NPD EOC-0402


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NPD EOC-0402

  1. 1. NEVADA PACIFIC DENTAL DENTAL PLAN EVIDENCE OF COVERAGE IMPERIAL, VENTURA, SONOMA, NAPA, REGENCY, MAXIMA, ADVANTAGE PLANS (1005-P, 1006-P, 1007-P, 1008-P, 1010-P, 1011-P, 1013-P) ISSUED BY NEVADA PACIFIC DENTAL 1432 SOUTH JONES BLVD. LAS VEGAS, NV 89146 TELEPHONE: (800) 926-0925 (702) 737-8900Your plan benefits may differ from the coverage outlined in this brochure. Please refer to the PLANBROCHURE for any differences.Please retain this booklet. It contains important information about your Nevada Pacific Dental Plan.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 1
  2. 2. (April 2002)EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 2
  3. 3. INDEXI. HOW TO USE YOUR PLANII. DEFINITIONSIII. PRINCIPAL BENEFITS AND SERVICES A. Emergency Procedures B. Claim PaymentsIV. EXCLUDED PROCEDURES AND SERVICES A. LimitationsV. PLAN MEMBER IDENTIFICATIONVI. TERMINATION OF BENEFITSVII. REINSTATEMENTVIII. BINDING ARBITRATIONIX. REPORTS AND RECORDSX. MISCELLANEOUS PROVISIONS A. Application, Statements, Etc. B. Liability of the Plan C. Relations Among Parties D. Grievance Procedure E. Governing Law F. Termination of a Provider G. Public Policy Committee H. Benefits CommitteeXI. COORDINATION OF BENEFITSXII. ELIGIBILITY NEVADA PACIFIC DENTAL 1432 SOUTH JONES BLVD. LAS VEGAS, NV 89146 (702) 737-8900 or (800) 926-0925EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 3
  4. 4. NEVADA PACIFIC DENTAL EVIDENCE OF COVERAGE AND DISCLOSURE FORMA specimen copy of the contract will be furnished to you upon request. Any questions you haveconcerning the contract or its coverage should be addressed to your ORGANIZATION, or if youprefer, you may direct your inquiry to: Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900Nevada Pacific Dental (hereinafter referred to as "COMPANY") agrees to furnish benefits to youand your eligible dependents, subject to the terms and conditions of the Group Contract issued toyour ORGANIZATION.I. HOW TO USE YOUR PLANYou MUST select a dentist from among the Plan Providers and all family members MUST use thesame office. Thereafter, to obtain services, you need only contact the selected Plan Provider andmake an appointment. In the event you are dissatisfied with any Plan Provider selected, for anyreason, and desire to transfer to another, you may do so by contacting the COMPANY by telephone.If the COMPANY is notified by the 20th of the month, the transfer will be effective the first day ofthe following month.Information regarding emergencies, services available, and the locations and hours of PlanProviders may be obtained by calling the COMPANY offices at (702) 737-8900 or (800) 926-0925.II. DEFINITIONS"AESTHETIC DENTISTRY" means any dental procedures which are performed purely forcosmetic purposes, and where there is not restorative value."BENEFIT AGREEMENT" means the written agreement, Group Subscriber Agreement, enteredinto between COMPANY and groups or individuals, under which COMPANY provides,indemnifies, or administers dental benefits to persons or groups.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 4
  5. 5. "BENEFITS and COVERAGE" means the dental care services available under the GroupSubscriber Agreement in which a member is enrolled."CAPITATION" means a uniform prepayment fee due the DENTIST, per Member, per month,based on the BENEFITS AGREEMENT issued to the Member and the services available to theMember pursuant to this BENEFIT AGREEMENT."COMPANY" means, NEVADA PACIFIC DENTAL, INC."COPAYMENT" means additional fee charged to a Member, which is approved by the Division ofInsurance, provided for in BENEFIT AGREEMENT and disclosed in the Evidence of Coverage orthe Disclosure Form used as the Evidence of Coverage."CONTRACT" means this agreement between ORGANIZATION and COMPANY."DENTAL DIRECTOR" means a Nevada licensed dentist who is contracted or employed byCOMPANY to provide professional advise concerning the operation of the BENEFITAGREEMENTS."DENTIST" means an individual who is licensed as a Doctor of Dental Surgery (D.D.S.) or Doctorof Dental Medicine (D.M.D.) in accordance with applicable Nevada state laws and who ispracticing within the scope of such license, including any hygienists and technicians recognized bythe dental profession who act and assist the Dentist."DEPENDENT" shall mean the spouse and children, if enrolled in COMPANY, of a member andshall include all newborn infants whose coverage shall commence from the moment of birth.Adopted children, foster and stepchildren are covered from the legally certified date of placement.Children are also subject to the applicable age limitations as established by each group ororganization and any additional requirement in accordance with BENEFIT AGREEMENT."ELECTIVE DENTISTRY" means any dental procedures which are unnecessary to the dentalhealth of the patient, as determined by a Plan Dentist."ELIGIBLE PARTICIPANTS" shall mean employees, members, dependents or beneficiaries ofORGANIZATION who are eligible to participate in the Plan under the eligibility requirement setforth by ORGANIZATION.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 5
  6. 6. "EMERGENCY" means a condition in which the Member has severe pain or symptoms which, ifnot treated immediately, would lead to unnecessary suffering, disability, or death."EMERGENCY CARE" means services required for alleviation of severe pain, bleeding and/orimmediate diagnosis and treatment of unforeseen conditions, which, if not immediately diagnosedand treated may lead to disability, dysfunction or death."EXCEPTION" means any variance with the provisions of BENEFIT AGREEMENT."EXCLUSION" means any provision of BENEFIT AGREEMENT whereby coverage for aspecified hazard or condition is entirely eliminated."GENERAL PRACTITIONER" means a dentist who practices general dentistry and who does nothold himself/herself out to be a specialist in a particular field of dentistry."LIMITATION" means any provision other than an exclusion which restricts coverage under theBENEFIT AGREEMENT."MEMBER" shall mean a person who is actually enrolled in COMPANY and eligible to receiveservices as provided for herein under a Benefit Agreement with COMPANY. The term "Member"or "Members" as used in this BENEFIT AGREEMENT shall be deemed to include all eligibledependents of a Member as defined herein, if so enrolled in a BENEFIT AGREEMENT withCOMPANY."ORGANIZATION" means an organized group or body of Members, Eligible Participants, and /orothers that have entered in a BENEFIT AGREEMENT with the COMPANY."PEER REVIEW COMMITTEE" means regional committees composed of Dentists pursuant to therequirements of the State of Nevadas Department of Insurance."PLAN" means those Benefits, Coverages and other charges as set forth herein the BENEFITAGREEMENT."PLAN DENTIST" means the professional provider under contract with the COMPANY."PLAN PROVIDER" means the professional provider under contract with the COMPANY."PREPAYMENT FEE" means the amount payable each month on a prepayment basis by a Memberor the ORGANIZATION (or both) to obtain benefits provided under the BENEFIT AGREEMENT.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 6
  7. 7. "PREVAILING RATES" means the usual, customary and reasonable charges (UCR) prevailing inthe geographic area in which the Professional Providers office is located; a copy of such charges areto be kept at the Professional Providers office."PRINCIPAL BENEFITS AND COVERAGE WITH COPAYMENTS" means those Benefits andCoverages for which the Member has a Co-payment."PRINCIPAL BENEFITS AND COVERAGE WITHOUT COPAYMENTS" means those Benefitsand Coverage for which the Member has no Co-payment."PRINCIPAL EXCLUDED PROCEDURES AND SERVICES" means those services which arespecifically not Benefits and Coverage."PRINCIPAL LIMITATIONS" means those Benefits and Coverage, which are limited in frequency,number or scope of treatment."PROFESSIONAL PROVIDER" shall mean the dentist under contract with COMPANY."PUBLIC POLICY COMMITTEE" means an advisory committee composed of Dentists, Membersand members of COMPANYs Board of Directors pursuant to the requirements of the State ofNevadas Department of Insurance."QUALITY REVIEW" means the bonafide formal confidential review program of the facilities,treatment methods, treatment results and individual members treatment records for eachprofessional provider."SERVICE AREA" means a geographical area designated by the COMPANY within which theCOMPANY shall provide services."SPECIAL NOTICE" means communication requiring time deadline compliance by either party tothis AGREEMENT sent by Certified Mail, Return Receipt Requested."SPECIALIST" means a Dentist who is responsible for the specific specialized dental care of a PlanMember in one specific field of dentistry such as endodontics, periodontics, oral surgery, ororthodontics where the member is referred by a Professional Provider affiliated with theCOMPANY.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 7
  8. 8. "SPECIALTY REFERRAL GUIDELINES" means specific procedures to be followed for Benefitsand Coverage provided by dentists other than the DENTIST."SPECIFIC SPECIALIZED DENTAL CARE" means a treatment plan (dental care) diagnosed andadministered to a particular patient, which a patient receives as a result of the referral to a Specialistby the Professional Provider affiliated with the COMPANY."SUBSCRIBER" means any groups, organizations, or individuals that agree by the BENEFITAGREEMENT to pay for and receive Benefits and Coverage from the Company.III. PRINCIPAL BENEFITS AND SERVICESSubject to the following terms and conditions contained herein, Benefits outlined in the enclosedBenefit Schedule (located in the back of this Booklet) are available to Plan Members. All benefitsoutlined in the Evidence of Coverage must be obtained from a Plan Dentist. The scheduleestablishes the Dental Services that are available without charge, designated as "No Charge" or "0"copayment in the schedule, and those services for which Members are obligated to pay the PlanDentist. The amount of the co-payment which the Plan Dentist is permitted to charge for specificDental Services is set forth under the heading "Copayment." The Benefits and Services areavailable from the Plan Provider with co-payments required where indicated.NEVADA PACIFIC DENTAL contracts with general and specialized dentists to provide qualitydental services for eligible group members. You must select and seek all dental services from aNEVADA PACIFIC DENTAL Primary Care Provider listed in the NEVADA PACIFIC DENTALprovider directory. NEVADA PACIFIC DENTAL compensates its providers using directreimbursement, discounted fee for service, fee for service and capitation. The dentist also receivescompensation from COMPANY enrollees who pay a defined COPAYMENT for specific dentalservices. These are the only forms of compensation the general dentist receives from theCOMPANY. NEVADA PACIFIC DENTAL does not use provider incentives or bonus plans toinfluence specific dental care decisions.EMERGENCY PROCEDURESIn the event of an out-of-area emergency, you should contact the COMPANY at (702) 737-8900 or(800) 926-0925. The COMPANY will direct you to an available Provider. Should no Plan Providerbe available within a 50-mile radius, you will be advised to seek treatment from a non-PlanProvider. However, should it prove impossible for you to advise the COMPANY, services renderedEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 8
  9. 9. by a non-Plan Provider will be covered if notice is given to the Plan within forty-eight (48) hoursafter the service was provided. The COMPANY will reimburse you for the cost of such services upto a maximum of $100.00 per event less any usual co-payment required for the procedureperformed on a free-for-service basis.CLAIM PAYMENTSYou must submit a claim form when requesting reimbursement. Necessary forms are available atthe COMPANY administrative office. A claim for payment must be made within ninety (90) daysafter the services were rendered.All claims shall be approved or denied within thirty (30) days after receipt by the COMPANYunless additional information is required. If the claim is approved, the claim will be paid withinthirty (30) days after it is approved. If the COMPANY requires additional information, the claimantshall be notified with twenty (20) days after it receives the claim. The claim will then be paid ordenied with thirty (30) days after receiving the additional information. If the claim is partiallydenied, you will receive written notification of the decision, including the specific reasons for thedenial is based, and notice that the pertinent COMPANY provisions on which the denial, and noticethat you may request reconsideration of the denial by filing a written notice with the COMPANYwithin one (1) year after receiving notice of the denial. Reconsideration will be made by theGrievance Committee, and the decision of said Committee shall constitute a final determination ofthe claim.The Nevada Division of Insurance is responsible for regulating health care service plans, includingNEVADA PACIFIC DENTAL. The Division has a toll-free telephone number (888)872-3234 toreceive complaints regarding health plans.IV. EXCLUDED PROCEDURES AND SERVICESThe following dental procedures and services are not included in the PLAN:1. Dental services for esthetics only. Cosmetic dental care.2.General Anesthesia, intravenous and inhalation sedation, prescription drugs, and the services of a special anesthesiologist.3. Dental conditions arising out of and due to members employment or for which Workers Compensation is payable.3. Treatment required by reason of war or any act of war, whether declared or not; disaster or epidemic; a suicide attempt, while sane or insane; a intentional self-inflicted injury; anyEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 9
  10. 10. accident or sickness resulting from participation in an insurrection or riot or participation in the commission of an assault or felony or as the aggressor in an altercation.5. Hospital and medical charges of any kind, except for dental services otherwise covered.6. Treatment of fractures and dislocations.7. Loss or theft of dentures, partials, or other appliances (crowns, bridges, full or partial dentures).8.Preventive extractions (e.g. the removal of asymptomatic or non-pathologic teeth). Orthodontic extractions. Extractions resulting from fractures, neoplastic surgery, or radiation treatment.9. Services which are normally reimbursed by a third party or liability insurance and/or under the medical portion of an insurance/health and welfare plan.10. Services which are provided to the member by state government or agency thereof, or are provided without cost to the member by any municipality, country or other subdivision.11. Dental procedures started when not eligible for Benefits and Coverage.12. Procedures, appliances, or restorations to correct congenital or developmental malformations.13. 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 restorations to correct or replace soft or hard tissue defects resulting from such treatment.14. Dispensing of drugs not normally supplied in a dental office.15. Any treatment which, in the opinion of dentist, is not necessary for the Members dental health.16. Replacement of an existing bridge, partial or denture which is satisfactory or which can be made satisfactory.17. Orthognathic surgery.18. Implants or any prosthesis attached to or dependent upon an implant.19. An experimental or exotic procedure not approved by the ADA Council on Dental Therapeutics.20.Dental services received from any dental office other than a PLAN DENTIST, unless expressly authorized in writing by COMPANY or as cited "Out of Area Emergency."21.Treatment to alter vertical dimension or to restore occlusion, unless full dentures are involved.22. Major therapy for Temporo-Mandibular Joint (TMJ) problems including, assessment beyond that customarily provided in general dental practice. Minor therapy such as night guards, bite planes and minor equilibration (e.g., occlusal adjustment for one or two teeth) are covered.22.Expenses incurred for any procedure which commenced within ninety (90) days before the date the Member joined the plan.23.Crown lengthening procedures.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 10
  11. 11. 24.Dental treatment or services rendered by an individual who is a relative by blood or marriage to the eligible member or dependent, or who normally lives in the subscriber’s home.25.Expense or charge incurred by a subscriber confined in an institution that is primarily a place of rest, a place for the aged or a nursing home.26.Treatment related to the use of alcohol and injuries of all types which may be attributable to the use of alcohol.27.Any expenses for treatment due to drug abuse.28.Cases in which, in the reasonable professional judgment of the attending Dentist, a satisfactory result cannot be obtained.29.Replacement of long-standing missing tooth/teeth in an otherwise stable dentition.30.Dental services that cannot be performed in the PLAN general dental office because of physical, medical or behavioral limitations of eligible members over the age of six (6) years.24. The following orthodontic services are excluded: a) Retreatment of orthodontic cases. b) Treatment in progress at inception of eligibility. c) Changes in treatment necessitated by accident or patient neglect. d) Cases involving surgical orthodontics, myofunctional therapy, TMJ, cleft palate, micrognathia, hormonalimbalances. e) Phase I orthodontic care or orthodontic care prior to age ten. f) Extractions for orthodontic purposes.LIMITATIONSThe following dental procedures and services are the limitations that are applicable to this Plan: 1. Prophylaxis is limited to one treatment each six (6) month period (includes periodontal maintenance following active therapy). 2. Oral evaluation is limited to one each six (6) month period. (excluding 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. Treatment of emergencies is limited to care that will alleviate acute symptoms, including palliative treatment of infection, pain, swelling or bleeding, or to repair an appliance. 6. Crowns, bridges and dentures (including immediate dentures) are not to be replaced within a five (5) year period from initial placement. 7. 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.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 11
  12. 12. 8. Denture relines are limited to one per denture during any twelve (12) consecutive months. 9. 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. 10. Covered charge for both a temporary and a permanent prosthesis will be limited to the charges for a permanent one only. Charges for specialized techniques involving precision attachments, personalization or characterization, and additional charges for adjustments within six months of installation are not included as covered benefits. 11. 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 fractured or decayed to the extent that they do not hold a filling). Veneers, posterior to the second bicuspid, are considered purely cosmetic dentistry. Allowance will be made for cast full crown. If performed, patient must pay the additional fee. 12. Treatment for conditions is generally limited to conventional techniques and does not include splinting, hemisection, implants, overdentures, grafting, precision attachments, duplicate dentures and bruxating appliances. 13. Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during any twelve (12) consecutive months. Only two quads are allowable per appointment. 14. Full mouth debridement (gross scale) is limited to one treatment in any twenty-four (24) consecutive month period. 15. Osseous surgery is limited to not more than one treatment in any five (5) year period. 16. Bitewing x-rays are limited to not more than one series of four films in any six (6) month period. 17. Full mouth x-rays and/or panographic type films are limited to one set every twenty- four (24) consecutive months. A full mouth x-ray is defined as a minimum of 6 periapical films plus bite wing x-rays. 18. Sealant benefits include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact, for first molars up to age nine and second molars and bicuspids up to age fourteen. Sealant benefits do not include the repair or replacement of a sealant on any tooth within three (3) years of its application. 19. Single unit cast metal and/or ceramic restorations and crowns are covered only when the tooth cannot be adequately restored with other restorative materials. Crown build ups including pins are only allowable as a separate procedure in the exceptional instance where extensive tooth structure is lost and the need for a substructure can be demonstrated by written report and x-rays. 20. With complete or partial dentures, or fixed bridges, using standard procedures, is covered. However, treatment involving the following procedures is considered optionalEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 12
  13. 13. and, if performed, Member should be advised of his/her responsibility for the additional fee: a. precious metal for removable appliances; b. precision attachments; c. overlays and implants; and d. personalization and characterization. 21. Cosmetic dental care is limited to composite restorations on posterior teeth “distal to canines” when a NPD dentist determines treatment to be appropriate dental care. Composite restorations will be covered on premolar facial surfaces. 22. 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. 23. The BENEFITS and COVERAGES apply only when performed at a participating PLAN dental office, and may require preauthorization. Specialty services require predetermination of benefits. 24. Treatment may vary according to the DENTISTS treatment plan and the Members individual needs. An individuals treatment plan may require dental procedures that are not covered under the PLAN. 25. If two or more covered procedures would appropriately correct a clinical situation, the COMPANY will select the most appropriate procedure.V. PLAN MEMBER IDENTIFICATION The Plan shall make available the Benefits outlined in the Benefit Schedule to those persons who are Members. The Plan may furnish you an identification card evidencing enrollment. Cards issued by the Plan to you are for identification only. Possession of a Plan Identification Card confers no rights to services or other Benefits. To be entitled to such services or Benefits, you must, in fact, be a Member on whose behalf all applicable fees have actually been paid. Any services or other benefits received to which you are not then entitled will be charged at Prevailing Rates. If any Member permits the use of his Plan Identification Card by any other person, such card may be retained by the Plan, and all rights of such Member pursuant to the contract shall be immediately terminable at the will of the Plan.VI. TERMINATION OF BENEFITS If Plan Providers, after reasonable efforts to establish and maintain a satisfactory Provider- Patient relationship with any Member, is unable to do so, then the rights of the Member may be terminated on not less than thirty (30) days written notice to the Subscriber.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 13
  14. 14. If a Member fails to pay any amount due Plan or Plan Providers within sixty (60) days after notice to the Subscriber of the amount due, then the Plan may terminate the rights of the Subscriber and the Subscribers Dependents effective immediately upon written notice, and the rights may be reinstated only by payment of the amounts due and by renewed application and re-enrollment. Services received after the effective date of termination are charged at Prevailing Rates. The determination of any MEMBER termination, relative to the Rules and Regulations of the Organization, shall be decided by the Organization and the Company shall have the right to rely upon that determination. Any disputes or inquiries regarding such a termination shall be referred by the Company to the Organization, which shall then advise the Company of its determination. The time and the date or occurrence upon which Benefits and Coverage will terminate will be determined in such a termination by the Organization. A spouse who is enrolled in the Plan who ceases to be a qualified family member by reason of termination of marriage or death of the MEMBER will be afforded certain conversion rights and conditions as described within the Organization’s subscriber Benefit Agreement. A MEMBER who alleges that a subscription has been terminated or not renewed because of the MEMBER’s dental health status or requirements for dental health care services may request a review of cancellation by the Division of Insurance.VII. REINSTATEMENT OF MEMBER AND INDIVIDUAL CONTINUATION OFBENEFITS:6.1. INDIVIDUAL CONTINUATION OF BENEFITS A. Loss of Group Eligibility The Member who becomes ineligible for group coverage may apply within thirty (30) days of notice of ineligibility to continue Plan coverage. The terms and conditions under the Subscriber Agreement in which such Member was enrolled shall continue in effect with the following exceptions: Notices and distribution of materials as required for the member, will be delivered directly to the ORGANIZATION; Member shall pay the applicable monthly premium in effectEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 14
  15. 15. at the time the application to continue coverage is approved by the ORGANIZATION. Such extension of coverage shall apply to the Dependent(s) of the converting Members upon the same terms and conditions as applied to the converting Member. Such application may be accepted or rejected at the option of the COMPANY; no automatic right of individual continuation of benefits exist. B. Conversion Upon Death or Divorce of a Member A spouse who is enrolled in the Plan who ceases to be a qualified family member by reason of termination of marriage or death of the Member will be afforded to same conversion rights and conditions granted to the member under paragraph A of this Section. C. Loss of Eligibility Due to Termination of Group Subscriber Benefit Agreement Members have no individual rights to renewal or reinstatement of the Group Subscriber Agreement if it is terminated by Plan because the Subscriber Group fails to make monthly payments when due or otherwise breaches the Group Subscriber Agreement.VIII. BINDING ARBITRATION In the event of any controversy or dispute between interested parties (which term includes the ORGANIZATION, a Member, a Dependent, or the heirs-at-law or personal representatives of a Member or Dependent, and COMPANY, its agents, Professional Providers, or Employees), whether involving a claim in tort, contract, or otherwise, and including disputes which are not adequately resolved by the COMPANYs grievance procedures, shall be submitted to binding arbitration. Such arbitration may be initiated by any interested party but if the matter in dispute is one which is subject to review under the COMPANYs grievance procedures, arbitration may not be initiated until completion of such procedures. All such claims, controversies and disputes shall be submitted to arbitration in accordance with the applicable rules of the American Arbitration Association. Judgment upon any award rendered by the arbitrator may be duly entered in any court in the State of Nevada, having jurisdiction thereof. The prevailing party shall be entitled to court costs and reasonable attorneys fees.IX. REPORTS AND RECORDSEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 15
  16. 16. The Member agrees that the ORGANIZATION may make available to the Plan such employment records that have a bearing upon the eligibility of the Subscriber or MEMBER.X. MISCELLANEOUS PROVISIONS A. Application, Statements, Etc. Member(s) or those persons applying for membership shall complete and submit to the Plan such applications, forms or statements as the Plan may reasonably request. Member(s) represent(s) that all information contained in such applications, questionnaires, forms or statements submitted to the administration hereof are not knowingly untrue, incorrect and incomplete and all rights to benefits hereunder are subject to the condition that all such information is true, correct and complete. B. Liability of the Plan Members may be liable to pay non-contracting providers, where the Member has not been referred to said non-contracting Provider by his Plan Provider. In the event a Provider fails to pay a specialist for services rendered to an enrollee referred by said Provider to said specialist, the Plan shall be liable to the specialist. C. Relations Among Parties Plan Providers maintain the dentist-patient relationship with Members and are solely responsible to Members for all dental services. Information from dental records of Members and information received by Plan Providers incidental to the Provider-patient relationship is kept confidential, and, except for use incidental to bona fide medical or dental research or Quality Assurance, and unless reasonably necessary in connection with the administration of the Contract, including Medicare requirements, is not disclosed without the consent of the Member. Access to all such information, however, will be granted to the State of Nevada Department of Insurance. D. Grievance Procedures Members are encouraged to contact the COMPANY regarding any problems that are encountered while obtaining services. The COMPANY maintains a Grievance System to deal with Member problems and complaints. Member complains or grievances can be made in person at the COMPANY Offices at 1432 South Jones Blvd., Las Vegas, NV 89146, (702) 737-8900 or (800) 926-0925, FAX: (702) 737-0967, or can be made in writing. Complaint forms may be obtained from and should be returned to the COMPANY office. Members will receive a written response within thirty (30) days of an appeal. If the member is not satisfied with treatment received from a PLAN provider, a proposed treatment plan, denial of treatment or has concerns or questions about treatment that cannot be addressedEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 16
  17. 17. by the member’s assigned Provider and/or the COMPANY’S Dental Director, the member may request a second opinion from a COMPANY contracted general dentist or specialist. There is no cost for a second opinion from a Company contracted general dentist or specialist, except for applicable copayments, if any. The request for a second opinion is reviewed by the COMPANY’S Dental Director or Dental Consultant. The Nevada State Division of Insurance is responsible for regulating health care service plans, including Nevada Pacific Dental. The Division has a toll-free telephone number (888) 872-3234 to receive complaints regarding health plans. Consumer complaint forms can also be obtained from the Divisions website ( If you have a grievance against the health plan, you should first contact your Plan at 702-737-8900 or (800) 926-0925 and use the PLANs grievance process before contacting the Insurance Divisions Consumer Services. E. Governing Law The Plan is subject to the requirements of the Laws and Regulations of the State of Nevada, and any provision required to be in this Evidence of Coverage; or the Group Subscriber Agreement shall bind the Plan whether or not set forth herein. F. Termination of a Provider In the event that a Plan Provider contract is terminated, the Plan will be liable for covered services rendered by such Plan Provider to Member under the Plan contract or by operation of law, for care provided at the time of the termination until the services being rendered are completed. The Plan reserves the option to make reasonable and medically appropriate provisions for the assumption of such services by another Plan Provider. G. Public Policy Committee The Plan has established a Public Policy Committee consisting of representatives of the Plan, Plan Providers and Subscriber Groups to provide input to the Plan regarding services and benefits and to participate in policy-making decisions. H. Benefits Committee The Plan has a newly established Benefits Committee consisting of representatives of the Plan, Plan Providers and out-of-Plan dentists to provide input to the Plan regarding dental benefits and dental treatment decisions.XI. COORDINATION OF BENEFITS (C.O.B.)EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 17
  18. 18. If an eligible Member is entitled to coverage under other group insurance policies, then the benefits of this Plan shall be provided as follows: A. A plan which does not contain a C.O.B. provision must release its benefits first, ahead of a plan which does contain such a provision. B. A plan which covers the patient as an insured must release its benefits first, ahead of a plan which covers the patient as a dependent. C. A plan which covers the patient as a dependent, the plan covering the parent whose birthday falls earlier in the year pays first. D. The plan covering the parent whose birthday falls later in the year pays second E. If both parents have the same birthday, the plan which covered the partent longer pays first. F. The Plan which covered the other parent for a shorter time pays second. G. A persons year of birth is not relevant in applying this rule. H. If a father and mother are legally separated or divorced, the plan covering the patient as the dependent child of the mother will release its benefits first, ahead of the plan covering the patient as a dependent child of the father unless the father has legal custody. If the father has legal custody of the dependent child, this exception does not apply. I. If a father and mother are divorced and the mother has remarried, the plan which covers the patient as a dependent child of the step- father must release its benefits first, ahead of the plan covering the patient as a dependent of the natural father. J. If evidence is submitted showing that the natural father has legal custody of the child, this order shall be reversed. K. The plan which has covered the patient for the longer period of time will release its benefits first. In determining the length of time an individual has been covered the following rules apply:EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 18
  19. 19. a) Two successive plans of a given group should be regarded as one continuous plan as long as the patient was eligible under the new plan within twenty-four (24) hours after coverage under the prior plan terminated; b) If the patients individual effective date of coverage is subsequent to the group policys effective date, measure the length of time from the patients individual effective date; c) If the patients individual effective date is the same as the group policys effective date, request the groups administrator to furnish the date coverage first became effective under the earliest of any previous plans the group may have had. If that date is not readily available, the date the patient first became a member of the group shall be used as the date from which to determine the length of time he has been covered by the Plan. L. If the plan of benefits provided by this program is primary as provided above, the other policies or plan shall provide additional benefits to the fullest extent possible to provide all payment of any included co-payments. If the other policy(ies) or plan(s) is (are) primary, the other plan or policy shall provide benefits to the maximum extent possible. If those benefits provided by the other policies or plans exceed or equal any included co- payments, the co-payments will be reduced to the extent of benefits provided by the other plan or policies. M. It is possible for a person to be both an eligible participant and a dependent. If a husband and wife are both eligible employees, they will be each others dependents and their dependent children will be dependents of each of them. All dual eligibility claims submitted under Plans of benefits covered by this Evidence of Coverage will be coordinated for benefit payment. In no case will more than 100% of services be covered.XII. ELIGIBILITY11.1 The determination of who is eligible to participate and who is actually participating in the Plan shall be decided by ORGANIZATION, as set forth in the Rules and Regulations of the ORGANIZATION, and the COMPANY shall have the right to rely on that determination. Any disputes or inquiries regarding eligibility, including rights regardingEOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 19
  20. 20. renewal, reinstatement and the like, if any, shall be referred by the COMPANY to ORGANIZATION, which shall then advise the COMPANY of its determination.11.2. Subject to all of the above eligibility requirements, the COMPANY guarantees the following: 11.2-l. Dependents shall include Member’s spouse, all newborn infants whose coverage shall commence from the moment of birth, and all adopted, foster and step children whose coverage shall commence from the date of placement. 11.2-2. Dependents shall include all unmarried children under the age of 19 years who are chiefly dependent on the Member for their support. Eligibility shall be extended for full-time students under the age of 23 years, if unmarried and chiefly dependent on the Member for support. 11.2-3. Coverage shall not terminate while a Dependent child is and continues to be: a. Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and b. Chiefly dependent upon the Member for support and maintenance, provided the Member furnishes proof of such incapacity and dependency to COMPANY within 31 days of the Dependents attaining the limiting age as set forth in Section XI (11-2-2), and every two years thereafter. 11-2-4. Should a Member be terminated or become ineligible for benefits, that Member shall continue to be eligible to receive services and COMPANY shall be entitled to its monthly fee for that Member until such time as the ORGANIZATION notifies the COMPANY in writing of the Members termination or loss of eligibility and the Member is removed from the eligibility list. Should COMPANY be notified of a Members termination or loss of benefits after the eligibility list is provided or after the first of the month, coverage for that Member shall continue until the end of the month and COMPANY shall retain or must be paid its monthly fee for that Member to the end of the month.EOCNPD.1005, 1006, 1007, 1008, 1010, 1011,1013Copyright 2002 20