Access to and Confidentiality of Dental or Medical Records
Blue Cross and Blue Shield and health care providers may, in accordance with applicable law, have access to all dental or medical records and related information needed by Blue Cross and Blue Shield or health care providers. Blue Cross and Blue Shield may collect information from health care providers, other insurance companies or the plan sponsor to help Blue Cross and Blue Shield administer the benefits described in this Dental Blue Freedom Benefit Description and to get facts on the quality of care provided under this and other health care contracts. In accordance with law, Blue Crossand Blue Shield and health care providers may use this information, and may disclose it to necessary persons and entities as follows:
- For administering benefits (including coordination of benefits with other insurance plans); managing care; quality assurance; utilization management; the prescription drug history program; grievance and claims review activities; or other specific business, professional or insurance functions for Blue Cross and Blue Shield.
- For bona fide medical research according to the regulations of the U.S. Department of Health and Human Services and the Food and Drug Administration for the protection of human subjects.
- As required by law or valid court order.
- As required by government or regulatory agencies.
- As required by the subscriber’s group or its auditors.
- For the purpose of processing a claim, dental or medical information may be released to your group’s reinsurance carrier.
Note: To obtain a copy of Blue Cross and Blue Shield’s Commitment to Confidentiality statement, call the Blue Cross and Blue Shield customer service office at the toll-free telephone number shown on your Dental Blue Freedom identification card.
Blue Cross and Blue Shield will not share information about you with the Medical Information Bureau (MIB). Except as described above, Blue Cross and Blue Shield will keep all information confidential and not disclose it without your consent.
You have the right to get the information Blue Cross and Blue Shield collects about you. You may also ask Blue Cross and Blue Shield to correct any information that you believe is not correct. Blue Cross and Blue Shield may charge a reasonable fee for copying records.
Acts of Dentists
Blue Cross and Blue Shield is not liable for the acts or omissions by any dentists that furnish care or services to you. In addition, a dentist does not act as an agent on behalf of or for Blue Cross and Blue Shield. And, Blue Cross and Blue Shield does not act as an agent for dentists. Blue Cross and Blue Shield will not interfere with the relationship between dentists and their patients. You are free to select or discharge any dentist. It is not up to Blue Cross and Blue Shield to find a dentist for you. Blue Cross and Blue Shield is not responsible if a dentist refuses to furnish services to you.
Assignment of Benefits
You cannot assign any benefit or monies due under Dental Blue Freedom to any person, corporation or other organization without the plan sponsor’s and Blue Cross and Blue Shield’s written consent. Any assignment by you will be void. Assignment means the transfer of your rights to the benefits provided by Dental Blue Freedom to another person or organization. There is one exception to this rule. If Medicaid has already paid the provider, you can assign your benefits to Medicaid.
You may choose to have another person act on your behalf concerning your benefits under Dental Blue Freedom. You must designate this person in writing to Blue Cross and Blue Shield. Or, if you are not able to do this, a person such as a conservator, a person with power of attorney or a family member may be your authorized representative. In certain situations, Blue Cross and Blue Shield may consider your dentist to be your authorized representative. For example, Blue Cross and Blue Shield may tell your dentist about the extent of your dental benefits for services reported on a Pre-treatment Estimate or may ask your dentist for more information if more is needed to make a determination about your dental benefits. Blue Cross and Blue Shield will continue to send benefit payments and written communications regarding health care coverage in accordance with Blue Cross and Blue Shield’s standard practices, unless specifically requested to do otherwise. (You can get a form to designate an authorized representative from the Blue Cross and Blue Shield customer service office.)
Changes to Dental Blue Freedom
The plan sponsor or Blue Cross and Blue Shield may change the benefits described in this Dental Blue Freedom Benefit Description. For example, a change may be made to the amount you must pay for certain services. The plan sponsor is responsible for sending you a notice of any change. The notice will describe the change being made. It will also give the effective date of the change. When a change is made to your benefits, you can get the actual language of the change from your plan sponsor. The change will apply to all Dental Blue Freedom benefits for services you receive on or after its effective date.
Your dentist may submit a Pre-treatment Estimate to Blue Cross and Blue Shield in order to determine the extent to which dental services are covered. A “Pre-treatment Estimate” is a detailed description of the procedures that the dentist plans to perform and includes the charge for each procedure. Blue Cross and Blue Shield recommends that a Pre-treatment Estimate be submitted for any Group 2 or Group 3 Service expected to cost more than $250. Blue Cross and Blue Shield will let you and your dentist know about the extent of your benefits for the services reported. Pre-treatment Estimates are calculated based on current available benefits and member eligibility. Pre-treatment Estimates are not a guarantee of payment and are subject to change based on remaining benefits available and eligibility in effect at the time services are completed and a claim is submitted for payment. If your dentist does not file a Pre-treatment Estimate, Blue Cross and Blue Shield will decide the extent of your benefits based on a review of those services and standards that are considered generally accepted dental practice.
Time Limit for Legal Action
Before pursuing a legal action against Blue Cross and Blue Shield for any claim under Dental Blue Freedom, you must complete a formal internal grievance review (see Part 7). You may, but do not need to, pursue an external review prior to pursuing a legal action. If, after completing the grievance review, you choose to bring legal action against Blue Cross and Blue Shield, this action must be brought within two years after the cause of action arises. For example, if you are filing a legal action because you were denied a service or a claim for benefits under Dental Blue Freedom, you will lose your right to bring a legal action against Blue Cross and Blue Shield unless you file your action within two years after the date you were first sent a notice of the service or claim denial. Going through the internal formal grievance process does not extend the two-year limit for filing a lawsuit. However, if you choose to pursue a voluntary external review, the days from the date your request is received by the external reviewer until the date you receive the response are not counted toward the two-year limit.