CurrentlibertydentalplanPolicy 573-526-4898
Evidence of Coverage (EOC) for LIBERTY Dental Plan group benefits
Customize your policy alerts
Sign up for libertydentalplan Policy 573-526-4898 alerts
Get alerted when Policy 573-526-4898 changes without checking for updates manually.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
This document governs eligibility, enrollment, termination, use of plan providers, covered services definitions, and claims procedures for eligible employees and their eligible family members under the LIBERTY Dental Plan group contract (GEA). It affects Subscribers, their Dependents, Plan Providers, and Groups contracting with LIBERTY.
Policy Summary
Payerlibertydentalplan
PolicyEvidence of Coverage (EOC) for LIBERTY Dental Plan group benefits
Policy CodePolicy Policy 573-526-4898
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionTo receive benefits for Specialist care, obtain a referral from a Plan Provider and secure prior authorization from LIBERTY.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
26 yearsdependent child limiting age for coverage
1 per 6 monthsprophylaxis frequency limit
5 yearsreplacement interval for crowns, bridges, dentures
180 daystime to file 1st Level Formal Appeal
72 hoursdecision timeframe for Expedited Appeal
Coverage, Limits, and Appeals
Covered Services and Provider Requirements
Covered services are limited to those that meet LIBERTY's definition of Dentally Necessary and must be delivered by Plan Providers; Specialist care requires referral and preauthorization. Copayments and benefit limits are shown in the Benefit Schedule.
Services and supplies must meet LIBERTY's definition of Dentally Necessary to be considered Covered Services.
Benefits and applicable copayments/limits are those shown in the member's Benefit Schedule.
Members must obtain Covered Services from a Plan Provider to utilize Plan benefits; when services are provided by a Plan Provider, no claim forms are required.
Specialist care: to receive benefits for care provided by a Specialist the Member must be referred to the Specialist by a Plan Provider and the care must be preauthorized by LIBERTY.
Covered services, exclusions and limitations (partial)
The following exclusions, frequency limits, replacement rules and other limitations govern what LIBERTY will cover.
Exclusions
- Dental services provided for aesthetics only and/or cosmetic dental care.
- General anesthesia, intravenous and inhalation sedation, prescription drugs for anesthesia, and services of a special anesthesiologist.
- Hospital and medical facility charges of any kind and charges from medical doctors or other medical professionals except for dental services otherwise covered herein.
- Treatment of fractures or dislocations.
- Loss or theft of dentures, partials or other appliances (including crowns, bridges, full or partial dentures).
- Services normally reimbursed by third-party liability or under the medical portion of a group health plan.
- Dental procedures that started prior to the Member's eligibility for benefits.
- Procedures, appliances or restorations to correct congenital or developmental malformations; treatment/removal of certain malignancies, cysts or tumors outside usual dental care scope.
- Drugs/medications not normally supplied or prescribed by a dental office.
- Any treatment the LIBERTY Dental Director determines is not necessary for the Member's dental health.
- Replacement of an existing bridge, partial or denture that the Dental Director deems satisfactory or can be made satisfactory.
- Orthognathic surgery and major TMJ therapy beyond routine general dental assessment.
- Implants or any prosthesis attached to or dependent upon an implant.
- Experimental, investigational or exotic procedures not approved by the ADA Council on Dental Therapeutics.
- Orthodontic services unless specifically listed as covered in the Member's Benefit Schedule.
Out‑of‑area emergency reimbursement: If no Plan Provider is available within a 50‑mile radius, Member may seek out‑of‑network emergency treatment; LIBERTY will reimburse up to $75 less applicable copayments as if the Member had visited a Plan Provider.
Frequency limits and replacement rules
- Prophylaxis limited to one treatment every 6 months (includes periodontal maintenance after active therapy).
- Oral evaluation limited to one every 6 months.
- Oral hygiene instruction limited to one per 24 months.
- Fluoride treatment limited to one per 12 months.
- Crowns, bridges and dentures may not be replaced within 5 years from initial placement; partial dentures not replaced within 5 years unless necessary due to natural tooth loss.
- Denture relines limited to one per denture during any 12 consecutive months.
- Charges for adjustment of a prosthesis limited to one in a 6 month period.
Periodontal and surgical limits
- Periodontal treatments (including root planing and scaling) limited to four quadrants during any 24 consecutive months.
- Full mouth debridement (gross scale) limited to one treatment in any 36 consecutive month period.
- Osseous surgery limited to one treatment in any 5 year period.
- Crowns covered only if, in the opinion of LIBERTY's Dental Director, there is insufficient retentive quality to hold a filling.
Radiographs and sealants
- Bitewing x‑rays limited to one series per 6 months; full mouth x‑rays or panographic films limited to one set every 24 consecutive months.
- Sealant benefits limited to permanent first and second molars with no decay up to age 15; sealants limited to once per 36 months per tooth.
Administrative provisions
- Members must provide written notice of claim within 20 days; LIBERTY will furnish claim forms within 15 days of notice or proof considered sufficient.
Appeals and Grievance Procedural Criteria
Procedural steps, required contents, filing windows and investigation/decision timeframes for Informal Reviews, 1st Level Formal Appeals and Expedited Appeals.
Informal Review: Voluntary first‑level review available for Grievances including Adverse Benefit Determinations; must be requested to Member Services within 60 days of the Adverse Benefit Determination; determination made as soon as reasonably possible but not to exceed 30 days unless additional fact‑finding is required.
First Level Formal Appeal — filing and contents: If not resolved by Informal Review (or member skips Informal Review), Member must submit a written Grievance requesting a 1st Level Formal Appeal within 180 days of the Adverse Benefit Determination (or 180 days from the event for other grievances). The written grievance must include Member identification, membership and Group, a statement of reasons, and may include supporting records or dentist letters.
First Level Formal Appeal — acknowledgement and investigation: LIBERTY will acknowledge receipt within 10 working days and conduct a complete investigation within 20 working days; if investigation cannot be completed in 20 working days, LIBERTY will notify the Member on or before the 20th working day and complete the investigation within 30 working days thereafter. Decision communicated within 5 working days of investigation completion; decision notice must include specified content (reasons, plan references, access to documents, voluntary procedures, ERISA civil action notice when applicable, availability of relied‑upon criteria or scientific explanation).
Expedited Appeal: Available for Pre‑Service Claims when the Member or their Dentist believes health could be seriously harmed by waiting. Expedited Appeals must be decided no later than 72 hours after receipt if all necessary information is submitted. If information is insufficient, LIBERTY must notify the Member within 24 hours and allow at least 48 hours to provide requested information; if the Member's Dentist requests or supports the Expedited Appeal and indicates waiting could seriously harm the Member, LIBERTY will automatically grant the Expedited Appeal. Expedited Appeals are not available for Post‑Service Claim payment appeals.
Member supports and assistance: Members may request assistance from a Member Services Representative at any time; members are entitled to reasonable access to and copies of documents relevant to their Claim for Benefits free of charge. Members may contact MDI for assistance and, if coverage is subject to ERISA, must exhaust mandatory appeal levels before pursuing court action.
Codes, Frequency Rules, and Glossary Codes
Inventory placeholder codesmixed
| No codes listed |
Glossary — appeals terminologymixed
| Glossary definitions relevant to claims and appeals (e.g., Adverse Benefit Determination, Claim for Benefits, Pre-Service/Post-Service Claims). |
inv-07: Sealant age and frequency — key rules
Covered teethPermanent first and second molars only
Age limitUp to age 15
Frequency per toothOnce per 36 months per tooth
ConditionTooth must have no decay at time of application
Provider Responsibilities, Authorizations, and Notices
Prior Authorization
Specialist referral and preauthorization required
To receive benefits for care provided by a Specialist you must be referred to the Specialist by a Plan Provider and have your care preauthorized by the Plan.
Billing Rule
Out‑of‑area emergency reimbursement up to $75 less copay
If no Plan Provider is available within a fifty (50) mile radius, the Member may seek treatment from an out-of-network provider; the Plan will reimburse for Emergency Services as if you had visited a Plan Provider, up to a maximum of seventy‑five dollars ($75) less applicable co-payments.
Prior Authorization
Dentist-supported expedited appeals — automatic grant when harm risk indicated
A Member or the Member's Dentist may request an Expedited Appeal for a Pre‑Service Claim when waiting could seriously harm the Member; if the Member's Dentist requests or supports the Expedited Appeal and indicates waiting could seriously harm the Member or subject them to unmanageable severe pain, LIBERTY will automatically grant the Expedited Appeal.
- Expedited Appeals must be decided no later than 72 hours after receipt if all necessary information is submitted.
- If information is insufficient, LIBERTY will notify the Member and allow at least 48 hours to provide the specified information.
Documentation Required
Release of records authorized by Member
Each Member authorizes their providers to permit examination and copying of the Member's dental records as requested by LIBERTY.
- Providers must permit LIBERTY to examine and copy dental records when requested.
Prior Authorization
Obtain prior authorization for nonemergency services
Prior Authorization requires a Provider to get approval from LIBERTY before providing nonemergency services for those services to be considered Covered Services; prior authorization is not an agreement to pay for a service.
- Obtain prior authorization for nonemergency procedures to ensure services are considered Covered Services.
- Prior authorization does not guarantee payment.
Key Definitions
inv-13: Subscriber — definition
DefinitionAn employee of the Group who meets eligibility requirements, has enrolled under the Plan, and for whom premiums have been received
RolePrimary contract holder for Member coverage and recipient of Benefit Schedule and EOC communications
Contact info referenceMember Services contact and enrollment details provided in EOC Section 1
inv-14: Dependent — scope and continuation
Included personsLegal spouse, registered domestic partner, biological/adopted/step/placed-for-adoption children, minor children covered by court order
Limiting ageDependent child coverage generally up to the child's 26th birthday (subject to employer-sponsored coverage rules)
Handicapped continuationUnmarried child incapable of self-sustaining employment due to mental/physical handicap may continue if enrolled before limiting age and proof provided within 31 days, with periodic proof thereafter
inv-15: Dentally Necessary — definition
Core definitionServices and supplies that meet LIBERTY's definition of Dentally Necessary will be considered Covered Services
Clinical criteriaConsistent with the diagnosis and treatment of the Member and the most appropriate level of service safely provided
Evidence consideredPeer-reviewed literature, evidence-based guidelines, expert opinion and other relevant information may be considered
Not automaticServices are not Dentally Necessary solely because prescribed by a Dentist
inv-16: Relationship of Parties — independent contractor
Relationship statusPlan Providers are independent contractors to LIBERTY, not agents or employees
LiabilityLIBERTY is not liable for claims or demands for damages from injuries suffered while receiving care from a Plan Provider
Mutual non-employmentLIBERTY employees are not employees or agents of Plan Providers
inv-17: Notice — mailing addresses and rules
LIBERTY mailing addressLIBERTY Dental Plan, P.O. Box 26110, Santa Ana, CA 92799-6110
MethodNotice may be given by United States mail, first class, postage paid
Notice to MemberNotice to a Member will be sent to the Member's last known address
inv-18: Adverse Benefit Determination — appeals definition
DefinitionA decision by the Plan to deny, in whole or in part, a Member's Claim for Benefits
EffectReceipt entitles the Member or Authorized Representative to appeal using LIBERTY's Appeals Procedures
FinalityAn Adverse Benefit Determination is final if the Member has exhausted all complaint and Appeal Procedures set forth herein
inv-19: Claim for Benefits — definition and handling
DefinitionA request for a Plan benefit or benefits made by a Member in accordance with the Plan's Appeals Procedures, including Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment)
ScopeIncludes Pre-Service Claims and Post-Service Claims handled under Appeals Procedures
Appeals handlingClaims are subject to the Plan's Appeals Procedures as described in Section 7 and the Glossary
inv-20: Authorized Representative — appeals/claim representation
DefinitionA person designated by the Member to act on his behalf in pursuing a Claim for Benefits, filing an appeal of an Adverse Benefit Determination, or obtaining an External Review
AuthorityMay act on Member's behalf in appeals and external review processes per Plan procedures
UseDesignation allows the Authorized Representative to receive correspondence and pursue Claims under the Appeals Procedures
inv-21: Adverse Benefit Determination (dup)
Definition (dup)A decision by the Plan to deny, in whole or in part, a Member's Claim for Benefits; receipt entitles the Member or Authorized Representative to appeal using LIBERTY's Appeals Procedures
Appeal entitlementTriggers right to utilize LIBERTY's Appeals Procedures set forth in Section 7
Finality noteFinal after exhaustion of complaint and appeal procedures
inv-22: Authorized Representative (dup)
Definition (dup)A person designated by the Member to act on their behalf in pursuing a Claim for Benefits, filing an appeal, or obtaining an External Review
FunctionsFile appeals, pursue external review, and act in claims processes per Plan rules
ApplicabilityUsed throughout Appeals and Glossary sections to allow representation
inv-23: Dentist — licensed DDS/DMD
DefinitionAn individual licensed as a Doctor of Dental Surgery (D.D.S.) or a Doctor of Dental Medicine (D.M.D.) practicing within the scope of such license under applicable state laws
ScopeMust practice within the scope of the applicable state license
RoleProvides dental care to Members as a Dentist under Plan or non-Plan arrangements
inv-24: Emergency Services — definition and scope
DefinitionCovered Services provided after the sudden onset of a dental condition with severe symptoms where lack of immediate attention could result in serious jeopardy, disability, dysfunction, or death
Scope of servicesIncludes dental screening, examination, evaluation by a dentist or dental specialist and care to alleviate emergency symptoms in a dental office
Member standardCondition that would lead a prudent person to believe immediate attention is necessary (including threats to an unborn child)
inv-25: Prior Authorization — definition
DefinitionA system requiring a Provider to get approval from LIBERTY before providing nonemergency services for those services to be considered Covered Services
Not payment guaranteePrior authorization is not an agreement to pay for the service
Applies toNonemergency health care services where Plan conditions receipt of benefit on advance approval
inv-26: Dentally Necessary (dup)
Core definition (dup)Services and supplies needed to improve or preserve a Member's dental health consistent with diagnosis and the most appropriate level of service will be considered Dentally Necessary
ConsiderationsDeterminations may consider clinical appropriateness, peer-reviewed literature, evidence-based guidelines, expert opinion and other relevant information
ExclusionNot Dentally Necessary if performed solely for convenience of Member or Provider
Policy Summary
Payerlibertydentalplan
PolicyEvidence of Coverage (EOC) for LIBERTY Dental Plan group benefits
Policy CodePolicy Policy 573-526-4898
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionTo receive benefits for Specialist care, obtain a referral from a Plan Provider and secure prior authorization from LIBERTY.
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.