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This section:
- Summarizes Dental Basic and Dental Plus
features in a table to help you quickly compare and
choose the right plan for you and your dependents.
- Defines the applicable benefit period, deductibles, and
annual maximum benefits.
- Outlines which dental services are covered and which ones
are not covered under these plans.
- Describes your choices in working with dental plan
providers and links you to a list of providers.
- Explains how to appeal a claim and other membership
policies in detail.
Return to Dental
Table of Contents
Our Year 2004 FlexAbility Benefits Plan gives you
a choice of three dental plan options:
- Dental Basic
A continuation of the dental plan offered by PeaceHealth
in the past, this option provides the same features and
level of coverage it always has. No changes have been
made to this plan.
- Dental Plus
For a slightly higher premium, this new plan offers a
higher level of coverage. It includes all the features of
our Dental Basic plan, increases your annual
maximum to $1,500, and provides orthodontia coverage at
50% for children and adults to a lifetime maximum of
$1,500.
- No Coverage
You may elect to waive dental coverage entirely and apply
the credits toward other benefits or take them as cash.
Note that you do not have to be covered under another
dental plan to waive dental coverage.
Both Dental Basic and Dental Plus
plans provide you and your family with comprehensive dental
benefits, and use the same network of providers through the
Washington Dental Service (WDS). Through this network you have a
wide selection of dental health providers committed to providing
you with the highest quality dental care for the lowest possible
costs.
The table below compares Dental Basic and
Dental
Plus features in overview to help you choose the right plan
for you and your dependents. The Plan Features listed in this
table are described in detail later in this section entitled
"What Is Covered."
| Plan Features |
Amount
Covered
|
Dental
Basic
|
Dental Plus
|
| Preventive
Care |
100%
|
100%
|
| Basic
Care |
80%
|
80%
|
| Major
Care |
50%
|
50%
|
| Accidental
Injury |
100%
|
100%
|
| Orthodontia
|
Not covered
|
50% up to a lifetime maximum of $1,500
|
| Deductible - Waived for preventive care and
orthodontia |
$25.00/$75.00
|
$25.00/$75.00
|
| Annual
maximum benefit amount per individual |
$1,000
|
$1,500
|
To provide maximum flexibility, you may re-elect
or change your dental plan option every year. The coverage period
for both dental plans is 12 months, running from January 1
through December 31.
There is no deductible for dental services covered under Preventive Care or Accidental Injury, whether provided to you or another eligible member of your family.
For dental services covered under Basic Care and Major Care, an annual deductible of $25 applies to each eligible person, with a maximum deductible of $75 for each family during the 12-month period. In other words, you pay the first $25 of care for each person in your family who uses these services.
Once an eligible person has satisfied the deductible amount for the period, no further deduction applies to that person until the next 12-month period. Likewise, once a family has satisfied the maximum deductible amount of $75 during the 12-month coverage period, no further deductions apply to that family until the next period. For example, if you pay the $25 deductible for three of your family members, your family deductible is satisfied: no deductible payments are required for any other eligible family members for the remainder of the 12-month period.
Dental Basic
The plan pays a maximum benefit of up to
$1,000 towards covered dental services (including preventive care) for each eligible person
for each 12-month period. If you undergo a dental procedure
requiring multiple treatments on different dates, all charges are
applied to the annual maximum in effect on the date the procedure
is completed.
Dental Plus
The plan pays a maximum benefit of up to
$1,500 towards covered dental services (including preventive care) for each eligible person
for each 12-month period. Dental Plus covers orthodontia
for adults and children at 50% up to a lifetime maximum of
$1,500. If you undergo a dental procedure requiring multiple
treatments on different dates, all charges are applied to the
annual maximum in effect on the date the procedure is completed.
For extensive dental care, (non-emergency care
for which charges will be more than $100), you may want to
determine in advance exactly what procedures are covered, the
amount Washington Dental Service will pay toward treatment, and
what your financial responsibility will be. To do this:
- Have your dentist complete a standard claim form showing
the estimated costs, and submit it to WDS. (If your
dentist is not part of the network, you must submit the
claim form yourself.)
- Washington Dental Service reviews the claim form and lets
either you or your dentist (depending on who submitted
the claim) know what amounts will be covered by the plan.
Return to Dental
Table of Contents
Many dental conditions can be treated properly in
more than one way. This plan is designed to help offset your
dental expenses and to cover treatments necessary to maintain
good dental health.
Both Dental Basic and Dental Plus
plans provide identical coverage for Preventive Care, Basic Care,
Major Care, and Accidental Injury. In addition, Dental Plus
provides coverage for Orthodontia. The specific services covered
are listed in the paragraphs following.
To be eligible for payment, charges must be
included in the "Services Covered" as listed here.
Services or treatments not covered by the plans are listed under
"Services Not Covered" under each of the care
types. Additional dental services not covered by these plans are
listed in the section entitled "What Is Not Covered."
Both plans cover 100 percent of the preventive
care services listed here. You do not need to meet a deductible
to receive these services. (Please note - the cost of the preventive care
applies to your annual maximum benefit)
Services
Covered
- Routine examination, twice in a benefit period
- Complete series (4 bitewing x-rays and up to 10
periapical x-rays) or panorex X-rays, once in a
three-year period
- Supplementary bitewing X-rays, twice in a benefit period
- Emergency examination
- Examination by a specialist in a specialty recognized by
the American Dental Association
- Cleaning (prophylaxis), twice in a benefit period
- Fluoride applications or preventive
therapies (but not both) twice in a benefit period up to the patient's
19th birthday
- Fissure sealants, once in a three-year period per tooth
for children through age 14; the tooth must be a
permanent molar with incipient or no caries (decay) on an
intact occlusal surface. If eruption of permanent molars
is delayed, sealants will be allowed if applied within 12
months of eruption with documentation from the attending
dentist
- Space maintainers that are used to maintain space for
eruption of permanent teeth
Services
Not Covered
- Diagnostic services and X-rays that are related to the
jaw joints, also called the temporomandibular joints
- Consultations
- Study models
- Tests for susceptibility to decay (caries)
- Plaque control programs such as oral hygiene instruction,
dietary instruction, and home fluoride kits
- Cleaning of a prosthetic appliance
- Replacement of a space maintainer previously paid for by
WDS
Return to Dental
Table of Contents
Both plans cover 80 percent of the
cost of basic care services listed below. Payments you make for these services
apply to your yearly deductible. For more information on dental plan
deductibles, go to Deductibles.
General anesthesia, when medically
necessary, for children through age six (6), or a physically or developmentally
disabled person, when in conjunction with Preventive care, Basic care, Major
care and Orthodontic covered dental procedures. General anesthesia is
covered only when administered by a licensed Dentist or other WDS-approved
Licensed Professional who meets the educational, credentialing and privileging
guidelines established by the Dental Quality Assurance Commission of the State
of Washington, when medically necessary, for children through age six (6), or a
physically or developmentally disabled person, when in conjunction with covered
dental procedures.
Services
Covered
- Treatment of carious lesions (visible destruction of hard
tooth structure resulting from the process of dental
decay) or fracture resulting in significant loss of tooth
structure (missing cusp) using amalgam, composite or
filled resin restorations (fillings).
- Stainless steel crowns are covered once in a two-year
period.
- Restorations on the same surface(s) of the same tooth,
once in a two-year period.
- If a composite or filled resin restoration is placed in a
posterior tooth, an amalgam allowance will be made that
can be applied to that procedure.
Services
Not Covered
-
Restorations to correct vertical dimension or to restore
the occlusion.
-
Overhang removal, re-contouring, or polishing of
restoration.
Services
Covered
-
Removal of teeth and surgical extractions.
-
Preparation of the alveolar ridge and soft tissue of the
mouth for insertion of dentures.
-
Treatment of pathological conditions and traumatic facial
injuries.
-
General anesthesia/IV sedation only when administered by
a licensed dentist or other WDS approved licensed
professional who meets the educational, credentialing and
privileging, guidelines established by the Dental Quality
Assurance Commission of the State of Washington in
conjunction with a covered oral surgery procedure.
Services
Not Covered
Return to Dental
Table of Contents
Services
Covered
-
Surgical and non-surgical procedures for treatment of the
tissues supporting the teeth
-
Gingivectomy.
-
Limited adjustments to occlusion (8 teeth or less) such
as smoothing of teeth or reducing of cusps, once in a
12-month period.
-
Periodontal scaling/root
planing, once in a 12-month
period.
-
General anesthesia/IV sedation only when administered by
a licensed dentist or other WDS approved licensed
professional who meets the educational, credentialing and
privileging, guidelines established by the Dental Quality
Assurance Commission of the State of Washington in
conjunction with covered periodontal surgery procedure.
Services
Not Covered
-
Nightguards and occlusal splints
-
Periodontal splinting and/or crown and bridgework in
conjunction with periodontal splinting
-
Crowns as part of periodontal therapy
-
Major (complete) occlusal adjustment
-
Periodontal appliances
-
Gingival curettage
Services
Covered
-
Procedures for pulpal and root canal therapy.
-
Pulp exposure treatment,
pulpotomy, and apicoectomy.
-
Root canal treatment on the same tooth, once in a
two-year period.
-
General anesthesia/IV sedation only when administered by
a licensed dentist or other WDS approved licensed
professional who meets the educational, credentialing and
privileging, guidelines established by the Dental Quality
Assurance Commission of the State of Washington in
conjunction with a covered endodontic surgical procedure.
Services
Not Covered
The plan covers 50 percent of the cost of major
care services listed here. The deductible amount applies to any
payments for major care services. For more information on dental
plan deductibles, go to Deductibles.
Services
Covered
-
Treatment of carious lesions (visible destruction of hard
tooth structure resulting from the process of dental
decay) or fracture resulting in significant loss of tooth
structure (missing cusp) using crowns, inlays, (only when
used as an abutment for a fixed bridge), and onlays
(whether they are gold, porcelain, WDS-approved gold
substitute castings, (except processed resin) or
combinations of these) when verification is provided by
the attending dentist that teeth cannot be restored with
filling materials such as amalgam, composite or filled
resin.
-
Crowns, inlays, or onlays on the same teeth, once in a
five-year period.
-
If a tooth can be restored with a filling material such
as amalgam, or filled resin, an allowance will be made
for such a procedure toward the cost of any other type of
restoration that may be provided.
-
WDS will allow the appropriate amount for an amalgam or
composite restoration toward the cost of processed filled
resin or processed composite restorations.
-
Crown buildups, subject to
limitations and exclusions.
Services
Not Covered
-
A crown used as an abutment to a partial denture for
purposes of re-contouring, repositioning or to provide
additional retention is not covered unless the tooth is
decayed to the extent that a crown would be required to
restore the tooth whether or not a partial denture is
required.
-
Crowns used to repair micro-fractures of tooth structure
when the tooth is asymptomatic (displays no symptoms) or
existing restorations with defective margins when no
pathology exists.
-
Crowns and/or onlays placed because of weakened cusps or
existing large restorations without overt pathology.
-
Crown buildup for the purpose
of improving tooth form, filling in undercuts or reducing bulk in castings
are considered basing materials and are not a covered benefit.
Return
to Dental Table of Contents
Services
Covered
-
Dentures, fixed bridges, removable partial dentures, and
the adjustment or repair of an existing prosthetic
device.
-
Surgical placement or removal of implants or attachments
to implants
-
Replacement of an existing prosthetic device once every
five years and then only if it is unserviceable and
cannot be made serviceable.
-
Replacement of implants and superstructures is covered
only after 5 years have elapsed from any prior provision
of the implant
-
The appropriate amount for a full, immediate, or
overdenture toward the cost of any other procedure that
may be provided, such as personalized restorations or
specialized treatment.
-
The amount of a reline toward the cost of an interim
partial or full denture. After placement of the permanent
prosthesis, an initial reline will be a benefit after 6 months.
-
Root canal therapy performed in conjunction with
overdentures, limited to two teeth per arch and paid at
the 50% or major care payment level.
-
If a partial denture can be replaced with a cast chrome
and acrylic partial denture, an allowance will be made
for the cost of such a partial denture toward the cost of
any other procedure that may be provided to restore a
partial denture.
-
Denture adjustments and relines done more than six months
after the initial placement, except as noted above.
-
Subsequent relines and jump rebases (but not both), once
in a 12-month period.
Services
Not Covered
The plan pays 100 percent of dental expenses that
are a direct result of an accidental injury, provided the
accidental injury claims do not exceed the unused portion of the
annual maximum benefit.
-
Charges that exceed the unused portion of the annual
maximum benefit are paid for by you.
-
You or your covered family member must be eligible under
the plan at the time the accidental bodily injury
occurred.
-
A bodily injury does not include teeth broken or damaged
during the act of chewing or biting on foreign objects.
-
Coverage includes necessary procedures for dental
diagnosis and treatment rendered within 180 days
following the date of the accident.
If you receive benefits through this plan and
from a third party for an injury or condition caused by another
person, you must include in your insurance claim or liability
claim the amount of those benefits.
After you have been compensated for your loss,
any money recovered in excess of full compensation must be used
to reimburse WDS on behalf of the Plan Sponsor.
Dental Plus provides orthodontia coverage
for you, your spouse, and your unmarried children up to age 23 if
they meet the Internal Revenue Code's definition of a dependent.
Orthodontic treatment is defined as the necessary procedures of
treatment, performed by a licensed dentist, involving surgical or
appliance therapy for movement of teeth and post-treatment
retention.
It is strongly suggested that all
orthodontic treatment be submitted to, and authorized by, WDS prior to
commencement of treatment.
The benefit pays 50% of the treatment cost up to
a lifetime maximum benefit of $1,500. Not more than half the
lifetime maximum ($750) is payable by WDS during the
"construction phase" of treatment. The final payment is
made during the seventh month following the construction phase,
providing the employee is eligible and the dependent is within
the age limitation.
Services
Covered
Services
Not Covered
-
Charges for replacement or repair of an appliance.
-
Orthognathic surgery
-
No benefits will be provided
for services considered inappropriate and unnecessary, as determined by
WDS.
-
Charges for the treatment plan in the event treatment is
terminated before completion.
If you or one of your dependents is already
undergoing orthodontia treatment, you can still receive benefits
under this plan. The amount of benefit you are eligible for will
be pro-rated based on the amount of treatment you have left to
complete.
For example:
You elect the Dental Plus plan,
effective January 1, 2004. Your dependent son started orthodontia
treatment a year ago in January 2003. He requires one more year
of treatment. In this case, WDS will pro-rate the benefit based
on the total cost of the orthodontia treatment plan, and the
number of months remaining in that treatment program.
|
Starting Date:
|
January 2003
|
|
Length of Treatment:
|
24 months
|
|
Remaining Treatment:
|
12 months
|
|
Total Cost:
|
$3,600
|
|
Average Monthly Cost:
|
$150 ($3,600 ¸ 24)
|
|
Pro-rated Amount Paid:
|
$150 x 12 = $1,800
|
|
Pro-rated Balance:
|
$3,600 - $1,800 = $1,800
|
- Plan Pays:
- (50% of the $1,800 balance up to a lifetime
maximum of $1,500)
|
50% x $1,800 = $900
(Payable in 2 equal payments of $450/each)
|
Return to Dental
Table of Contents
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Services for injuries or conditions that are compensable
under Workers' Compensation or Employers' Liability laws,
and services provided by any federal, state, or
provincial government agency or provided without cost by
any municipality, county, or other political subdivision,
other than medical assistance in this state, under
medical assistance RCW74.09.500, or any other state,
under 42 U.S.C., Section 1396a, section 1902 of the
Social Security Act.
-
Dentistry for cosmetic reasons.
-
Restorations or appliances necessary to correct vertical
dimension or to restore the occlusion. Such procedures
include restoration of tooth structure lost from
attrition and restorations for malalignment of teeth.
-
Application of desensitizing agents.
-
Experimental services or supplies. Experimental services
or supplies are those whose use and acceptance as a
course of dental treatment for a specific condition is
still under investigation/observation. In determining
whether services are experimental, WDS, in conjunction
with the American Dental Association, will consider if 1)
the services are in general use in the dental community
in the State of Washington; 2) the services are under
continued scientific testing and research; 3) the
services show a demonstrable benefit for a particular
dental condition; and 4) they are proven safe and
effective. Any individual whose claim is denied due to
this experimental exclusion clause will be notified of
the denial within 20 working days of receipt of a fully
documented request. Any denial of benefits by WDS on the
grounds that a given procedure is deemed experimental,
may be appealed to WDS. By law, WDS must respond to such
appeal within 20 working days after receipt of all
documentation reasonably required to make a decision. The
20-day period may be extended only with written consent
of the covered individual.
-
Services with respect to treatment of jaw
(temporomandibular) joints.
-
General anesthesia/intravenous (deep) sedation, except as
specified by WDS for certain oral, periodontal or
endodontic surgical procedures. General anesthesia except when
medically necessary, for children through age six (6), or a physically or
developmentally disabled person, when in conjunction with covered dental
procedures.
-
Analgesics (such as nitrous oxide) conscious sedation,
euphoric drugs, injections or prescription drugs.
-
In the event an Eligible Person fails to obtain a
required examination from a WDS-appointed consultant
dentist for certain treatments, no benefits shall be
provided for such treatment.
-
Hospitalization charges and any additional fees charged
by the dentist for hospital treatment.
-
Broken appointments.
-
Patient management problems.
-
Completing insurance forms.
-
Habit-breaking appliances.
-
Orthodontic services or supplies - Dental Basic
only.
-
WDS shall have the discretionary authority to determine
whether services are covered benefits in accordance with
the general limitations and exclusions shown in the
contract but shall not exercise this authority
arbitrarily or capriciously or in violation of the
provisions of the contract.
-
This program does not provide benefits for services or
supplies to the extent that benefits are payable for them
under any motor vehicle medical, motor vehicle no-fault,
uninsured motorist, under-insured motorist, personal
injury protection (PIP), commercial liability,
homeowner's policy or other similar type of coverage.
-
All other services not specifically included in this
program as covered dental benefits.
Return
to Dental Table of Contents
Both Dental Basic and Dental Plus plans are
administered through the Washington Dental Service (WDS), and use
the same network of providers. You may choose a dentist from the
WDS or ODS (Oregon Dental Service) network. Or you may select any
licensed dentist to provide your dental care. Either way, you can
still receive dental benefits under both plans.
Note, however, dentists not participating in the
WDS or ODS networks are under no obligation to provide dental
services for the allowable costs specified by WDS. Consequently
your out-of-pocket expenses may be higher if you choose a
dentist who is not a network member.
In addition, there is a difference in the way
dental claims are submitted to WDS for payment:
-
If the dentist you select is part of the network, the
dentist’s office will complete and submit the claim
for your dental work. Your dentist is paid directly by WDS.
-
If the dentist you select is not part of the network, you
must have the dentist complete a claim form. You pay the
dentist's bill directly, then submit the completed claim
form to WDS to be reimbursed.
Many dentists in Washington, Alaska, and Oregon
belong to the WDS provider network. For a list of participating
dentists in your area:
-
Go to the WDS web site by clicking on this link:
WDS.
-
Click on the "Find a Dentist" button on the
left sidebar.
-
Select the appropriate directory:
-
Select DeltaPremier Plan directory.
-
To see a general list of providers in your area, enter
city, state, and zip code information. And Select
"any" for the Dentist Specialty."
-
Tell the dentist that you are covered by a WDS dental
program, and provide:
-
-
your social security number,
-
the program name: PeaceHealth
Employee Benefit Plan
-
the program identification number:
339.
-
Your dentist submits the claim form to WDS and receives
payment based on the dentist's filed fees. You need to
pay fees only if you use a non-covered service.
If you receive care from a dentist within
Washington, Alaska, or Oregon who is not a WDS or ODS member, or
if you receive care from a dentist outside these three states:
-
It is your responsibility to have the dentist complete a
claim form.
-
You are responsible for paying the dentist's bill and for
submitting the claim to WDS.
-
Payment for services performed will be based upon
dentist's charge or the amount that would have been
payable if treatment had been provided by a member
dentist in the network, whichever is less.
-
The amounts payable by WDS for
Covered Dental Benefits provided to an Eligible Person by a Dentist who is
not a Member Dentist in the State of Washington shall be based on the
applicable percentage applied to the lesser of Washington Dental Service's
allowable fees for nonmember Dentists, or such Dentist's actual charges.
All dental claims are processed by the Claims
Administrator at WDS.
Claim forms can be obtained either from your
local Human Resources department or directly from WDS by calling
(800) 554-1907.
Submit claims as soon as possible after the
dental work has been done. All claims must be submitted to WDS
within 6 months after the expenses were incurred.
Claim Review
and Appeal
Initial
Claims/Benefit Determination
An initial claim determination will
be performed on all properly submitted claims within 30 days of receipt. The
30-day period may be extended for an additional 15 days, however, if the claim
determination is delayed for reasons beyond our control. In that case, we will
notify the subscriber prior to the expiration of the initial 30-day period of
the circumstances requiring an extension and the date by which we expect to
render a decision. If the extension is necessary to obtain additional
information from the subscriber, the notice will describe the specific
information we need, and the subscriber will have 45 days from the receipt of
the notice to provide the information. Without complete information, the
subscriber claim will be denied.
If a claim is denied, in whole or in
part, the Eligible Person will be furnished with a written notice of an adverse
benefit determination that will include:
-
the specific reason or reasons
for the denial,
-
reference to the specific plan
provision on which the denial is based,
-
a description of any additional
material or information necessary for the Eligible Person to complete the
claim and an explanation of why such material or information is necessary to
process the claim, and
-
the appropriate information as
to the steps to be taken if the Eligible Person wishes to appeal the
decision.
Predetermination/Claims
Predetermination or claims require
notification or approval prior to receiving dental care. The claims
administrator will provide notice of the claim decision within 15 days after
receiving the claim. If a predetermination is filed improperly, the claims
administrator will provide notification of the improper filing and how to
correct the filing within 5 days after receipt of the predetermination. If
additional information is required, the claims administrator will notify the
Eligible Person of what information is needed within 15 days after the claim is
received. The claims administrator may request a one-time extension not longer
than 15 days and pend your claim until all information is received. Once
notified of the extension the Eligible Person has 45 days to provide this
information. Once the information is received the claims administrator will make
a determination within 15 days. If the information is not provided within 45
days, the claim will be denied. A denial notice will explain the reason for
denial, refer to the part of the plan on which the denial is based, and provide
the claim appeal procedure.
Urgent Claim
Review
Dental benefit coverage typically
does not require urgent claim review. Urgent care claims require notification or
approval prior to receiving dental care when a delay in treatment could
seriously jeopardize life, health, the ability to regain maximum function, or
could cause severe pain in the opinion of a physician who had knowledge of the
medical condition or a dentist who has knowledge of the dental condition. These
are rare dental situations and require determination by a physician or dentist
with knowledge of the condition.
WDS will provide notice of the
benefit determination, in writing or electronically, within 72-hours after
receipt of all necessary information. When practical, WDS may provide notice of
denial orally with written or electronic confirmation to follow within 72 hours.
Immediate treatment is allowed
without a requirement to obtain prior authorization in an emergency. The claim
will be evaluated after treatment. The Eligible Person or the dental office may
obtain information regarding covered benefits anytime prior to treatment.
If an urgent care claim is filed
improperly, WDS will notify the Eligible Person within 24 hours along with
instructions on how to file properly. If additional information is needed to
process the claim, the Eligible Person will be notified of the information
needed within 24 hours after the claim is received. The Eligible Person then has
48 hours to provide the requested information.
WDS will notify the Eligible Person
of the determination no later than 48 hours after receipt of the requested
information or at the end of the 48-hour period within which the Eligible Person
was to provide the additional information.
A denial notice will explain the
reason for denial, refer to the part of the plan on which the denial is based,
and provide the claim appeal procedures.
Claims
Should a claim be denied, in whole
or in part, the Eligible Person has a right to a full and fair review. The
request to have a denied claim reviewed must be submitted orally or in writing
within 180 days from the date the claim was denied. Further consideration will
not be allowed after 180 days.
A final benefit determination will
be made within 30 days following receipt of an appeal. An appeal must include
name, identification number, group number, claim number, and dentist's name as
shown on the Explanation of Benefits.
Send your appeal
to:
Washington Dental Service
Appeals/Customer Service
Post Office Box 75688
Seattle, WA 98125-0688
Written comments, documents, or
other information may be submitted in support of an appeal. Upon request and
free of charge, reasonable access to and copies of all relevant records used in
making the decision will be provided. The review will take into account all
information regarding the denied or reduced claim (whether or not presented or
available at the initial determination) and the initial determination will not
be given any consideration.
The review will be conducted by
someone different from the original decision-makers and without deference to the
initial decision. If the appeal is based in whole or in part on a medical
judgement including a determination as to whether a particular treatment, drug
or other item is experimental, investigational, or not dentally necessary or
appropriate, WDS will consult with a dental professional who has appropriate
training and experience. In such a case, the professional will not be the same
individual whose advice was obtained in connection with the initial adverse
benefit determination (nor a subordinate of any such individual). In addition,
we will identify any expert whose advice was obtained on our behalf, without
regard to whether the advice was relied upon in making the benefit
determination.
Predetermination
Appeals
If a predetermination is required by
WDS or is requested by an Eligible Person, or his/her designee and an adverse
decision is rendered, any person aggrieved thereby shall have the right to
appeal the same to WDS orally or in writing. In the event of such an appeal, the
question will be re-evaluated and communicated to the appealing party within 15
days by the Dental Director, or his/her designee, unless WDS notifies the
aggrieved person that an extension is necessary, in which case the decision
shall be communicated within 30 days absent informed, written consent of the
aggrieved person for a longer extension. An appeal shall be evaluated by a
dentist who was not involved in the decision which is the subject of the appeal.
Authorized
Representative
Eligible Person may authorize
another person to represent them and with whom they want WDS to communicate
regarding specific claims or an appeal. The authorization must be in writing,
signed by Eligible Person, and include all the information required in an
appeal. (An assignment of benefits, release of information, or other similar
form that Eligible Person may sign at the request of their health care provider
does not make your provider an authorized representative.) You can revoke the
authorized representative at any time, and you can authorize only one person as
your representative at a time.
If your claim is denied in whole or in part and
you want the decision reviewed, you must file a written request
for a review within 60 days of the date your claim was denied.
Explain why you believe the service should be covered and include
any supporting information.
Send your appeal to:
WDS
Customer Service
PO. Box 75688
Seattle, WA 98125
Customer Service will forward your appeal to the
Dental Director, who will review your appeal to determine if the
service in question qualifies as a covered expense. You will be
notified in writing of the decision within 60 days of when WDS
receives your appeal.
If the review results in your claim being denied
again, you can appeal this decision to:
WDS Dental Director
P.O. Box 75688
Seattle, WA 98125
Your appeal will be evaluated by the Dental
Director and a WDS consultant dentist.
You will be notified of the decision.
If your appeal is denied, you can appeal this
decision in writing within 60 days to the Plan Administrator:
FlexAbility Plan Administrator
PeaceHealth
15325 SE 30th Place Suite 300
Bellevue, WA 98007
You will receive a response to your appeal from
the Plan Administrator by mail within 90 days after the Plan
Administrator receives the appeal. If the Plan Administrator
needs more than 90 days to review your appeal, you will be
notified of the delay and the reasons for it.
If the claim is again denied, no additional
appeals will be considered unless accompanied by additional
supporting dental information.
We encourage all members to make
suggestions on how WDS can improve their service. Call or write:
WDS
Customer Service
P.O. Box 75688 Seattle, WA 98125
(800) 554-1907 (206) 522-2300
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Your coverage terminates at the end of the month
in which you cease to be an eligible employee. (See Health Benefit Protection in the
"What You Need to Know" section of this book.)
When going on leave of absence, employees in some
regions may need to elect Continuation Coverage for dental
benefits in order to avoid waiting periods upon returning from
leave of absence.
Coverage of dependents terminates at the end of
the month in which your coverage terminates, or the dependent
ceases to be an eligible dependent, whichever occurs first.
The only services that WDS pays for after the
date that coverage ends would be the cost to complete (within
three weeks) any single procedures (root canals, crowns, bridges,
partial or full dentures) that were already started before the
coverage was terminated and that would have been covered under
the terms of the contract.
In accordance with section 4 of ESSB 6392,
Chapter 312, Laws of 1996, the Managed Care Entitles Disclosure
Act, WDS is pleased to provide important information about our
various dental care plans. The goal of this law is to provide
individuals who are making health care decisions for themselves
and their families with as much information as possible to make
the best decisions. WDS fully supports this principle and
supplies most of the required information in enrolled benefit
booklets, which are sup plied to each enrollee at the start of
their coverage.
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