Agent Guide | Dental, Vision, & Hearing Select
ManhattanLife Insurance and Annuity Company
Product Highlights Waiting Periods: Depending on the benefit, there are waiting periods for certain services. Please consult your brochure and ensure that the consumer understands the waiting period provisions as outlined in the brochure. Annual Maximums: There are four Policy Year Plan Maximums available ($1,000, $1,500, $3,000 and $5,000). (may vary by state). Unused Annual Maximums do not roll over to the next year. Annual Deductible: There is a $100 per person/per year deductible. Deductible applies to all services. Claim Adjudication: When services are eligible for claim, the amount is based on a percentage based on how long the policy has been effective. It is important and helpful that applicants understand how the policy works and the manner in which a claim is to be adjudicated. For example, if after a 12-month waiting period a policyholder was to have Major Services, they would receive 60% of the billed charge in Year 1 that the policy is in force. If the same procedure were to occur in Year 2, the benefit percentage would be 70% of the billed charge (due to certain state regulations, percentage may vary in certain states, notably Ohio). Usual Customary, and Reasonable (UCR): As standard in the industry, we adjudicate claims based on UCR fees. It is important that agents and applicants understand this (see below). Usual Fee: Dentists charge this fee most often for a given type of dental work. Customary Fee: This refers to the fee level that the administrator of a dental benefit plan sets. They base this amount on actual fees dentists have billed for a certain type of dental work. It is the most an insurer will pay under a plan for that type of work. Reasonable Fee: This is the fee a dentist charges for dental work that is more complex than usual. For instance, work that has been changed by the nature and severity of the problem that is being treated. It accounts for any medical or dental complications or unusual circumstances. Thus, it may differ from the dentist’s “usual” fee or the plan’s “customary” fee. Indemnity plan claims (including ours, are based on UCR. This type of plan pays each claim based on the amount insurers determine to be usual, customary, and reasonable for each type of work and for each market area. Fees for service may vary by geographical area. Claim Processing: Claims billing is determined by the provider; Providers can bill MAC by completing the ADA form or insured can file a claim by completing the MAC claim form. Claims forms must be submitted with supporting documentation. Claims may be filed up to 15 months from the service date
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AGT-DVH7016-0924
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