Agent Guide | Dental, Vision & Hearing
ManhattanLife Insurance and Annuity Company
Definitions 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). (These may vary by state). Unused Annual Maximums do not roll over to the next year. Annual Deductible: DVH: There is a $100 per person/per year deductible. Deductible applies to all services. DVH Select: There is a $0 or $100 per person/per year deductible. Deductible applies to all services except Preventative Services. Claim Adjudication: When services are eligible for claim, the amount is based on a percentage according to how long the policy has been effective. It is important and helpful that applicants understand how the policy works and the way a claim is to be adjudicated. DVH: 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). DVH Select: For example, if after day one a policyholder was to have Major Services, they would receive 20% of the billed charge for Year 1 that the policy is in force. If the same procedure were to occur after Year 1, the benefit percentage would be 50% of the billed charge (due to certain state regulations, percentage may vary in certain states, notably Ohio). Contracted Rate: The amount a Dental Practitioner that has a contract with the Dental Provider Network agreed to accept as total payment for the treatment provided. Usual, Customary and Reasonable: As standard in the industry, we adjudicate claims based on Usual, Customary and Reasonable fees (UCR). 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.
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