Dental Blue FT - Definitions

Definitions

 

The following terms are shown in italics in this Dental Blue Freedom Benefit Description and in any riders that apply to your Dental Blue Freedom benefits. These terms apply to both the Dental Blue PPO plan and the Dental Blue plan that together form Dental Blue Freedom. These terms will help you understand your dental benefits.

Allowed Charge
The charge that is used to calculate payment of your Dental Blue Freedom benefits. The allowed charge depends on the type of health care provider that furnishes a covered dental service to you.

  • Dental Blue PPO Preferred Dentists. For covered dental services furnished by dentists who have a written payment agreement to furnish dental services to members enrolled under a Dental Blue PPO plan, your benefits are calculated based on the provisions of the dentist’s preferred payment agreement and the dentist’s contracted rate that is in effect at the time a covered dental service is furnished. (This contracted rate is referred to as the dentist’s allowed charge.)
  • Dental Blue Participating Dentists Who Do Not Have a Blue Cross and Blue Shield PPO Provider Contract. For covered dental services furnished by dentists who have a Blue Cross and Blue Shield participating provider payment agreement but not a PPO provider contract, your benefits are calculated based on the provisions of that Blue Cross and Blue Shield participating dentist’s payment agreement and the dentist’s Dental Blue contracted rate that is in effect at the time the covered dental service is furnished. (This contracted rate is referred to as the dentist’s allowed charge.)
  • Dentists Who Do Not Have a Payment Agreement. For covered dental services furnished by dentists who do not have a payment agreement to furnish covered dental services to Dental Blue PPO or Dental Blue members, the dentist’s actual charges are used to calculate your benefits, unless these provisions are changed by your Benefits Payable Rider which is part of your Dental Blue Freedom Benefit Description.

In most cases when a dentist has a written payment agreement to furnish covered dental services to members, you do not have to pay the amount of the dentist’s actual charge that is in excess of the dentist’s contracted rate. However, there are certain situations when you may have to pay the difference between the claim payment and the dentist’s actual charge. This is the case when: you have received your maximum dental benefits; you and your dentist decide to use a procedure that is more expensive than a less costly, but acceptable alternative (in this case, benefits are provided at the lower fee and you pay any balance); you could have received benefits or services from someone else without charge or you have received or will receive payment from another person or insurance company (once these payments from the other person or insurance company have been applied to your provider balances and used up, you do not have to pay the amount in excess of the contracted rate); or you receive services from more than one dentist for the same procedure or for procedures that are furnished in a series during a planned course of treatment (in this case, the total amount of your benefits will not be more than the amount that would have been provided had only one dentist furnished all services).

Blue Cross and Blue Shield
Blue Cross and Blue Shield of Massachusetts, Inc., the organization that has been designated by your plan sponsor to provide administrative services to Dental Blue Freedom, such as claims processing, case management and other services, and to arrange for a network of dentists whose services are covered by Dental Blue Freedom. This includes an employee or designee of Blue Cross and Blue Shield who is authorized to make decisions or take action called for as described in this Benefit Description.

Covered Dental Services
The dental services, supplies, procedures and appliances for which Dental Blue Freedom provides benefits as described in this Benefit Description and any riders attached as part of your Benefit Description.

Deductible
The amount that you must pay before benefits are provided for certain covered dental services. The Benefits Payable Riders that are attached as part of your Benefit Description show the amount of your deductible (if any) and which covered dental services are subject to the deductible. The amount that is put toward your deductible is calculated based on the dentist’s contracted rate or the actual charge, whichever is less (unless otherwise required by law).

Effective Date
The date on which your membership in Dental Blue Freedom starts.

Fracture
The breakage of sound natural teeth. This does not include crazing (small surface breaks) resulting from temperature changes or chipping due to attrition.

Group
Any corporation, partnership, individual proprietorship or other organization that has entered in to an agreement under which Blue Cross and Blue Shield provides administrative services for the group’s self-insured dental benefits plan.

Member
You, the person who has the right to the benefits described in this Dental Blue Freedom Benefit Description. A member may be the subscriber or his or her enrolled spouse (or former spouse, if applicable) or any other enrolled dependent.

Necessary and Appropriate
All dental care, services, procedures, supplies and appliances must be necessary and appropriate to diagnose or treat your dental condition. Blue Cross and Blue Shield uses the following criteria to determine whether your dental care is necessary and appropriate for you:

  • Your dental care must be consistent with the prevention and treatment of oral disease or with the diagnosis and treatment of teeth that are decayed or fractured, or where the supporting structure is weakened by disease (including periodontal, endodontic and related diseases).
  • Your dental care must be furnished in accordance with standards of good dental practice.
  • Your dental care must not be solely for your convenience or the convenience of your dentist.

Under certain circumstances, Blue Cross and Blue Shield may review dental records describing your condition and treatment, Blue Cross and Blue Shield’s staff, including dental consultants, use their professional judgment to determine available benefits for certain types of procedures, including but not limited to crown restorations, periodontal services, oral surgery, fixed bridgework and partial dentures. A dental consultant may review the treatment plan objectively and determine whether the services are within the scope of benefits, and whether these services are necessary and appropriate for you. Based on Blue Cross and Blue Shield’s findings, Blue Cross and Blue Shield may determine that a service is not necessary and appropriate for you, even if your dentist has recommended, approved, prescribed, ordered or furnished the service.

Plan Sponsor
The plan sponsor is usually your employer and is the same as the plan sponsor designated under the Employee Retirement Income Security Act of 1974 (ERISA), as amended. If you are not sure who your plan sponsor is, contact your employer.

Rider
A “Benefits Payable Rider” which describes the amounts that you must pay for covered dental services and any benefit limits, or an amendment that changes the terms described in this Dental Blue Freedom Benefit Description. Blue Cross and Blue Shield or your group may change the terms of Dental Blue Freedom. For example, a rider may add or limit the benefits provided under Dental Blue Freedom. A rider describes the material change that is made to Dental Blue Freedom. You should keep any riders with your Dental Blue Freedom Benefit Description.

Subscriber
The eligible person who signs the enrollment form at the time of enrollment under Dental Blue Freedom.

Utilization Review
The approach that Blue Cross and Blue Shield uses to evaluate the necessity and appropriateness of many different dental procedures such as crown restorations and periodontal services. This review process involves the knowledge of dental contracts, policies and procedures in conjunction with the professional expertise of dental consultants which include dental hygienists, dental assistants and currently practicing dentists. These reviews consist of examination of dental history, radiographs, periodontal charting and narratives.