Coordination of Benefits
"Coordination of Benefits" is the procedure used to pay health care expenses when a person is covered by more than one plan. Delta Dental Plan of Ohio follows rules established by Ohio law to decide which plan pays first and how much the other plan must pay. The objective is to make sure the combined payments of all plans are no more than your actual bills.

When you or your family members are covered by another group plan in addition to this one, Delta Dental will follow Ohio coordination of benefit rules to determine which plan is primary and which is secondary. You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then submit the balance to the secondary plan.

Delta Dental pays for health care only when you follow the rules and procedures. If the rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use.

PLANS THAT DO NOT COORDINATE

Delta Dental will pay benefits without regard to benefits paid by the following kinds of coverage.

• Medicaid
• Group hospital indemnity plans which pay less than $100 per day
• School accident coverage
• Some supplemental sickness and accident policies

• When Delta Dental is primary, Delta Dental will pay the full benefit allowed by your contract as if you had no other coverage.

HOW DELTA DENTAL PAYS AS SECONDARY PLAN

• When Delta Dental is secondary, payments will be based on the balance left after the primary plan has paid. In no event will Delta Dental pay more than it would have paid as primary. For example, if the primary plan pays an amount higher than Delta Dental would have paid, no payment will be made by Delta Dental. If the primary plan pays less than Delta Dental allows, Delta Dental will pay the difference up to Delta Dental's allowed amount.
  
  
• Delta Dental will pay only for health care expenses that are covered by Delta Dental.
  
  
• Delta Dental will pay only if you have followed all of the procedural requirements, including care obtained from or arranged by your Dentist, Predeterminations, etc.
  
  
• Delta Dental will pay no more than the "allowable expenses" for the health care involved. If the allowable expense is lower than the primary plan's, Delta Dental will use the primary plan's allowable expense. That may be less than the actual bill.

WHICH PLAN IS PRIMARY?

To decide which plan is primary, Delta Dental has to consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The Primary Plan will be determined by the first of the following, which applies:

1. Non-coordinating Plan
   If you have another group plan that does not coordinate benefits, it will always be primary.
   
   
2. Employee
   The plan, which covers you as an employee (neither laid off nor retired), is always primary.
   
   
3. Children (Parents Divorced or Separated)
   If the court decree makes one parent responsible for health care expenses, that parent's plan is primary.
   If the court decree gives joint custody and does not mention health care, Delta Dental follows the birthday rule.
   If neither of those rules applies, the order will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.
   
   
4. Children and the Birthday Rule
   When your children's health care expenses are involved; Delta Dental follows the "birthday rule." The plan of the parent with the first birthday in a calendar year is always primary for the children. If your birthday is in January and your spouse's birthday is in March, your plan will be primary for all of your children.
   
   However, if your spouse's plan has some other coordination rule (for example, a "gender rule" which says the father's plan is always primary), Delta Dental will follow the rules of that plan.
   
   
5. Other Situations
   For all other situations not described above, the order of benefits will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.

Coordination Disputes

If you believe that Delta Dental has not paid a claim properly, you should first attempt to resolve the problem by contacting Delta Dental. If you are still not satisfied, you may call the Ohio Department of Insurance for instructions on filing a consumer complaint. Call (614) 644-2673 or 1-800-686-1526.

Disputed Claims Procedure

If you think that Delta Dental incorrectly denied all or part of your claim, here are the steps you can take:

First, you or your Dentist should contact Delta Dental's Customer and Claims Services department and ask them to check the claim to make sure it was processed correctly. You may do this by calling the toll-free number, 1-800-524-0149 and speaking to a telephone advisor. You may also mail your inquiry to the Customer and Claims Services department at P. O. Box 30416, Lansing, Michigan 48909-7916. When writing, please enclose a copy of your Explanation of Benefits and describe the problem. Be sure to include your name, telephone number, the date, and any information you would like considered about your claim.

If your claim is still denied, you can submit your claim for a formal review through the Disputed Claims Procedure. Send your request in writing and mail it certified mail, return receipt requested, to:

Dental Director
Delta Dental
PO Box 30416
Lansing, Michigan 48909-7916

Please include your name and address, the Subscriber's Social Security Number, the reason you believe the claim was wrongly denied, and any other information you would like considered about the claim.

Delta Dental will review your Disputed Claim. If your claim is still completely or partially denied, Delta Dental will notify you within 90 days after receiving your letter. Delta Dental's notice will explain why the denial was made and will also give you information about how to appeal.

Disputed Claims Appeal Procedure

If you do not agree with the results of the Disputed Claims Procedure, you may appeal to the Board of Directors of Delta Dental or its delegee. To do this, you must file a written request for review before the final appeal date listed in the Dental Director's notice denying your Disputed Claim. If no date is given in this notice, you have up to 150 days from the date you submitted your first letter under the Disputed Claims Procedure to appeal. Send your written request to the same address, Attention: Board of Directors (or its delegee), and it must say why you are requesting a review and why you believe the Dental Director's decision was incorrect. You have the right to review the Plan and documents related to it.

In your written request for this review, you may also ask for a hearing with the Board of Directors or its delegee. If the Board of Directors or its delegee decides to convene a hearing, you are entitled, at your own expense, to be represented by legal counsel, to request that a court reporter transcribe the hearing, to present evidence, to request the testimony of witnesses and to cross-examine the witnesses. A decision will be given to you as soon as possible, but not later than 120 days after receiving your written request.

If a hearing is not requested or held, the Board of Directors or its delegee will give you its decision within 60 days after receiving your written request for review. All decisions of the Board of Directors or its delegee will be in writing and will explain why the decision was made.

If you are still not satisfied, you may contact the Ohio Department of Insurance for instructions on filing a consumer complaint by calling 614-644-2673 or 1-800-686-1526. You may also write to the Consumer Service Division of the Ohio Department of Insurance, 2100 Stella Court, Columbus, Ohio 43215-1067.