Dental: □ Yes □ No
Printed Name: _____________________________________
Signature: __________________________________________ Plan Administrator Representative or Plan Sponsor Representative
Title: ____________________________________________
Date: _____________________________________________
BCBSKS Representative Signature: _____________________________________________
Date: ______________________
For Office Use Only
Effective Date: ________________________
Completed Date: __________________________
Contracting Dentists: Payment will be the maximum allowable charge for covered dental services. Payment will be sent directly to the dentist. The member will only be responsible for any coinsurance amounts and any charges for non-covered services. Non-Contracting Dentists In Company Service Area: The member will be responsible for any difference between the payment allowance and the provider’s charge, in addition to any coinsurance amounts and any charges for non-covered services. Payment will be sent directly to the member. Non-Contracting Dentists Outside Company Service Area: Payment is based on usual, customary and reasonable charges. If the member does not sign payment over to the dentist, or the dentist does not submit the claim on the member’s behalf, payment will be sent directly to the member.
Coinsurance: The coinsurance will be applied to the payments of a contracting dentist or a non-contracting dentist as described.
Out-of-State Dentists: As a BCBSKS member, you may go to any dentist located outside the state of Kansas that contracts with the local Blue Cross Plan. Payment amount is based on the local Blue Cross allowance arrangement with their contracting dentists. If the out-of-state Blue plan does not provide their discounted rates to BCBSKS, then the BCBSKS allowance is used. The member may be responsible for the difference between the allowed amount and the BCBSKS paid amount. BCBSKS payments will be sent directly to the member. Exclusions: Services not listed as eligible dental services in the certificate; duplicate benefits provided under federal, state or local laws, regulations or programs (except for Medicaid); patient education services; hospital calls and consultations; lab work; occlusal adjustments; dental implants (except limited coverage under Prosthodontics); services for diseases or injuries caused by or arising out of acts of war or aggression; services for cosmetic purposes; payments under any provision of a Blue Cross and Blue Shield of Kansas certificate when the payment would duplicate payment for coverage made under another provision of the dental certificate (but only to the extent that such payment would exceed the charge for the service); services provided by a dentist for which there would customarily be no charge; medically unnecessary services; services related to alveolar ridge augmentations; services related to temporomandibular joint dysfunction syndrome over the amount specified in the certificate; services covered and payable by any medical expense payment provision of any automobile insurance policy; services performed by immediate relatives or by members of the household of the employee; benefits received when a patient transfers during treatment, or if more than one dentist provides services for the same, payment for that benefit will not exceed the amount payable for one service.
This is a brief summary of the coverage available under this program. It is not a legal document. The exact provisions of the benefits and exclusions are contained in the certificate.
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