroactive denial through a written Explanation of Benefits (EOB). 

While timely premium payment is the best way to avoid a retroactive denial of a claim, it is also a standard that network providers contact LIBERTY to verify eligibility at the time of your dental appointment.  This comes in handy if you are receiving an Advance Premium Tax Credit and are in the second or third month of your grace period. For an explanation on how grace periods affect your coverage, please refer to the section of this document titled: Advance Premium Tax Credit Recipients and Grace Periods for Individual Dental Plan Enrollees.

For information about your member rights and responsibilities, please refer to your Evidence of Coverage.

Seeking a Refund

If duplicate payment has been sent, you may contact LIBERTY about your payment at
(877) 877-1893, Monday through Friday 8:00 am to 5:00 pm.

Medical Necessity

“Medical necessity” or “dental necessity” is used to describe treatment or a set of services that is reasonable, necessary, and meets accepted standards of dental practice. Your dentist will recommend treatment depending on your specific oral health and/or condition.  If a service requires proof of dental necessity, your treating dentist will include the appropriate documentation at the time a claim is submitted. Services may not be covered if the recommended treatment does not meet the plan’s requirements for dental necessity, appropriateness, dental care setting, or level of care or effectiveness.

Services determined to be unnecessary or which do not meet accepted standards of dental practice are not covered, and cannot be billable to the member by a contracted dentist unless the dentist notified the member of his/her financial liability prior to treatment and the member chooses to receive the treatment.

Pre-authorizations

No prior benefit authorization is required in order to receive dental services from your Primary Care Dentist. The Primary Care Dentist has the authority to make most coverage determinations. The coverage determinations are achieved through comprehensive oral evaluations which are covered by your plan. Your Primary Care Dentist is responsible for communicating the results of the comprehensive oral evaluation and advising of available benefits and associated cost.

In the event that you need to be seen by a specialist, LIBERTY Dental Plan does require prior benefit authorization. Your Primary Care Dentist is responsible for obtaining authorization for you to receive specialty care.

Once a specialty referral is processed, the Member, the referring Primary Care Dentist who originally submitted the referral, and the Specialist receive a copy of the approved referral which includes the services approved, the Member Copayment and the amount we will pay the Specialist (according to their contracted fees).  Once the services have been performed by the Specialist, the Specialist will send the Plan a claim form and we will pay the Specialist directly for the approved services.

Explanation of Benefits

An Explanation of Benefits (EOB) is a statement that explains which services were paid on your behalf, the amount your plan covered, and the copay that was due and paid at the time of the office visit.  EOBs are sent by mail within thirty (30) days of LIBERTY’s receipt of a claim.

If any part of your claim is denied you will receive a written EOB within thirty (30) days of LIBERTY Dental Plan’s receipt of the claim that includes:

• The reason for the denial.
• Reference to the Evidence of Coverage provisions on which the denial is based.
• Notice of your right to request reconsideration of the denial, and an explanation of the grievance procedures.

How to Read an EOB

LIBERTY’s EOBs have three main sections:

• Claim information is provided at the top and includes the subscriber and patient name, ID number, claim number, the dentist’s name and the date the claim was reviewed.
• Coverage information includes a list of services the provider billed for by the Date of Service (DOS) and the American Dental Association Code along with the description of the service, the tooth, surface and quantity and the Member Co-pay that was paid at the time of the office visit.
• Below the totaled amounts is the Service Line Explanation.  This section includes any additional information, including reasons for claim denials.

Coordination of Benefits

The coordination of benefits is a process that ensures that the payment of services is not paid multiple times when one person has several dental plans.  This can include situations where a child is enrolled on two different dental plans because each parent has his or her own separate dental policy.

As a covered Member, you will always receive your LIBERTY benefits. LIBERTY does not consider your Dental Plan secondary to any other coverage you might have. You are entitled to receive benefits as listed in your Evidence of Coverage despite any other coverage you might have in addition.