1. WELCOME TO NEVADA PACIFIC DENTAL
Nevada Pacific Dental, the State’s largest managed dental care organization, offers you and
your family a comprehensive and affordable dental benefit delivered through an Exclusive
Provider Network. Nevada Pacific Dental’s Direct Compensation Plans have no deductibles
to meet, high or no annual maximums on benefits, no pre-existing conditions (except for
treatment in progress), no waiting periods for benefits, and no claim forms to submit. You
pay the same affordable copayment for each procedure whether an Exclusive Provider
Network general dentist or exclusive contracted specialist treats you.
WHAT IS A MANAGED CARE DENTAL PLAN?
A “Managed Care” dental plan contracts directly with licensed dental professionals to deliver
quality dental care to its members. NPD’s Exclusive Provider Network dentists operate inde-
pendent privately owned dental offices, and are licensed and regulated by the State of Nevada.
The Direct Compensation Plan is designed for the employee and, if eligible, his/her family.
Unless stated otherwise by your Group Agreement, coverage is extended to the spouse
and/or unmarried dependent children. Dependent children include: 1. all natural, 2. adopt-
ed, 3. step-children. An unmarried dependent child will be eligible to age 19, or age 23 if a
full-time student, defined as at least 12 credit hours. Automatic coverage is provided for
mentally and/or physically challenged dependent children. You are eligible to enroll in the
Plan after you have met your organization’s waiting period for benefits or during your orga-
nization’s annual open enrollment.
SELECT YOUR DENTIST AND OFFICE
You and your family choose your dentist from a network of private practice dental offices. A
list of Nevada Pacific Dental Exclusive Provider Network offices is available to permit each
member to select the most convenient office. You may transfer to a different Provider Office
at any time. Changes made before the 20th
of the month are effective the 1st
of the following
month. Simply call Nevada Pacific Dental and speak to a Customer Service Representative.
If you do not select a provider office, one will be chosen for you.
Enrollment & Benefit Coverage
1432 SOUTH JONES BLVD.
LAS VEGAS, NEVADA 89146
• Send you an Exclusive Network
• Change your current dentist
(changes received by the 20th
month will be effective the 1st
• Explain your benefits and your costs
• Facilitate care for a dental emergency
• Process a new ID card (for Member
• Explain the specialty referral
• Resolve or report a concern
• Explain the formal grievance
• Additional benefit information
Customer Service Can Help: 1-800-926-0925 or 702-737-8900
Spanish speaking representatives available
PDQ PRINTING, LAS VEGAS
2. DENTAL FACILITIES
The NPD Exclusive Provider Network
list represents privately owned and
operated dental offices that provide
general dentistry services. Please
select a dental office from the list
and indicate the ID# on the enroll-
ment form or transfer card. If your
treatment plan requires the services
of a specialist, your NPD Exclusive
Provider Network dentist will refer
you to a NPD contracted specialist.
In-Network specialty care requires
pre-authorization from Nevada
You can schedule your appointment
with your chosen dental office after
you are eligible and enrolled (your
effective date) in the Plan. Your first
appointment will be to meet the den-
tist and receive an evaluation of your
oral health. Your dentist will then
complete a treatment plan that best
meets your individual dental health
needs. Office policies and practices
vary by dental office. Not all dentists
perform all procedures. Your
appointments are important. If you
are unable to keep your scheduled
appointment, please notify the dental
office at least 24 hours in advance or
the office can charge a missed
• No or high annual maximum • No
deductibles • No claim forms • No or
low copayments for procedures • No
pre-existing exclusions or limitations
(except for treatment in progress
prior to eligibility) • No waiting period
for benefits • Less “out-of-pocket”
expenses for treatment • No “balance
billing” from dentist • Customer
service located in Las Vegas
• Treatment only at an Exclusive
Provider Network office • Specialty
care must be preauthorized • Limited
out-of-network coverage ($100 emer-
gency only) • Does not cover cosmet-
ic or unnecessary dentistry.
TERMINATION OF BENEFITS
1. On Expiration Date of Dental
2. When dependent member gets
married, attains the age of 19 or
ceases to be a full-time student
prior to age 23 (unless stated
otherwise in your Plan
3. Members who violate the Plan’s
rules may have their benefits
suspended or be transferred to a
schedule of allowances plan.
4. Permitting or committing fraud.
Simply fill out and return the enroll-
ment form to your Benefits
Administrator at your place of
employment or to your Trust Fund
office. You will be eligible for benefits
when Nevada Pacific Dental receives
the enrollment card and eligibility
verification from your employer or
You must enroll you and your
dependents in the Plan within 31
days of becoming eligible for bene-
fits. If you do not enroll at that time,
you will not be able to enroll or add
dependents until your organization’s
annual Open Enrollment. Members
may add dependents immediately if
there is a “qualifying event”, i.e. birth
of child, adoption of child, or mar-
riage. All newly eligible dependents
must be added within 31 days of the
The Member pays the copayment
listed in the Member Copayment
Schedule for each dental procedure
completed as described. These fees
are paid directly to the Nevada
Pacific Dental Exclusive Network
Provider where dental treatment is
received. Payments are due the day
DIRECT COMPENSATION METHOD OF
Nevada Pacific Dental contracts with
private-practice general and special-
ized dentists to provide quality dental
services for eligible group members.
Nevada Pacific Dental compensates
its providers using direct reimburse-
ment, discounted fee-for-service, fee
for service and capitation. Nevada
Pacific Dental does not use provider
incentives or bonus plans to influ-
ence specific dental care decisions.
At Nevada Pacific Dental, we hope
that you will never have a dental
emergency, but if you do, please fol-
low these easy instructions. If you
have pain, swelling or bleeding, or
need an appliance repaired:
1. Call your NPD Exclusive
Provider, state that you have an
emergency and describe the
symptoms. Your provider should
be able to see you within 24
hours of your call.
2. If your selected NPD provider is
unable to see you within 24
hours, contact NPD Member
Services at 737-8900 or 800-
926-0925, at 8:00 a.m. week-
days. Every attempt will be made
to schedule you a same day
(within 24 hours) appointment
with an available NPD provider.
3. If an NPD provider is not avail-
able, your dental plan allows for
a $100 out-of-network emer-
gency benefit. Call any general
dentist who is not an NPD
provider and schedule an emer-
4. Submit your out-of-network emer-
gency only claim to Nevada
Pacific Dental, 1432 South Jones
Blvd., Las Vegas, NV 89146, and
you will be reimbursed up to $100
minus any copayment for covered
emergency procedures. Emer-
gency services are subject to the
limitations and exclusions in your
Plan’s evidence of coverage.
3. EXCLUSIONS & LIMITATIONS
The following dental procedures and
services are not included in the Plan:
1. Dental services for aesthetics only.
Cosmetic dental care.
2. General Anesthesia, intravenous
and inhalation sedation, prescrip-
tion drugs, and the services of a
3. Dental conditions arising out of and
due to member’s employment or for
which Workers’ Comp-ensation is
4. Hospital and medical charges of any
kind, except for dental services
5. Treatment of fractures or disloca-
6. Loss or theft of dentures, partials,
or other appliances (crowns,
bridges, full or partial dentures).
7. Preventive extraction (e.g. the
removal of asymptomatic or non-
pathologic teeth). Extractions re-
sulting from fractures, neoplastic
surgery, or radiation treatment.
8. Services which are normally reim-
bursed by a third party or liability
insurance and/or under the medical
portion of an insurance/health and
9. Dental procedures started when not
eligible for Benefits and Coverage.
10. Procedures, appliances, or res-
torations to correct congenital or
11. Treatment/removal of malignancies.
Cysts or benign tumors not within
the scope of usual comprehensive
dental care. Odontogenic cysts
exceeding 1.25 cm in diameter.
Procedures, appliances, or restora-
tions to correct or replace soft or
hard tissue defects resulting from
12. Dispensing of drugs not normally
supplied in a dental office.
13. Any treatment which, in the opinion
of dentist, is not necessary for the
member’s dental health.
14. Replacement of an existing bridge,
partial or denture which is satisfacto-
ry or which can be made satisfactory.
15. Orthognathic surgery.
16. Implants or any prosthesis attached
to or dependent upon an implant.
17. An experimental or exotic proce-
dure not approved by the ADA
Council on Dental Therapeutics.
18. Treatment to alter vertical dimen-
sion or to restore occlusion, unless
full dentures are involved.
19. Major therapy for Temporo-
Mandibular Joint (TMJ) problems
including, assessment beyond that
customarily provided in general
dental practice. Minor therapy such
as night guard, bite planes and
minor equilibration (e.g. occlusal
adjustment for one or two teeth)
may be covered.
20. Expenses incurred for any procedure
which commenced within ninety (90)
days before the date the Member
joined the plan.
21. Expense or charge incurred by
a subscriber confined to an
22. Cases in which, in the reasonable
professional judgment of the
attending Dentist, a satisfactory
result cannot be obtained.
23. Replacement of long-standing
missing tooth/teeth in an otherwise
24. Orthodontic services. Care related
to the bite, alignment of teeth, or
bite correction. Unless provided by
an additional orthodontic benefit
(rider) attached to Plan.
1. Prophylaxis is limited to one treat-
ment each six (6) month period
(includes periodontal maintenance
following active therapy).
2 Oral evaluation is limited to one
each six (6) month period. (exclud-
ing limited oral evaluation).
3. Oral hygiene instruction is limited
to one per twenty-four (24) months.
4. Fluoride treatment is limited to one
per twelve (12) months.
5. Crowns, bridges and dentures
(including immediate dentures) are
not to be replaced within a five (5)
year period from initial placement.
6. Partial dentures are not to be
replaced within any five (5) year
period from initial placement,
unless necessary due to natural
tooth loss where the addition or
replacement of teeth to the existing
partial is not feasible.
7. Denture relines are limited to one
per denture during any twelve (12)
8. Replacement will be provided for an
existing denture, partial denture or
bridge only if it is unsatisfactory
and cannot be made satisfactory by
reline or repair.
9. Covered charge for both a tempo-
rary and a permanent prosthesis
will be limited to the charges for a
permanent one only. Charges for
specialized techniques involving
precision attachments, personaliza-
tion or characterization, and
additional charges for adjustments
within six months of installation are
not included as covered benefits.
10. Crowns will be covered only if there
is not enough retentive quality left
in tooth to hold a filling. (Example:
buccal or lingual walls either frac-
tured or decayed to the extent that
they do not hold a filling). Veneers,
posterior to the second bicuspid,
are considered purely cosmetic den-
tistry. Allowance will be made for
cast full crown. If performed,
patient must pay the additional fee.
11. Periodontal treatments (root planing/
subgingival curettage) are limited
to four quadrants during any twenty-
four (24) consecutive months.
12. Full mouth debridement (gross
scale) is limited to one treatment in
any thirty-six (36) consecutive
13. Osseous surgery is limited to not
more than one treatment in any five
(5) year period.
14. Bitewing x-rays are limited to not
more than one series of four films in
any six (6) month period.
15. Full mouth x-rays and/or pano-
graphic type films are limited to one
set every thirty-six (36) consecutive
months. A full mouth x-ray is
defined as a minimum of 6 periapical
films plus bite wing x-rays.
16. Sealant benefits include the appli-
cation of sealants only to perma-
nent first and second molars with
17. PLAN does not pay for any expense
or charge for failure to appear for
an appointment as scheduled, for
the completion of claim forms, or
18. If two or more covered procedures
would appropriately correct a clinical
situation, the COMPANY will select
the most appropriate procedure.
4. GRIEVANCE PROCEDURE
The Nevada Division of Insurance is
responsible for regulating health
care service plans. The Division has
a toll-free telephone number (888)
872-3234 to receive complaints
regarding health plans. If you have a
grievance against the health plan,
you should contact the Plan and use
the Plan’s grievance procedure. The
Plan has 30 days to make a decision
when an emergency is not involved.
You may also have the right to take a
dispute with a Plan to arbitration
with an independent arbitrator from
the American Arbitration
Association. If you require the
Division’s help with a complaint
involving a grievance that has not
been satisfactorily resolved by the
Plan, you may call the Division’s toll-
free telephone number. A member
can submit a grievance in writing to
NPD or call NPD Member Services
during regular business hours and
request a Grievance form.
HOW IS CARE RECEIVED?
To access your Exclusive Provider
Network Dentist, NPD must receive
your enrollment information from
your Benefits Administrator or Trust
Office, and you must have selected a
Primary Care Dentist (before the
20th of the month for eligibility to be
effective the following month). After
the first of the month, the member
may receive care by simply calling
the selected dental provider office
and asking to schedule an appoint-
ment. (If you have an emergency,
please refer to the “Emergency
Care” section.) As a new patient, a
provider office may require a photo
ID for your insurance file.
HOW IS CARE DELIVERED?
Your Primary Care Dentist completes
an individual patient treatment plan
and then coordinates the “phasing”
of the appropriate benefited treat-
ment, including referrals, if neces-
sary, to “contracted” specialists. The
individual treatment plan reflects the
patient’s dental needs, and “phases”
in dental care as needed as the
patient achieves each level of dental-
health maintenance. Although, the
Nevada Pacific Dental Plans are quite
comprehensive in their benefit scope,
an individual’s treatment plan may
require dental procedures that are
not covered under the Member’s Plan.
WHAT ARE THE PHASES OF
Phase One of a dentist’s treatment
plan addresses a patient’s emergency
needs, including emergency extrac-
tions, followed by a complete diagno-
sis, x-rays, cleaning and home care
instructions. Once a patient is out of
pain and has reached a disease-free
level of hygiene health care, the
Phase Two clinical treatment will
begin, which includes fillings, root
canals, non-emergency extractions,
denture relines and repairs. Once the
patient understands the value of den-
tal wellness and assists the dentist
and/or hygienist in maintaining his
or her oral health, the patient is clin-
ically ready for Phase Three treat-
ment, if necessary, including scaling,
root planing, periodontal care and
osseous surgery, single crowns, full
dentures, space maintainers for chil-
dren, and preventive orthodontics.
(Again, an individual’s treatment
plan may require dental procedures
that are not covered under the
patient’s insurance Plan.) Phase
Four of treatment begins when the
patient has successfully completed
clinical phases One through Three.
Once the patient’s teeth and gums
are healthy, and the patient has
demonstrated meticulous home
health care, the patient is ready for
Phase Four treatment which
includes partial dentures, fixed
bridges and orthodontic care, if nec-
essary. Phase Five, the final phase,
is when the patient has reached a
level of dental health that can be
maintained with regular exams and
cleanings. It is important to note that
the success of each clinical Phase of
dentistry is dependent upon the indi-
vidual’s unique dental needs and per-
sonal oral hygiene.
WHAT ABOUT MISSED APPOINTMENTS?
Your appointments are important.
Each and every appointment you
make is time that your dentist per-
sonally sets aside to meet your fami-
ly’s dental health needs. That is why
it is important for you to notify your
dentist if you are unable to keep your
appointment at least 24 hours in
advance. Notifying ahead of time
allows your dentist to schedule
another Member in your place, and
saves you money. If a member fails to
cancel an appointment at least 24
hours in advance, a “failed appoint-
ment fee” will be charged and no fur-
ther appointments will be made until
the cancellation fee is paid.
Nevada Pacific Dental, Inc.
1432 S. Jones Blvd., Las Vegas, NV 89146
1-800-926-0925 • 702-737-8900