Provide Insurance Benefits Guide; notify subscribers of material changes

The Plan Administrator will provide eligible Subscribers an Insurance Benefits Guide summarizing plan benefits and rights; the Guide may contain more detail but the Plan controls in case of conflict. The Planholder may alter or amend benefits or premiums at any time and will provide Subscribers a summary of any material change.

Determine Allowed Amounts and pay least-cost alternate treatments

For procedures not listed in the Schedule of Dental Procedures and Allowed Amounts, the Allowed Amount is determined by the Third-Party Claims Processor through its medical staff and/or dental consultants based on comparable or similar services; when an alternate treatment meets accepted standards, payment is based on the least costly accepted alternative.

• Allowed Amount for unspecified procedures is set by Third-Party Claims Processor based on comparable services.
• Alternate Forms of Treatment: payment based on least costly alternative regardless of patient or dentist choice.

Plan Administrator/TPP discretion in Medical Necessity determinations

The Plan Administrator and the Third-Party Claims Processor have discretion to apply and rely upon dental and medical standards, policies, guidelines, criteria, protocols, manuals, publications, studies, or literature to determine whether a procedure meets the Plan's definition of Medically Necessary.

• Medical Necessity defined by multi-part criteria (appropriateness, prescribed by Dentist, rendered per recognized practices, not cosmetic/experimental).
• Plan Administrator/TPP may use any criteria they determine generally accepted by the dental/medical community.

Request voluntary Pre‑Treatment Estimate for proposed treatment

A Pre-Treatment Estimate is a written estimate of benefits requested by a dentist and provided to the patient and dentist before treatment; Providers and Covered Persons are encouraged to submit the completed form and X-rays to the Third-Party Claims Processor for review when estimated charges are $250 or more.

• Pre-Treatment Estimate is voluntary but suggested for estimated charges of $250+.
• If treatment is not rendered within one year of the estimate, submit a new Pre-Treatment Estimate.
• Completed form and X-rays should be sent to the Third-Party Claims Processor for a determination of benefits.

File enrollment/election forms within 31 days using PEBA-approved method

Employees and Retirees must submit an election of benefits and any other required forms in a manner approved by PEBA within 31 days of the date coverage would commence; failure to timely submit limits enrollment to Open Enrollment or Special Eligibility Situations.

• Submission must follow PEBA-approved method and include payroll deduction authorization (where applicable).
• Retirees also must submit required information within 31 days of Retirement to enroll; late submissions restrict enrollment options.

Submit required supporting documentation for special eligibility events

Special eligibility events require timely submission of satisfactory documentation with the election of benefits within the specified timeframe (typically 31 days, or 60 days for certain Medicaid/CHIP or premium assistance events).

• Examples: add a child within 31 days of birth/adoption/placement/foster care/stepchild/custody; add coverage within 60 days of loss of Medicaid/CHIP or determination of premium assistance, with a satisfactory statement of circumstances.
• Failure to submit required documentation within the event time frame results in waiting until Open Enrollment or the next Special Eligibility Situation.

Verify SCRHI Trust Fund participation and apply Earned Service funding rules

To determine SCRHI Trust Fund retiree premium funding, verify whether the retiree's last employer participates in the SCRHI Trust Fund and apply funding rules based on hire date and years of Earned Service (including consecutive full‑time service requirements where applicable).

• If last employer does not participate in SCRHI Trust Fund, retiree is not eligible for SCRHI funding; employer may elect to pay none, part, or all of premium.
• For hires before May 2, 2008, employer portion may be paid by SCRHI if retiree had ≥10 years Earned Service and last 5 years consecutive full‑time with an SCRHI‑participating employer.
• For hires on/after May 2, 2008: <15 years = no SCRHI funding; 15–24 years = SCRHI pays 50% of employer portion; ≥25 years = SCRHI pays employer portion.

Equate non‑SCRS service to Earned Service per specified rules

One year of full‑time paid State ORP employment or employment with a non‑State Retirement System employer equates to one year of Earned Service for retiree eligibility determinations; solicitor's office employment counts only if at least one county in the circuit participates and is not eligible for SCRHI funding.

• ORP or non‑State Retirement System service: 1 year = 1 year Earned Service (for eligibility purposes).
• Solicitor's office employment counts as Employer service only if at least one county in the judicial circuit participates; such retirees are not eligible for SCRHI Trust Fund funding.

Submit retiree election and information within 31 days of Retirement

Retirees must submit an election of benefits and any required information within 31 days of Retirement to enroll; failure to do so limits enrollment to Open Enrollment or Special Eligibility Situations and retiree coverage cannot begin earlier than the date of Retirement.

• Retiree coverage effective first day of month after active coverage terminates (or would have ended) if timely elected.
• If not timely elected, enrollment only during Open Enrollment or Special Eligibility Situations.

Elect active or decline coverage when returning to active employment post‑retirement

A Retiree who returns to Active Employment must elect active employee coverage or decline coverage; Medicare‑eligible retirees and retirees receiving SCRHI Trust Fund funding may not remain on Retiree coverage while in such employment.

• If a retiree receiving SCRHI funding returns to active employment with employer‑paid contributions, they may not continue Retiree coverage during that employment.
• Upon termination from post‑retirement active employment, the retiree may re‑enroll in Retiree coverage by filing an election within 31 days.

Enroll dependents acquired after Retirement within 31 days

Dependents acquired after Retirement must be enrolled by the Retiree within 31 days of acquisition using PEBA's approved method and required information; if timely enrolled, dependent coverage commences as of the acquisition date per special eligibility rules.

• Dependents at retirement or acquired afterward require Retiree to submit election and required info within 31 days to obtain coverage.
• If not timely enrolled, dependent may only be added during Open Enrollment or applicable Special Eligibility Situations.

Submit claims via provider invoices or claim forms; payment after TPP processing

Providers must submit invoices or completed claim forms to the Plan Administrator; after processing by the Third‑Party Claims Processor, payment will be made to the Covered Person or directly to the Dentist if benefits have been properly assigned and accepted by the Dentist.

• Payment follows receipt of invoices from providers or completed claim forms as required by the Plan Administrator and processing by the Third‑Party Claims Processor.
• If benefits are assigned and the Dentist accepts assignment and files a completed Dental Benefits Claim Form signed by the Covered Person using procedure codes designated by the Third‑Party Claims Processor, payment may be made directly to the Dentist; otherwise payment is made to the Covered Person upon due proof of loss.

Third‑Party Claims Processor must receive, investigate, and determine claim payments

The Third‑Party Claims Processor must act under the direction of the Plan Administrator to receive, review, verify, investigate claims as necessary, determine amounts/method/timing of payments, maintain records, and furnish reports to the Plan Administrator.

• TPP duties include receiving information from State, Plan Administrator, Subscribers and Dependents as necessary for proper processing.
• TPP determines payment amounts and timing, investigates claims, maintains claim records, and reports disbursements to the Plan Administrator.

Exchange information for COB and require subscriber to file other‑plan claims

For coordination of benefits the Third‑Party Claims Processor may obtain and release necessary information without consent to determine applicability of other plans; Subscribers remain responsible for filing/processing claims through other dental plans.

• TPP may exchange information with other insurers or organizations as necessary without consent or notice.
• Subscriber is responsible for filing claims through other dental insurance plans when this Plan is secondary.

Provide proof to continue coverage for an incapacitated dependent after age 26

To continue coverage for an incapacitated dependent child past age 26, the Employee must provide proof of the child's incapacity and dependency to the Plan Administrator within 31 days of the dependent turning 26 and thereafter as requested but no more than annually.

• Employee's own coverage must remain in force to maintain incapacitated dependent coverage.
• Proof must be submitted within 31 days of the dependent reaching age 26 and at reasonable times thereafter (not more than annually).

File Former Spouse election and court order within 31 days; pay full premium

A Former Spouse seeking continuation must submit an election of benefits and a filed, signed, dated court order or divorce decree within 31 days of the filing date; Former Spouse coverage is billed at full premium and coverage cancelled for nonpayment is final.

• Court order/decree requiring the employee/retiree to provide coverage is required for eligibility.
• Coverage effective first day of month after filing; coverage billed at full premium; cancellation for nonpayment makes re‑enrollment ineligible.

Employer must notify Plan within 30 days of death/termination/reduction in hours

Employers must notify the Plan Administrator or its designee within 30 days after the later of the Qualifying Event or the date a Qualified Beneficiary would lose coverage when a Covered Employee or Retiree dies, terminates employment (other than gross misconduct), or has a reduction in hours.

• Employer notice triggers Plan Administrator obligations to provide COBRA election notices to Qualified Beneficiaries.
• Timely employer notice (within 30 days) is required to support continuation rights.

Timely pay COBRA premiums: initial payment within 45 days, monthly by the 10th

Qualified Beneficiaries electing COBRA must make the initial premium payment within 45 days of election; subsequent monthly payments are due by the tenth day of each month with a 30‑day grace period (except the first payment), and failure to pay results in termination retroactive to when coverage would have ended.

• Plan may charge up to 102% of the applicable premium (or up to 150% for disability months 19–29).
• Initial premium due within 45 days of election; subsequent payments due by the 10th with 30‑day grace period; failure to pay cancels coverage and no claims payable for unpaid periods.

Submit voluntary Pre‑Treatment Estimate (recommended for $250+) with form and X‑rays

Providers (or Covered Persons and Dentists) may voluntarily request a Pre‑Treatment Estimate for estimated dental charges of $250 or more by submitting a completed claim form describing the course of treatment and X‑rays to the Third‑Party Claims Processor; the determination of benefits is provided to the Covered Person and Dentist, and the actual payment will be based on benefits in effect and services rendered at time of service.

• Pre‑Treatment Estimate is suggested (not mandatory) for estimated charges ≥ $250.
• Estimate is valid for one year; if treatment not rendered within one year, submit a new estimate.
• Completed form must be signed by Covered Person and Dentist and submitted with X‑rays to the Third‑Party Claims Processor.

Accept assignment of benefits only with completed claim form and designated procedure codes

Benefits may be assigned and paid directly to the Dentist only if the Covered Person has assigned benefits, the Dentist accepts the assignment, and the Dentist files a completed Dental Benefits Claim Form signed by the Covered Person using procedure codes designated by the Third‑Party Claims Processor.

• Assignment requires Dentist acceptance and submission of the designated Dental Benefits Claim Form completed in full and signed by the Covered Person.
• Procedure codes designated by the Third‑Party Claims Processor must be used for all services rendered.

Authorize release of medical records to TPP for claims administration and necessity certification

The Third‑Party Claims Processor, as agent of the Plan Administrator, is entitled to obtain authorizations for medical and hospital records from providers as reasonably required for benefits administration and for the attending Dentist's certification of Medical Necessity; the Plan Administrator will have access to claims data and supporting documents for audits, subject to HIPAA restrictions.

• TPP may obtain medical/hospital records authorizations from providers as reasonably required.
• Plan Administrator access to claims data restricted to employees conducting audits and handled confidentially per HIPAA guidelines.

Require cooperation with subrogation; failure to cooperate may cause denial/recovery

The Plan may require a Covered Person to cooperate with subrogation and assert claims against third‑party coverages; failure or refusal to cooperate may result in denial of payment, offset/recovery of prior payments, and imposition of constructive trust or other legal remedies.

• Plan will not pay fees or costs associated with a claim or lawsuit without express written authorization and will not reduce reimbursement by attorney fees.
• If a Covered Person fails to cooperate, the Plan Administrator may deny payment of claims and recover prior payments by offset or other action.

Procedural Steps to Request a Pre‑Treatment Estimate

A Pre‑Treatment Estimate is a written estimate requested by the dentist and provided to the patient and dentist before treatment; submit a completed claim form describing the course of treatment to the Third‑Party Claims Processor to obtain a benefits determination.

• The estimate identifies what portion of estimated expenses is covered and is provided prior to treatment; actual payment is based on services rendered and Basic Dental at the time of service.

Voluntary Pre‑Treatment Estimate — Submission Threshold & Instructions

Submit a completed Pre‑Treatment Estimate form and X‑rays to the Third‑Party Claims Processor when estimated charges are $250 or more; the Processor will review and return a determination of benefits to the Covered Person and Dentist (estimate suggested to be resubmitted if treatment not rendered within one year).

• Form must include course of treatment and cost; if treatment is not rendered within one year, submit another Pre‑Treatment Estimate.

Assignment of Benefits — Dentist Acceptance & Use of Designated Procedure Codes

Benefits may be assigned and paid directly to the Dentist only if the Dentist accepts the assignment and files a Dental Benefits Claim Form signed by the Covered Person, completed in full, and using procedure codes designated by the Third‑Party Claims Processor for all services rendered.

Billing Implications When Procedure Not in Schedule / Alternate Treatment Payment

If a procedure is not listed in the Schedule, the Allowed Amount will be determined by the Third‑Party Claims Processor using its medical staff and/or dental consultants and comparable services; payment for alternate treatments will be based on the least costly accepted alternative, which may affect billing and patient liability.

• Patient is responsible for any charges above the Allowed Amount.

How Third‑Party Claims Processor Processes Provider Claims

Upon receipt of invoices or required completed claim forms, the Third‑Party Claims Processor will receive, review, verify, investigate as necessary, process claims, and, after processing and Plan Administrator review, pay benefits to the Covered Person or assigned Dentist.

• Claims are payable only for Covered Dental Benefits not covered under any other group plan; coordination of benefits rules apply if another plan pays.

Provider Must Authorize Access to Records When Requested

Providers must permit the Third‑Party Claims Processor, as agent of the Plan Administrator, to obtain necessary authorizations and access to medical and hospital records and the attending Dentist's certification of Medical Necessity when reasonably required for benefits administration.

TPP Authority to Exchange Information for Coordination of Benefits

The Third‑Party Claims Processor may obtain and release information without consent as necessary to determine coordination of benefits and implement this Plan's provisions; Subscribers remain responsible for filing claims through other dental plans.