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NPD Administrative Manual POS Dental 6 04

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  • 1. Freedom PlansAdministrative Manual SORTCO, INC. GROUP #1043
  • 2. TABLE OF CONTENTSTab 1 General Information----------------------------------------------------------------- 4Tab 2 NEVADA PACIFIC DENTAL - A New Approach to Dental Care ------- 6Tab 3 Submitting Enrollee Eligibility --------------------------------------------------- 9 Electronic File Submissions and Transfers ------------------- 11 NEVADA PACIFIC DENTAL Electronic File structure ------ 12 Magnetic File Specification ----------------------------------------- Appendices Hard Copy or Manual Report --------------------------------------- 13 Tape - Diskette Shipping Protocol -------------------------------- 14Tab 4 Instructions for New Enrollees -------------------------------------------------- 16Tab 5 Glossary of Common Dental Terms ------------------------------------------- 18Tab 6 Glossary of Common NEVADA PACIFIC DENTAL Terms -------------- 23Tab 7 NEVADA PACIFIC DENTAL Cut-Off Dates ----------------------------------- 28Tab 8 NEVADA PACIFIC DENTAL Contacts ----------------------------------------- 30Tab 9 Exhibits Things to Remember ----------------------------------------------------------- 32 Most Common Questions----------------------------------------------------- 33 Enrollment / Change Form --------------------------------------------------- 35 Current Provider Directory --------------------------------------------------- Appendices EDI Optimal Layout File Format -------------------------------------------- Appendices
  • 3. GENERAL INFORMATION General InformationGROUP INFORMATION:
  • 4. Group Name: Sortco, Inc. Your Group Number(s): 1043 Effective Date: June 1, 2004WHO TO CALL IN NEVADA:Your Account Representative: Roxanna Whitehead ---------------- (702) 737-6681NPD Fax # -------------------------------------------------------------------------- (702) 259-0904Toll-free Number: --------------------------------------------------------------- (800) 926-0925INSTRUCTIONS FOR MAILING:What To Send: Where To Send It:Electronic Submission PACIFIC DENTAL BENEFITS, INC.Manual Reports/Hard Copy 1390 Willow Pass Road, Suite 800Enrollment / Change Forms Concord, CA 94520-5240Premium Payment NEVADA PACIFIC DENTAL, INC. P.O. Box 993 Las Vegas, NV 89125Other Correspondence NEVADA PACIFIC DENTAL, Inc. 1432 South Jones Blvd. Las Vegas, NV 89146
  • 5. NEVADA PACIFIC DENTAL A NEW APPROACH TO DENTAL CARENEVADA PACIFIC DENTAL – A New Approach to Dental CareIn an age of rising dental care costs, NEVADA PACIFIC DENTAL offers an alternative way toprovide for you and your family’s dental care needs -- economically and conveniently throughNEVADA PACIFIC DENTAL. NEVADA PACIFIC DENTAL was founded on the principle ofdelivering quality dental care and preventing dental problems before they start.NEVADA PACIFIC DENTAL has contracted with a network of private dental offices. A listingof these Exclusive Network offices is enclosed. As a member of the NEVADA PACIFICDENTAL Plan you select one office from any of these dental offices for you and your family’sneeds. This network of dental offices is composed of established dental practices. It has beenfound that most people feel more secure if the same dental office is providing for their family’streatment.Your NEVADA PACIFIC DENTAL FREEDOM PLAN also gives you and your family membersthe option to receive care at any licensed dentist in the U.S. Please review your Plan materialsfor information on this option. A deductible, annual maximum, exclusions and limitations willapply.IN-NETWORK PLAN ADVANTAGESNo Claim Forms
  • 6. The dental location you choose provides all primary dental services. There are no claim formsto complete or percentage of usual charges for you to pay.No DeductiblesThere is no required deductible to pay so your benefits begin immediately.No MaximumThere is no annual maximum of benefits for you or your eligible dependents.No Pre-Existing Conditions RestrictedThe NEVADA PACIFIC DENTAL Plan does not have pre-existing condition exclusion. Theonly exceptions to this would be work in progress - preparation for crowns/root canals,impressions for dentures, etc., orthodontic treatment in progress or the replacement of longstanding missing tooth/teeth in an otherwise stable dentition.Managed Care Plan Saves on Dental CostYour out-of-pocket savings are substantial. You know the exact cost prior to treatment andthis aids in better fiscal planning for you and your family. Your "out-of-pocket" expense(copayment) is the same whether a NPD contracted general dentist or specialist performs theservice.Quality Review of Dental ProvidersOn site audits of participating dental locations are performed to ensure that establishedstandards of quality are maintained. NEVADA PACIFIC DENTAL – A New Approach to Dental CareContinuedSpecialty ServicesThe NEVADA PACIFIC DENTAL Plan offers services in dental specialty areas. These includeperiodontics (treatment of diseased gums and bone), endodontics (root canal therapy), andoral surgery procedures. To receive IN-NETWORK benefits, you must be under the care of aNPD Exclusive Provider. Specialty care must be pre-authorized by NPD.OUT-OF-NETWORK PLAN ADVANTAGESMay Be Used At Any DentistYou choose your own dentist to receive dental services.Benefit Allowance Fixed In AdvanceAfter meeting your deductible, your benefit pays a specific amount, so your dentist can tell youyour exact “out-of-pocket” expense, up to your annual maximum.
  • 7. NEVADA PACIFIC DENTAL – A New Approach to Dental CareContinuedHOW IT WORKSWhen you enroll in NEVADA PACIFIC DENTAL, select an Exclusive Network dental officefrom the list in this brochure. This location is now the center for your entire dental needs.After you have enrolled and are eligible for benefits, to receive all necessary dental carecovered by the Plan, simply call your chosen dental provider to make an appointment andbegin a plan of treatment.To receive your IN-NETWORK benefits, you must contact your selected Exclusive Networkdental office. Dental services that are not performed by your Exclusive Network dentist or priorauthorized by NEVADA PACIFIC DENTAL Plan will not be covered by the NEVADA PACIFICDENTAL Plan.WHO CAN JOINIf you meet your employer’s eligibility requirements for dental coverage you can enroll inNEVADA PACIFIC DENTAL. You can also enroll your eligible dependents, which include yourlawful spouse and/or unmarried children. Dependent children include: 1) All natural, 2)Adopted, 3) Step-children. Automatic coverage is provided for mentally and/or physicallychallenged dependent children.You must enroll you and your dependents in the Plan within 31 days of becoming eligible forbenefits. If you do not enroll at that time, you will not be able to enroll or add dependents until
  • 8. your organization’s annual Open Enrollment. Employees may add dependents immediately ifthere is a “qualifying event” , i.e. birth of child, adoption of child, or marriage. All newly eligibledependents must be added within 31 days of the “qualifying event.”SUMMARY OF BENEFITSThe NEVADA PACIFIC DENTAL Plan provides all reasonable and customary dental care,subject to the master contract provisions, limitations and exclusions, out-of-network deductible,and out-of-network annual maximum. (See Description of Benefits, In-Network Copayments, &Out-of-Network Allowances.)Note: This is only a brief summary of the Plan. The Group Subscriber Agreement and Evidence ofCoverage must be consulted to determine the exact terms and conditions of coverage. SUBMITTING ENROLLEE ELIGIBILITY
  • 9. SUBMITTING ENROLLEE ELIGIBILITYENROLLMENTNEVADA PACIFIC DENTAL can facilitate either electronic (EDI) or manual eligibility. If youwould like to switch methods of submitting eligibility at any time, please remember that weneed 30 days notice if you are going from EDI to manual and 90 days notice if you are goingfrom manual to EDI.ManualFor every enrollee, an enrollment card needs to be completed. NEVADA PACIFIC DENTALcan supply these forms. The employee needs to fill out all the information on the upper part ofthe enrollment card and submit to his/her Human Resource/Benefits department, making sureto select what action is taking place (address change, new enrollment, add dependent,termination, etc.). Please make sure to include the effective date the action should take place.Enrollment cards can be sent in with the bill or separately at any time during the month. Acard received by the 20th of the month is guaranteed to make the provider’s eligibility list. Theenrollment cards can be sent directly to: NEVADA PACIFIC DENTAL Enrollment Department 1432 South Jones Blvd. Las Vegas, NV 89146Please remember that depending on when the information is received, it may not reflect on thenext bill. If the bill does not reflect the changes, please mark the bill appropriately.ADDITIONS: At the end of the bill please list the adds. Please include: Enrollee’s Social security number Enrollee’s Name (first and last) Number of members in the family being covered Premium rate Month/year for which this enrollee is to be effective All additions must fill out an enrollment card, if they have not already done so.TERMINATIONS:
  • 10. Please draw a line through the person’s name that you wish to terminate. Next to the name, please include the termination date. Enrollees terminated during the month are eligible through the last day of that month unless otherwise specified in your contract.CHANGES (Name or Social Security): Please draw a line through the incorrect information and write the correct information next to it.CHANGES (Rate): Please indicate the new rate and who is being added or terminated. When adjusting the billing total, please remember to determine the difference between the current rate and what the new rate is. Remember to complete an enrollment card when adding and/or deleting a spouse/dependent.Once all the changes have been noted on the bill, please adjust the total appropriately. Pleaseremember our standard contract only allows for 90 days of retroactivity.The adjusted bill should accompany the payment. This will ensure proper posting of yourpayment to your account. Please send the payment and the adjusted bill to: NEVADA PACIFIC DENTAL P.O. Box 993 Las Vegas, NV 89125NEVADA PACIFIC DENTAL encourages the use of Electronic Data Interface (EDI) as aneffective means of delivering the membership/eligibility information. In order to qualify for theelectronic method, your company needs to have a minimum of 200 employees enrolled withNEVADA PACIFIC DENTAL.Our Information System (IS) department has the capability to handle multiple media types andfile transfer technology including FTP, magnetic media and email.Many of our larger groups are presently utilizing the electronic method to administer theireligibility. NEVADA PACIFIC DENTAL can handle a variety of eligibility submissions, includingmonthly, semi-monthly, and weekly. The obvious benefit of timely processing has resulted inimproved coordination between your group and us.NEVADA PACIFIC DENTAL maintains a standard Eligibility and Enrollment file layout (seeAppendix B), which provides a basis for your data’s immediate assimilation into our system. Ifyour system capabilities do not allow for customization to meet our file layout, our analysts willwork with your system representative to develop a mutually attainable layout.
  • 11. Electronic File Submissions and TransfersNEVADA PACIFIC DENTAL encourages the use of Electronic Data Transfer (EDT) as aneffective means of delivering our members data. Our Information Systems (IS) Department hasthe capacity to handle multiple media types and file transfer technologies, including FTP,magnetic media and email.Eighty percent of the enrollment and eligibility administration done by NEVADA PACIFICDENTAL administrators is presently conducted via Electronic Data Interchange (EDI) with ourclients. Formats that report on a variety of eligibility periods (weekly, semi-monthly or monthly)are routinely supported within our administration framework. The benefits of timely processinghave resulted in greatly improved coordination between the Client and the Administrator, andprovide a much greater measure a data security by eliminating the postal delivery ofconfidential data. NEVADA PACIFIC DENTAL, INC., Electronic File Structure
  • 12. Thank you for choosing electronic file transfer as the means of communicating period eligibilityfor members who have selected NEVADA PACIFIC DENTAL. We believe this medium to bethe most efficient and secure method of moving and sharing data, and hope to be able to serveour members better as a result of getting timely, sanctioned eligibility from you, the authorizedadministrator.Please review the accompanying file layout in regards to your capacity to deliver eligibility inthis, our standard format. Please call our Information Services Department if you have anyquestions on the file structure. We look forward to working with you.TRANSFER MEDIAThe file will be acceptable to NEVADA PACIFIC DENTAL in one of four media types:1). FILE TRANSFER PROTOCOL (FTP) Files will be posted to a secure FTP site SafeTP is recommended Server/Client software2. NINE TRACK TAPE EBCDIC 1600 BPI RECORD SIZE : 170 BLOCK SIZE : 10 Records per block3. E-MAIL ATTACHMENT ASCII file attachment to Internet E-MAIL: EDI@pdbi.com 4. PC DISKETTE Double Sided - 1.2 MB High Density 5 1/4” Standard Double Sided - 1.44 MB High Density 3 1/2” Standard Hard Copy or Manual ReportA hard copy or manual report is a list generated by you each month comprising your eligibleenrollees. This list should be sent to NEVADA PACIFIC DENTAL Plan prior to the 15th of themonth. NEVADA PACIFIC DENTAL Plan will perform a comparison of the members on oursystem to the list of members you provided. After the two lists have been compared, NEVADAPACIFIC DENTAL Plan will run a preliminary run which provides the staff the opportunity to
  • 13. correct any problems before the system is actually updated. Once the preliminary run hasbeen approved by a Supervisor, the NEVADA PACIFIC DENTAL Plan system is updated withthe changes.The Enrollment / Change forms may be sent at any time during the month if you wish toexpedite our entering the members on our system. These forms should be sent directly to: NEVADA PACIFIC DENTAL 1432 SOUTH JONES BLVD. LAS VEGAS, NV 89146Any time you send an enrollment card to NEVADA PACIFIC DENTAL you must ensurethat the member is included on the hard copy of the manual report being sent or theywill be terminated.Note: Including dependent information on your report is optional. All changes withrespect to dependents should be on an Enrollment / Change form. Tape/Diskette Shipping ProtocolPlease note:The tape/diskette should be clearly marked on the outside packaging with the followinginformation: • Name of Group • Group Number • Eligibility Month • Return Address • Number of Records • Label Type
  • 14. The tape/diskette should contain complete eligibility. Any employee that appears on oursystem but is not on your tape will be terminated. However, all terminating employees,whether retroactive or current, should be reported to us once with a term date and then beexcluded from future tapes/diskettes.Tapes/diskettes should have NEVADA PACIFIC DENTAL eligibility only and the file namesshould be consistent.
  • 15. INSTRUCTIONS FOR NEW ENROLLEES Instructions for New Enrollees
  • 16. Customer ServiceIf you have questions about the plan benefits or how to use the NEVADA PACIFIC DENTALPlan, please call our Customer Service Department toll free at 1-800-926-0927 or(702) 737-8900.Contacting Your Chosen/Assigned Exclusive Network Dental ProviderIf you have forgotten which dental office you have chosen or if you have transferred to anotherdental provider, please call (702) 737-8900 or 1-800-926-0925 toll-free to verify your dentalprovider. Enrollees must go to their chosen dental provider from the NEVADA PACIFICDENTAL Plan Provider Directory in order to receive the In-Network Benefits under the Plan.You do not need an ID card in order to make an appointment with your dental office. Simplycall your dental office and make any necessary appointments to begin a plan of treatment.Specialty CareIn-Network benefited specialty care is provided by an Exclusive Network of dental specialists.If specialty care is required, the provider will request authorization from NEVADA PACIFICDENTAL Plan and will refer the enrollee to the appropriate specialist. All specialty care mustbe pre-authorized by NEVADA PACIFIC DENTAL. Out-of-Network specialty care will bebenefited at the Out-of-Network Schedule of Allowances (please see your Benefit brochure forspecific amounts.)Changing Dental ProvidersEnrollees may change dental providers as needed. This can be done by calling our CustomerService Department at (702) 737-8900 or 1-800-926-0925. The change will be effective on thefirst day of the following month. Enrollees should not request a change of dental providers ifthey are in the middle of treatment or owe money to their current NPD provider. The CustomerService Department can advise the enrollee on the definition of the “middle of treatment”.
  • 17. Instructions for New EnrolleesContinuedClaim Forms, Deductibles, Maximums or Pre-AuthorizationsThere are no claim forms, deductibles, dollar maximums or pre-treatment authorizations, withthe exception of specialty care, for the NEVADA PACIFIC DENTAL In-Network benefits. Out-of-Network benefits require the submission of a claim form, and also have deductibles to meet,an annual maximum to limit care, and preauthorization is recommended.Pre-Existing ConditionsNEVADA PACIFIC DENTAL Plan does not have a pre-existing condition exclusion. However,coverage is not provided for any treatment started after termination of eligibility for coverage;and dental expenses incurred for treatment in progress prior to the enrollee’s eligibility withNEVADA PACIFIC DENTAL (e.g.: teeth prepared for crowns, root canals in progress,orthodontia, fixed and removable prosthetics). Please check your group contract. NEVADAPACIFIC DENTAL will not replace long standing missing tooth/teeth in an otherwise stabledentition.Enrollment / Change FormAn Enrollment / Change form is available for the enrollee’s convenience when they wish toupdate their personal information on the NEVADA PACIFIC DENTAL Plan system.Note: If a member owes the previous dental office a balance for copayments or “noshow” fees, the balance must be paid before NEVADA PACIFIC DENTAL Plan willproceed with their transfer to another dental office.
  • 18. GLOSSARY OF COMMON DENTAL TERMS
  • 19. Glossary of Common Dental TermsAbutmentA tooth or implant used to support a prosthesis.AmalgamAn alloy used in dental restorations; includes mercury.AnteriorRefers to the teeth in the forward part of the mouth - incisors and canines.Bitewing RadiographInterproximal view radiograph of the coronal portion of the tooth.BridgeA fixed bridge is a prosthetic replacement of one or more missing teeth usually cemented tothe abutment teeth adjacent to the space; removable bridge (partial denture) is a prostheticreplacement of one or more missing teeth on a framework that can be removed by the patient.CariesCorrect technical term for decay.CavityLesion or hole in tooth caused by caries.CrownPart of the tooth that is covered with enamel and normally projects beyond the gingival margin;artificial replacement is called by the same name.CurettageScraping or cleaning of the walls of a cavity or gingival pocket.Dental ProphylaxisScaling and polishing procedure performed to remove coronal plaque, calculus and stains.DentureAn artificial substitute for natural teeth and adjacent tissues.FractureA breaking of a part, especially of a bony structure, breaking of a tooth.
  • 20. Glossary of Common Dental TermsContinuedGingivaSoft tissues overlaying the crowns of unerupted teeth and encircling the necks of those thathave erupted, serving as the supporting structure for sub-adjacent tissues.GingivectomyThe excision or removal of gingivaImpacted ToothAn unerupted or partially erupted tooth that is positioned against another tooth, bone or softtissue so that complete eruption is unlikely.Maintenance PeriodontalTherapy for preserving the state of health of the periodontium.MalocclusionImproper alignment of biting or chewing surfaces of upper and lower teeth.OcclusionAny contact between biting or chewing surfaces of upper and lower teeth.PalliativeAction that relieves pain but is not curative.Partial DentureUsually refers to the prosthetic device that replaces the missing teeth on a framework that canbe removed by the patient.PonticThe term used for the artificial tooth on a bridge.ProphylaxisScaling and polishing procedure performed to remove coronal plaque, calculus and stains.QuadrantOne of the four equal sections into which the dental arches can be divided; begins at themidline of the arch and extends distally to the last tooth; usually includes five or more teeth. Glossary of Common Dental TermsContinued
  • 21. RelineProcess of resurfacing the tissue side of a denture with a new base material.RetainerOrthodontic retainer - appliance to stabilize teeth following orthodontic treatment; prosthodonticretainer - a part of a fixed bridge that attaches a pontic to the abutment tooth.Root Canal TherapyTreatment of the pulp cavity to eliminate periapical disease and to promote healing and repairof periapical tissues.Root PlaningA procedure designed to remove microbial flora, bacterial toxins on the root surface or in thepocket, calculus and diseased cementum or dentin.ScalingRemoval of plaque, calculus and stain from teeth.Study ModelPlaster or stone model of teeth and adjoining tissues; also referred to as diagnostic cast.Temporomandibular Joint (TMJ)The connecting hinge mechanism between the mandible (lower jaw) and base of the skull(temporal bone).
  • 22. GLOSSARY OF COMMONNEVADA PACIFIC DENTAL TERMS
  • 23. Glossary of Common NEVADA PACIFIC DENTAL TermsAuditAn examination of records or accounts to check their accuracy. A post-treatment recordreview or clinical examination to verify information reported on claims.BenefitThe dental service or procedure covered by the Plan.Benefit Booklet/ScheduleA booklet or pamphlet provided to the subscriber which contains a general explanation of thebenefits and related provisions of the managed care dental program. Consult the BenefitSchedule for a complete description of your benefits, limitations and exclusions of the plan.Claim FormThe form used to file for benefits under a managed care dental program; includes sections forthe patient and the dentist to complete. The completed form serves as the basis for paymentof benefits.Exclusive NetworkAn Exclusive Network dental benefits plan exists when patients eligible to receive benefits canreceive them only if services are provided by dentists who have signed an agreement with thebenefits plan to provide treatment to eligible patients. As a result of the dentist reimbursementmethods characteristic of an Exclusive Network plan, only a small percentage of practicingdentists in a given geographical area are typically contracted by the Plan to provide dentalservices.Consolidated Omnibus Budget Reconciliation Act (COBRA)Legislation relative to mandated benefits for all types of employee benefits plans. The mostsignificant aspects within this context are the requirements for continued coverage foremployees and/or their dependents who would otherwise lose coverage.ContractA legally enforceable agreement between two or more individuals or entities which confersrights and duties on the parties. Common types of contracts include: 1) contracts between adental benefits organization and an individual dentist to provide dental treatment to membersof an alternative benefits plan. These contracts define the dentist’s duties both to beneficiariesof the dental benefits plan and the dental benefits organization and usually define the mannerin which the dentists will be reimbursed; and 2) contracts between a dental benefitsorganization and a group plan sponsor. These contracts typically describe the benefits of thegroup plan and the rates to be charged for those benefits.Contract DentistA licensed dentist that contractually agrees to provide services under special terms, conditionsand financial reimbursement arrangements. Glossary of Common NEVADA PACIFIC DENTAL TermsContinued
  • 24. Coordination of Benefits (COB)A method of integrating benefits payable under more than one plan. Benefits from all sourcesshould not exceed 100% of the total charges.CopaymentEnrollee’s share of the dentist’s fee.Covered ChargesCharges for services rendered or supplies furnished by a dentist that qualify as coveredservices and are paid for in whole or in part by the managed care dental program. May besubject to deductibles, copayments, coinsurance, annual or lifetime maximums or table ofallowances, as specified by the terms of the contract.Covered PersonAn enrollee who is eligible for benefits under a managed care dental program.Customary FeeThe fee level determined by the administrator of a dental benefits plan from actual submittedfees for a specific dental procedure to establish the maximum benefit payable under a givenplan for that specific procedure. (See also Usual Fee and Reasonable Fee).DependentsIncludes legal spouse and children of the primary enrollee, as defined by terms of the dentalbenefits contract.Dual Choice ProgramA benefits package from which an eligible individual can choose to enroll in either a managedcare dental program or an indemnity dental program.Eligibility DateThe date an individual and/or dependents become eligible for benefits under a dental benefitscontract. Often referred to as effective date.ExaminationComplete examination - a dentist thoroughly evaluates the state of health of the patientincluding a thorough examination of the hard and soft tissues of the oral cavity andcontinguous structures. This includes but is not limited to the use of diagnostic informationacquired through interpretation of appropriate dental radiographs; may also include pulp vitalitytest, transillumination, study models and laboratory tests, when indicated. Limited examination- a dentist thoroughly evaluates the state of health of the patient and includes an Glossary of Common NEVADA PACIFIC DENTAL TermsContinuedevaluation of the hard and soft tissues of a portion of the oral cavity. Includes but is not limitedto the use of diagnostic information acquired through interpretation of selected dentalradiographs; may also include diagnostic information acquired through interpretationof other diagnostic tests as indicated.Exclusions
  • 25. Dental services not covered under a managed care dental program.Expiration Date1) The date on which the dental benefits contract expires. 2) The date an individual ceases tobe eligible for benefits.Explanation of BenefitsA written statement indicating the benefit/charges covered or not covered by the dentalbenefits plan.Indemnity PlanA dental plan where a third-party provides payment of an amount for specific services,regardless of the actual charges made by the provider. Payment may be made either toenrollees or by assignment, directly to dentists. Schedule of Allowances, Table of Allowancesor Reasonable and Customary plans are examples of indemnity plans.LimitationsRestrictive conditions stated in a dental benefits contract, such as age, length or time coveredand waiting periods, which affect an individual’s or group’s coverage. The contract may alsoexclude certain benefits of services or it may limit the extent or conditions under which certainservices are provided. (See Exclusions).Managed Care Dental PlanA program that manages patient care through clinically accepted treatment guidelines andphasing of treatment based on the patients unique dental needs and personal oral hygiene.MedicareA federal insurance program enacted in 1965 at Title XVIII of the Social Security Amendmentsthat provides certain inpatient hospital services and physician services for all persons age 65and older and eligible disabled individuals. The program is administered by the Health CareFinancing Administration.MemberAn individual enrolled in a managed care dental program. Glossary of Common NEVADA PACIFIC Dental TermsContinuedNecessary TreatmentA necessary dental procedure or service as determined by a dentist to either establish ormaintain a patient’s oral health. Such determinations are based on the professional diagnosticjudgment of the dentist and the standards of care that prevail in the professional community.Open EnrollmentThe annual period in which employees can select from a choice of benefit programs.PreauthorizationStatement by a third-party indicating that proposed treatment will be covered under the termsof the dental benefits contract. (See also Predetermination).
  • 26. PredeterminationAn administrative procedure that may require the dentist to submit a treatment plan to the thirdparty before treatment is begun. The third party usually returns the treatment plan indicatingone or more of the following: patient’s eligibility, guarantee of eligibility period, coveredservices, benefit amounts payable, application of appropriate deductibles, copayment and/ormaximum limitation. Under some programs, predetermination by the third party is requiredwhen covered charges are expected to exceed a certain amount, such as $200. Also knownas preauthorization, precertification, pretreatment review or prior authorization.Quality AssuranceThe assessment or measurement of the quality of care and the implementation of anynecessary changes to either maintain or improve the quality of care rendered.Reasonable FeeThe fee charged by a dentist for a specific dental procedure that has been modified by thenature and severity of the condition being treated and by any medical or dental complicationsor unusual circumstances and therefore, may differ from the dentist’s “usual” fee or the benefitadministrator’s “customary” fee.SubscriberThe person, usually the employee, who represents the family unit in relation to the managedcare dental program. This term is most commonly used by service corporation plans. Alsoknown as: certificate holder or enrollee.Usual FeeThe fee that an individual dentist most frequently charges for a given dental service. (See alsoCustomary Fee and Reasonable Fee).
  • 27. CUT-OFF DATES
  • 28. NEVADA PACIFIC DENTAL Cut-Off DatesThe following cut-off dates have been established for the year 2004. Please adhere to thesedates when submitting enrollment forms or using electronic file submission to ensure that thedental offices are properly notified of your eligible members: SUBMIT FORMS BY TO BE ELIGIBLE BY January 20, 2004 February 1, 2004 February 20, 2004 March 1, 2004 March 20, 2004 April 1, 2004 April 20, 2004 May 1, 2004 May 20, 2004 June 1, 2004 June 20, 2004 July 1, 2004 July 20, 2004 August 1, 2004 August 20, 2004 September 1, 2004 September 20, 2004 October 1, 2004 October 20, 2004 November 1, 2004 November 20, 2004 December 1, 2004
  • 29. NEVADA PACIFIC DENTAL CONTACTS NEVADA PACIFIC DENTAL Plan Contacts
  • 30. Our systems are designed to accommodate all routine and non-routine situations. Pleaseconsult the following listing to determine the appropriate department that can best assist youwhen contacting our office.If you feel it necessary to bypass our automated routine system, or if your request requiresspecial handling, please contact your Account Executive or Marketing Services:Administrative Services Roxanna Whitehead, (702) 737-8900, Ext.213 Cathie Davenport, Ext 211 Ted DeCorte, Ext. 210Routine Benefit Determination Customer Service, (702) 737-8900Member Transfers Customer Service, (702) 737-8900Routine Quality Assurance Grievances Susy Storms, Ext. 212Routine Claims, Pre-Authorizations Customer Service, (702) 737-8900Emergency Referrals Customer Service, (702) 737-8900Eligibility Processing (Bills, Tapes, Hard Membership/Enrollment DepartmentCopies) and Reconciliations 1-800-999-3367Eligibility Problems or Issues Administrative Services, (702) 739-6681Electronic File Submission Questions or Enrollment/EligibilityLayout Changes Carin Olson, 1-800-999-3367 Ext. 6062Re-Issuing of Bills Membership/Enrollment Department 1-800-999-3367 Call us between the hours of 8:00 AM and 5:00 PM at our toll free numbers: (800) 926-0925 or (702) 737-8900 /Customer Service (800) 926-0925 or (702) 737-6681 / Administration NPD Fax Number(s): (702) 259-0904 - Enrollment Department Customer Service/Claims Department Marketing DepartmentPlan Information Can Be Found On the Web @ www.npdofnevada.com
  • 31. EXHIBITS
  • 32. Things to Remember1. Timing is critical to ensure that your eligible members appear on the dentist’s eligibility list and your following month’s NEVADA PACIFIC DENTAL Plan billing.2. Submit your electronic file to NEVADA PACIFIC DENTAL Plan by the 15th of each month.3. Enrollment cards can be sent to NEVADA PACIFIC DENTAL any time during the month, however, you should refer to the cut-off dates to ensure that the members appear on the doctor’s eligibility list.4. “NO SHOW” Appointment Fee: If a member fails to keep a scheduled appointment without 24 hours notice, they will be charged a “no show” appointment fee. The member will be required to pay this “no show” fee before they can set up any further appointments with the dental office, or transfer to another office.5. NEVADA PACIFIC DENTAL Plan retroactive credits for up to three months providing the amount of the credit does not exceed 10% of the billed amount.6. Dental type changes should be made directly on the NEVADA PACIFIC DENTAL Benefits billing.7. You must notify NEVADA PACIFIC DENTAL when changing your method of submitting eligibility. If you send your eligibility electronically, and you are changing your current layout, you must notify NEVADA PACIFIC DENTAL at least a month ahead of time and submit a test file at that time.8. If submitting a manual or hard copy report, you should identify the additions, terminations and changes separately to expedite processing. PLEASE NOTE: Enrollment cards must accompany all additions.9. Enrollment cards should include the group number and effective date of the employee.10. If a member does not select a dental location, one will be selected for him using his zip code. This can be changed by contacting the Customer Service Department at (702) 737-8900 or 1-800-926-0925. 22 Most Common Questions
  • 33. Q. Who is NEVADA PACIFIC DENTAL? NEVADA PACIFIC DENTAL is Nevadas largest managed care dental benefit organizations. We have created a Plan that offers our members quality dental health services at significant savings. We have contracted with quality, local dental professionals to provide services to you and your eligible dependents at no cost or for low fixed copayments. Under this Plan, there are no claim forms to complete, no deductibles to be met and no yearly dollar maximum of coverage. An Out-of-Network benefit is also available.Q. My dentist is not on the list. Can I still use Him? Not all dentists have contracted with NEVADA PACIFIC DENTAL. To benefit from the significant savings provided with this particular Plan, you must choose a dental office from our list of dental providers. If you use a dentist who is not on our provider directory - your services will be covered under your Out-of-Network schedule of allowances.Q. Who do I call if I need assistance or if I have questions? The NEVADA PACIFIC DENTAL Customer Service Department will assist you in all matters pertaining to the NEVADA PACIFIC DENTAL Plan. You may reach a customer service representative at one of the numbers listed on the back of this brochure. You may also call our toll-free number (800) 926-0925 or (702) 737-8900. Our office hours are Monday through Friday from 8:00 AM to 5:00 PM (excluding holidays).Q. How long does it take to get an appointment with a dentist? Three to four weeks is a reasonable amount of time to wait for a standard appointment. If you can’t accept the first available appointment or if you require weekend or evening appointments you may have to wait longer for an appointment.Q. If I have a pre-existing dental condition, may I join NEVADA PACIFIC DENTAL? YES. Pre-existing conditions are not an exclusion under NEVADA PACIFIC DENTAL. Benefits will not be provided for any dental expenses incurred for treatment started after termination of eligibility for coverage; or for treatment in progress prior to becoming eligible under the NEVADA PACIFIC DENTAL Plan. (e.g.: teeth prepared for crowns, root canals in progress, impressions for dentures, fixed and removable prosthetics, orthodontia, etc.) NEVADA PACIFIC DENTAL will not replace long standing missing tooth/teeth in an otherwise stable dentition.
  • 34. Most Common QuestionsContinuedQ. Does NEVADA PACIFIC DENTAL Plan provide coverage for specialty services? YES, for most Plans. NEVADA PACIFIC DENTAL Plan maintains an Exclusive Network of specialists and coordinates all your specialty care needs with your Exclusive Network provider. Should you require benefited specialty services, your Exclusive Network dentist will refer you to a specialist, upon prior authorization. Out-of-Network specialty care is benefited under your Out-of-Network schedule of allowances.Q. Once I’ve selected a dental provider, may I change Exclusive Network offices? YES. You may change your eligibility from one NEVADA PACIFIC DENTAL Plan provider to another by phoning or writing NEVADA PACIFIC DENTAL. If you select a provider prior to the 20th of the month, you will be eligible with the new provider office the first day of the following month.Q. How do I enroll in NEVADA PACIFIC DENTAL? Once you decide to enroll, complete the enrollment card. Choose a dental provider from the enclosed provider directory. (Contact Nevada Pacific Dental for the most current provider list.) Be sure to write the office number of your chosen dental provider on the enrollment card. Return this card to your employer as directed by your Human Resources Department. Note: If you do not select a dental provider, NEVADA PACIFIC DENTAL will choose a dental office for you in the closest zip code area.Q. What about missed appointments? If you fail to cancel an appointment at least 24 hours in advance of the appointment you may be required to pay a “failed appointment fee” ($25.00) and no further appointments will be made until the cancellation fee is paid. 24
  • 35. Enrollment Card – Change FormThe enrollment form is a tool that NEVADA PACIFIC DENTAL uses to obtain vital informationfor each of your eligible members. It is the responsibility of the employer to ensure that thedata is complete and accurate. The following information is required before a member can beenrolled: • Group Number • Effective Date • Social Security Number • Member’s Name • Provider SelectionOf course, we encourage you to make sure all the fields have been completed. NEVADAPACIFIC DENTAL will assign an Exclusive Network office to the member if one was notselected.Enrollment forms should be sent directly to NEVADA PACIFIC DENTAL and can be sent atany time during the month.NOTE: The enrollment / change form may also be used to submit any changes in status such as anaddress change, name change, provider change, or the deletion/addition of dependents.
  • 36. APPENDICES