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Direct Compensation Benefit Brochure
Direct Compensation Benefit Brochure
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Direct Compensation Benefit Brochure

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  • 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. MEMBER ELIGIBILITY 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. DirectCompensation Plans Enrollment & Benefit Coverage Nevada Pacific Dental, Inc. 1432 SOUTH JONES BLVD. LAS VEGAS, NEVADA 89146 1-800-926-0925 702-737-8900 FAX 702-259-8381 • Send you an Exclusive Network Provider list • Change your current dentist (changes received by the 20th of the month will be effective the 1st of the following month) • Explain your benefits and your costs • Facilitate care for a dental emergency • Process a new ID card (for Member only) • Explain the specialty referral process • Resolve or report a concern • Explain the formal grievance process • Additional benefit information QUESTIONS? Customer Service Can Help: 1-800-926-0925 or 702-737-8900 Spanish speaking representatives available ® 1 PDQ PRINTING, LAS VEGAS UNION LABELTRADES COUNCIL DIRECT COMPENSATION
  • 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 Pacific Dental. APPOINTMENTS 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 appointment fee. PLAN ADVANTAGES • 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 PLAN DISADVANTAGES • 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 Coverage. 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 Agreement). 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. ENROLLMENT PROCEDURE 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 Trust Fund. 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 “qualifying event”. PLAN CHARGES 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 of service. DIRECT COMPENSATION METHOD OF REIMBURSEMENT 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. EMERGENCY CARE 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- gency appointment. 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 EXCLUSIONS 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 special anesthesiologist. 3. Dental conditions arising out of and due to member’s employment or for which Workers’ Comp-ensation is payable. 4. Hospital and medical charges of any kind, except for dental services otherwise covered. 5. Treatment of fractures or disloca- tions. 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 welfare plan. 9. Dental procedures started when not eligible for Benefits and Coverage. 10. Procedures, appliances, or res- torations to correct congenital or developmental malformations. 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 such treatment. 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 institution. 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 stable dentition. 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. LIMITATIONS 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) consecutive months. 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 month period. 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 no decay. 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 OSHA-related fees. 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 DENTISTRY? 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. 2004 Nevada Pacific Dental, Inc. 1432 S. Jones Blvd., Las Vegas, NV 89146 1-800-926-0925 • 702-737-8900 Fax 702-259-8381

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