GROUP DENTAL PLAN Delta Dental Premier Plan www.modahealth.com Member handbooks and more are available at www.modahealth.com Oregon Dental Service provides dental claims payment services only and does not assume financial risk or obligation with respect to payment claims. TABLE OF CONTENTS SECTION 1. WELCOME ................................................................................................... 1 SECTION 2. USING THE PLAN ......................................................................................... 2 2.1 MEMBER RESOURCES ......................................................................................................... 2 SECTION 3. DEFINITIONS ............................................................................................... 3 SECTION 4. BENEFIT SUMMARY ..................................................................................... 7 4.1 NON‐PARTICIPATING DENTISTS ............................................................................................. 7 4.2 PAYMENT BASED ON ACTUAL FEES ........................................................................................ 8 SECTION 5. BENEFITS AND LIMITATIONS ....................................................................... 9 5.1 DIAGNOSTIC AND PREVENTIVE SERVICES ................................................................................. 9 5.1.1 Diagnostic .................................................................................................................. 9 5.1.2 Preventive ................................................................................................................ 10 5.2 BASIC SERVICES ............................................................................................................... 10 5.2.1 Restorative ............................................................................................................... 10 5.2.2 Oral Surgery ............................................................................................................. 11 5.2.3 Endodontic ............................................................................................................... 11 5.2.4 Periodontic ............................................................................................................... 11 5.2.5 Anesthesia ............................................................................................................... 12 5.3 MAJOR SERVICES. ............................................................................................................ 12 5.3.1 Restorative ............................................................................................................... 12 5.3.2 Prosthodontic .......................................................................................................... 12 5.4 GENERAL LIMITATION – OPTIONAL SERVICES ......................................................................... 13 SECTION 6. ORTHODONTIC BENEFIT ............................................................................ 14 6.1 ORTHODONTIC BENEFIT ..................................................................................................... 14 6.2 LIMITATIONS ................................................................................................................... 14 SECTION 7. EXCLUSIONS .............................................................................................. 15 SECTION 8. ELIGIBILITY ................................................................................................ 18 SECTION 9. CLAIMS ADMINISTRATION AND PAYMENT ................................................ 19 9.1 SUBMISSION AND PAYMENT OF CLAIMS ................................................................................ 19 9.1.1 Claim Submission ..................................................................................................... 19 9.1.2 Explanation of Benefits (EOB) .................................................................................. 19 9.1.3 Claim Inquiries ......................................................................................................... 19 9.2 APPEALS ......................................................................................................................... 19 9.2.1 Definitions ................................................................................................................ 19 9.2.2 Time Limit for Submitting Appeals .......................................................................... 20 9.2.3 The Review Process ................................................................................................. 20 9.2.4 First Level Appeal ..................................................................................................... 20 9.2.5 Second Level Appeal ................................................................................................ 20 ODSDent‐ASO 1‐1‐2014 (PEBB Premier Plan) 9.3 BENEFITS AVAILABLE FROM OTHER SOURCES ........................................................................ 20 9.3.1 Coordination of Benefits (COB) ............................................................................... 20 9.3.2 Third‐Party Liability .................................................................................................. 21 SECTION 10. COORDINATION OF BENEFITS .................................................................... 25 10.1 DEFINITIONS ................................................................................................................... 25 10.2 HOW COB WORKS .......................................................................................................... 26 10.3 ORDER OF BENEFIT DETERMINATION (WHICH PLAN PAYS FIRST?) ............................................. 27 10.4 EFFECT ON THE BENEFITS OF THIS PLAN ................................................................................ 28 10.5 ODS’ RIGHT TO COLLECT AND RELEASE NEEDED INFORMATION ................................................ 28 10.6 CORRECTION OF PAYMENTS ............................................................................................... 28 10.7 RIGHT OF RECOVERY ......................................................................................................... 29 SECTION 11. MISCELLANEOUS PROVISIONS ................................................................... 30 11.1 REQUEST FOR INFORMATION .............................................................................................. 30 11.2 CONFIDENTIALITY OF MEMBER INFORMATION ....................................................................... 30 11.3 TRANSFER OF BENEFITS ..................................................................................................... 30 11.4 RECOVERY OF BENEFITS PAID BY MISTAKE ............................................................................. 30 11.5 CONTRACT PROVISIONS ..................................................................................................... 30 11.6 WARRANTIES .................................................................................................................. 31 11.7 LIMITATION OF LIABILITY .................................................................................................... 31 11.8 PROVIDER REIMBURSEMENTS ............................................................................................. 31 11.9 INDEPENDENT CONTRACTOR DISCLAIMER ............................................................................. 31 11.10 NO WAIVER .................................................................................................................... 31 11.11 GROUP IS THE AGENT ........................................................................................................ 31 11.12 GOVERNING LAW ............................................................................................................. 32 11.13 WHERE ANY LEGAL ACTION MUST BE FILED .......................................................................... 32 11.14 TIME LIMITS FOR FILING A LAWSUIT ..................................................................................... 32 11.15 RESCISSION BY INSURER ..................................................................................................... 32 SECTION 12. CONTINUATION OF DENTAL COVERAGE .................................................... 33 12.1 OREGON CONTINUATION COVERAGE FOR SPOUSES AND REGISTERED DOMESTIC PARTNERS AGE 55 AND OVER ........................................................................................................... 33 12.2 COBRA CONTINUATION COVERAGE ...................................................................................... 34 SECTION 13. PROTECTED HEALTH INFORMATION .......................................................... 40 SECTION 14. TOOTH CHART ........................................................................................... 42 THE PERMANENT ARCH.................................................................................................................... 42 ODSDent‐ASO 1‐1‐2014 (PEBB Premier Plan) SECTION 1. WELCOME This handbook describes the main features of the Public Employees’ Benefit Board (the Group) dental plan (the “Plan”). The Plan itself is self‐funded by the Group and ODS has been contracted to provide claims and other administrative services. Members may direct questions to one of the numbers listed below or access tools and resources on Moda Health’s personalized member website, myModa,