Visa Inc. Cigna Dental Health Maintenance Organization (DHMO) Plan and Cigna Dental PPO Plan. Summary of Benefits for Active Employees

Transcription

1 Visa Inc. Cigna Dental Health Maintenance Organization (DHMO) Plan and Cigna Dental PPO Plan Summary of Benefits for Active Employees Effective January 1, 2015

2 Cigna Dental HMO Plan and CignaA Dental PPO Plan i Table of Contents ABOUT YOUR PARTICIPATION... 1 ID Cards... 1 Coverage Levels... 1 YOUR DENTAL OPTIONS... 1 HOW YOUR CIGNA DENTAL HMO PLAN WORKS... 2 YOUR CIGNA DENTAL HMO PLAN BENEFITS... 2 What to Do in an Emergency... 2 Pre-Treatment Plan... 3 What Is Covered... 4 Preventive and Diagnostic Care... 4 Restorative Care... 4 Major Restorative Care... 5 Orthodontia... 5 What Is Not Covered... 5 Limitations on Covered Services... 7 HOW YOUR CIGNA DENTAL PPO PLAN WORKS... 8 YOUR CIGNA DENTAL PPO PLAN BENEFITS... 9 What to Do in an Emergency... 9 Pre-Treatment Plan... 9 What Is Covered... 9 Preventive Care... 10

3 Cigna Dental HMO Plan and Cigna Dental PPO Plan ii Restorative Care Major Care Orthodontia What Is Not Covered CIRCUMSTANCES THAT MAY RESULT IN DENIAL, LOSS OR FORFEITURE OF BENEFITS ADDITIONAL RULES THAT APPLY TO THE PLANS Coordination of Benefits Non-Duplication of Benefits Cigna Dental PPO Plan Standard Coordination of Benefits Cigna DHMO Plan Determining Primary Coverage HOW TO REACH THE PLAN CLAIMS PROCEDURES FOR CIGNA DENTAL PPO PLAN Filing a Claim Time Frame for Initial Claim Determination If You Receive an Adverse Benefit Determination Procedures for Appealing an Adverse Benefit Determination APPENDIX A CIGNA DENTAL HMO PATIENT CHARGE SCHEDULE APPENDIX B CIGNA DENTAL PPO BENEFIT SUMMARY... 59

4 Cigna Dental HMO Plan and Cigna Dental PPO Plan 1 This document summarizes the Cigna Dental Health Maintenance Organization ( DHMO ) plan and the Cigna Dental Preferred Provider Organization ( PPO ) plan, effective January 1, 2015, for active employees. The plans are offered under the Visa Welfare Benefits and Cafeteria Plan. Please refer to the SPD for the Visa Welfare Benefits and Cafeteria Plan for information regarding eligibility, how to enroll, when coverage begins and ends, how to pay for coverage, making changes mid-year, your rights under ERISA and COBRA, and general administrative information. ABOUT YOUR PARTICIPATION ID Cards No cards are issued if you are enrolled in the Cigna Dental PPO plan. After you enroll in the Cigna Dental HMO plan for the first time, you will receive a DHMO ID card for yourself and each newly enrolled family member. The ID cards show that you are enrolled in the Cigna Dental HMO plan. Your Network General Dentist's name and telephone number are included on the informational sleeve. Coverage Levels You may choose a different level of dental plan coverage under the plans than you do for medical plan coverage. YOUR DENTAL OPTIONS Depending on where you live, you may be able to choose from the following dental plan options: Cigna Dental Health Maintenance Organization (DHMO) Plan; or Cigna Dental Preferred Provider Organization (PPO) Plan.

5 Cigna Dental HMO Plan and Cigna Dental PPO Plan 2 HOW YOUR CIGNA DENTAL HMO PLAN WORKS Here is a look at how the Cigna Dental HMO plan dental coverage works. Dental Health Maintenance Organization (DHMO) With a DHMO, you have access to a network of dentists and other dental providers who have agreed to offer their services at predetermined rates. A DHMO works much like a Health Maintenance Organization (HMO) for medical care. You must choose a Network General Dentist when you enroll and go to this dentist when you need dental care. If you wish, you and each covered member of your family may select a different Network General Dentist. If you do not select a Network General Dentist, one will be selected for you. Please note that your Network General Dentist s participation in the DHMO may change at any time. If this occurs, you will need to select a new Network General Dentist. Your Network General Dentist will provide all of your services, including referrals as needed to specialists such as endodontists or periodontists. You do not have to file claim forms your DHMO Network General Dentist files them for you. When you elect DHMO coverage, you pay a copayment for covered services each time you receive care. There is no deductible or annual maximum as long as you receive care from your Network General Dentist. A separate lifetime maximum applies to orthodontia services. Cigna Dental does not pay for treatment rendered by a nonnetwork dentist (except emergencies) or for services that were not authorized by Cigna Dental. YOUR CIGNA DENTAL HMO PLAN BENEFITS Please refer to Appendix A for some commonly used services that are covered by the Cigna Dental HMO plan. Contact Cigna s Member Services at , to find out how services not listed here are covered. What to Do in an Emergency An emergency is a dental condition of recent onset and severity which would lead a prudent layperson with an average knowledge of dentistry to believe that the condition

6 Cigna Dental HMO Plan and Cigna Dental PPO Plan 3 requires immediate dental procedures to control excessive bleeding, relieve severe pain or eliminate acute infection. The plan does not cover services provided in a hospital room, surgi-center or urgent care facility. You are covered for procedures provided in a dental office by a licensed dentist, provided they are covered under the plan and not covered under a medical plan policy or are services provided in a hospital. If you receive emergency services while you are outside of your service area or are unable to contact your Network General Dentist, you may receive emergency care for covered services as listed on your Patient Charge Schedule (schedules are available on BenefitSource), from any general dentist s office prior approval is not required for dental emergencies. If you receive emergency care for covered services, you will be responsible for the charges listed on your Patient Charge Schedule, and Cigna Dental will reimburse you for the difference between the dentist s usual fee for emergency covered services and your patient charge, up to $50 per incident. To receive reimbursement, you must send the appropriate reports and X-rays to Cigna Dental. Please note that the Patient Charge Schedule includes a patient charge for emergency care rendered after regularly scheduled office hours. This charge will be in addition to other applicable patient charges. Pre-Treatment Plan If you need specialist care, orthodontic care or any other dental care that is expected to cost $200 or more, we recommend that you ask your dentist to prepare a pre-treatment plan and send it to Cigna Dental. To file a pre-treatment plan, your dentist should complete a claim form he or she should omit the dates of service and identify it as a pre-estimate versus a claim for actual services. Once the form is complete, your dentist should return it to the address shown on the form before your care begins. You and your dentist will receive an explanation of benefits that details the benefits payable under the plan. The pre-treatment review of benefits is valid for 12 months, unless your benefits or eligibility change.

7 Cigna Dental HMO Plan and Cigna Dental PPO Plan 4 What Is Covered A summary of services covered under the Cigna Dental HMO plan is listed below. For a detailed listing of covered services and the associated copayment, please refer to your Patient Charge Schedule in Appendix A. Preventive and Diagnostic Care Oral exams, twice every calendar year Prophylaxis (teeth cleanings), twice every calendar year Bitewing X-rays Full-mouth X-rays, once every three calendar years Panoramic X-rays, once every three calendar years Fluoride treatments for dependents up to age 19, twice every calendar year Sealants Fixed space maintainers Preventive care training Diagnostic casts Restorative Care Amalgam and composite/resin fillings Root canal therapy, including X-rays, tests, exams and follow-up care related to the root canal Osseous surgery Periodontal scaling Denture adjustments Bridge recementation

8 Cigna Dental HMO Plan and Cigna Dental PPO Plan 5 Simple extractions Surgical removal of erupted teeth Removal of impacted teeth Local anesthesia, analgesic and routine postoperative care for extractions and oral surgery General anesthesia, if medically necessary Sedation, if medically necessary Major Restorative Care Crowns Bridges Dentures Prosthesis over implant Orthodontia Orthodontic work-up, including X-rays, diagnostic casts and treatment and retention appliances Active treatment Fixed or removable appliances What Is Not Covered The services listed below are not covered under your Cigna Dental HMO Plan. If you receive care for these services, you are responsible for the full fee charged by your dentist. Any service not listed on the Patient Charge Schedule in Appendix A Services provided by a non-network dentist without Cigna Dental s prior approval, unless it s an emergency

9 Cigna Dental HMO Plan and Cigna Dental PPO Plan 6 Services related to an injury or illness paid under workers compensation, occupational disease or similar laws Services provided or paid through a federal or state government agency, political program or public program, other than Medicaid Services required while serving in the armed forces or international authority that relates to a declared or undeclared war or act of war Cosmetic dentistry or cosmetic dental surgery (any dentistry or surgery performed solely to improve appearance) General anesthesia, sedation and nitrous oxide, unless medically necessary and provided in conjunction with covered services performed by an oral surgeon or periodontist Prescription drugs (If you are enrolled in a Visa-sponsored medical plan and your dentist prescribes drugs, you will need to have your dentist contact your primary care physician for approval of the expense. Prescription drugs are not covered under the dental plans; only the medical plans provide reimbursement for prescription drugs. If your primary care physician does not approve your dentist's prescription, no prescription drug benefits will be payable.) Procedures, appliances or restorations whose main purpose is to: Change vertical dimension Diagnose or treat abnormal conditions of the temporomandibular joint (TMJ), unless TMJ therapy is specifically listed on your Patient Charge Schedule Restore teeth that have been damaged by attrition, abrasion, erosion and/or abfraction Replacement of fixed or removable appliances that have been lost, stolen or damaged due to patient abuse, misuse or neglect

10 Cigna Dental HMO Plan and Cigna Dental PPO Plan 7 Services associated with the placement, repair, maintenance or removal of a dental implant; implant abutment(s); or any services related to the surgical placement of a dental implant Unnecessary or experimental services Procedures or appliances for minor tooth guidance or to control harmful habits Hospitalization and associated incremental charges for dental services performed in a hospital Services covered by a group medical plan, no-fault auto insurance policy or insured motorist policy The completion of crown, bridge, denture, root canal treatment, or implant supported prosthesis (including crowns bridges and dentures) that was in progress before you were covered by the Cigna Dental HMO plan Crowns, bridges and/or implant supported prosthesis used solely for splinting Resin bonded retainers and associated pontics Services for which benefits are not paid for by the Cigna Dental HMO plan or services not listed under the What Is Covered section above. Pre-existing conditions are not excluded if the procedures involved are otherwise covered under your Patient Charge Schedule in Appendix A. Limitations on Covered Services The CignaDental HMO plan places limits on certain covered services. The frequency of certain covered services, like cleanings is limited; refer to the Patient Charge Schedule in Appendix A for specific limitations on frequency. You must receive payment authorization from a Network Specialty Dentist for specialty care. The plan does not cover pediatric dentistry for children over age seven; children over age seven must receive care from a Network General Dentist.

11 Cigna Dental HMO Plan and Cigna Dental PPO Plan 8 Surgical removal of impacted wisdom teeth is only covered if the removal is required for orthodontic reasons or because the tooth is diseased. HOW YOUR CIGNA DENTAL PPO PLAN WORKS Here is a look at how the Cigna Dental PPO plan dental coverage works. Dental Preferred Provider Organization (PPO) With the Cigna Dental PPO plan, you can receive care from a dental provider who is part of the dental plan s network or from a dental provider outside the network. No matter where you receive care, the plan will pay a certain level of benefits. The difference is the dental plan has negotiated special discounted rates with its network providers. When you go to a network dental provider. You will pay less overall because the cost of the service is lower than what a non-network provider might charge. That is because network dentists have agreed to provide services at negotiated rates. Plus, there are no claim forms to file; your network dentist is paid directly by the plan. When you go to a non-network dental provider. The plan will pay benefits based on what is considered the maximum reimbursable charge (MRC) for a particular service. MRC is based on the typical amount charged by most providers in your geographic area for similar services. If the provider charges more, you will be responsible for paying the amount that exceeds the MRC charge, in addition to the applicable coinsurance and deductible. You will generally be asked to pay for your care at the time of your visit and submit a claim form for reimbursement. When you elect Cigna Dental PPO plan coverage, the plan pays 100% of the cost of preventive care. You pay a deductible and then a percentage of the cost for other dental services. There is an annual per person maximum of $2,000 for dental services and a separate lifetime orthodontia maximum of $2,000 per person for services from a Cigna Dental PPO plan orthodontist and $1,000 per person for services from an out-ofnetwork orthodontist.

12 Cigna Dental HMO Plan and Cigna Dental PPO Plan 9 YOUR CIGNA DENTAL PPO PLAN BENEFITS Please refer to Appendix B for some commonly used services that are covered by the Cigna Dental PPO plan. Contact Cigna s Member Services at , to find out how services not listed here are covered. What to Do in an Emergency The plan does not cover services provided in a hospital room, surgi-center or urgent care facility. You are covered for procedures provided in a dental office by a licensed dentist, provided they are covered under the plan. If you have an urgent dental condition, you should seek treatment at the nearest dentist s office, regardless of whether the dentist participates in the plan s dental network. An urgent dental condition is when dental services are required immediately to alleviate pain or treat the sudden onset of an acute dental condition, which if not treated will likely result in a more serious dental or medical condition. You do not need prior approval. However, the plan will only pay for covered services (at the negotiated rate for either a network or a non-network provider). Pre-Treatment Plan If you need specialist care, orthodontic care or any other dental care that is expected to cost $200 or more, we recommend that you ask your dentist to prepare a pre-treatment plan. To file a pre-treatment plan, your dentist should complete a claim form he/she should omit the dates of service and identify it as a pre-estimate versus a claim for actual services. Once the form is complete, your dentist should return it to the address shown on the form before your care begins. You and your dentist will receive an explanation of benefits that details the benefits payable under the plan. The pretreatment review of benefits is valid for 12 months, unless your benefits or eligibility change. What Is Covered The Cigna Dental PPO plan covers certain dental services and supplies, which meet the plan s definition of covered dental services. Please refer to Appendix B.

13 Cigna Dental HMO Plan and Cigna Dental PPO Plan 10 Preventive Care Oral exams and cleanings, three times every calendar year Bitewing X-rays, two times every calendar Full-mouth X-rays, once every three calendar years Panoramic X-rays, once every three calendar years Fluoride treatments for dependents up to age 19, once every calendar year Sealants for permanent molars for children up to age 14, once every three calendar years Emergency dental treatment Space maintainers, fixed unilateral limited to non-orthodontic treatment Periodontal cleaning (only after active periodontal treatment). Restorative Care Amalgam and composite/resin fillings Root canal therapy, including X-rays, tests, exams and follow-up care related to the root canal Osseous surgery Periodontal scaling and root planing entire mount Denture adjustments complete denture Bridge recementation Simple extractions Surgical removal of erupted teeth Removal of impacted teeth, soft tissue, partially bony, complete bony

14 Cigna Dental HMO Plan and Cigna Dental PPO Plan 11 Local anesthesia, analgesic and routine postoperative care for extractions and oral surgery General anesthesia, if clinically necessary Sedation, if clinically necessary. Major Care Crowns/abutment crowns Dentures Bridges porcelain fused or resin with high noble metal Abutment Crowns resin with high noble metal, porcelain resin with high noble metal or full cast gold. Surgical implants Prosthesis over implant Orthodontia Orthodontic work-up, including X-rays, diagnostic casts and treatment and retention appliances Active treatment Fixed or removable appliances (for tooth guidance to control harmful habits) only one appliance per person. What Is Not Covered The plan does not cover certain services, some of which are listed below. Please contact Cigna s Member Services at to confirm whether or not your service will be covered. Services performed for cosmetic reasons Replacement of lost or stolen appliances

15 Cigna Dental HMO Plan and Cigna Dental PPO Plan 12 Bridge, crown or denture replacement within five years of when the appliance was installed unless: The replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth The bridge, crown or denture, while in the mouth, was damaged beyond repair as the result of an injury received while a person is insured for dental benefits Any replacement of a bridge, crown or denture which is or can be made usable according to common dental standards Procedures, appliances or restorations (except full dentures) whose main purpose is to: Change vertical dimension Diagnose or treat TMJ Stabilize periodontally involved teeth Restore occlusion Porcelain or acrylic veneers of crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations, precision or semiprecision attachments or splinting Instruction on plaque control, oral hygiene or diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Services for which benefits are not paid for by the Cigna Dental PPO plan. Prescription Drugs (If you are enrolled in a Visa-sponsored dental plan and your dentist prescribes drugs, you will need to have your dentist contact your physician for approval of the expense. Prescription drugs are not covered under the dental

16 Cigna Dental HMO Plan and Cigna Dental PPO Plan 13 plans; only the medical plans provide reimbursement for prescription drugs. If your physician does not approve your dentist's prescription, no prescription drug benefits will be payable.) CIRCUMSTANCES THAT MAY RESULT IN DENIAL, LOSS OR FORFEITURE OF BENEFITS No dental payments will be made for the following Injuries that arise out of or in the course of any employment for wage or profit Sicknesses that are covered under any workers compensation or similar law Military-service-connected conditions which resulted in charges being incurred from a hospital owned or operated by or which provides care or performs services for, the United States government Expenses that are incurred unlawfully Charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Schedule) without Cigna s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received

17 Cigna Dental HMO Plan and Cigna Dental PPO Plan 14 Charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law Charges which would not have been made if the person had no insurance Expenses that are greater than the contracted fee or the maximum reimbursable charges Unnecessary care, treatment or surgery Expenses that are paid for through a public program other than Medicaid Experimental procedures or treatment methods not approved by the American Dental Association or the appropriate dental specialty society Benefits that are payable under the mandatory part of any auto insurance policy written to comply with a no-fault insurance law or an uninsured motorist insurance law. ADDITIONAL RULES THAT APPLY TO THE PLANS The following rules apply to both the Cigna Dental HMO and PPO plans. Coordination of Benefits In situations where you have other coverage that pays as a primary plan, the Cigna Dental PPO plan has a provision to ensure that payments from all of your group dental plans do not exceed the amount the Cigna Dental PPO plan would pay if it were your only coverage. The Cigna Dental HMO plan has a provision to ensure that the payments from all of your group dental plans do not exceed 100% of the amount the Dental HMO Plan would pay if it were your only coverage. The rules described here apply to the Cigna Dental HMO plan and the Cigna Dental PPO plan. The following rules do not apply to any private, personal insurance you may have.

18 Cigna Dental HMO Plan and Cigna Dental PPO Plan 15 Non-Duplication of Benefits Cigna Dental PPO Plan If you and your eligible dependents are covered under more than one group plan, the primary plan (the one responsible for paying benefits first) needs to be determined. If the Cigna Dental PPO plan is paying secondary, your Cigna Dental PPO plan coverage will ensure that, in total, you receive benefits up to what you would have received with Cigna as your only source of coverage (but not in excess of that amount), based on the primary plan s covered benefits. A summary of coordination rules (e.g., how Cigna coordinates coverage with another group plan to ensure non-duplication of benefits) is provided below. If you have questions, contact Cigna s Member Services at for help. Example: Assume your spouse has a clinically necessary procedure with a maximum reimbursable charge (MRC) of $100. If your spouse s plan (which we will assume is primary) pays 70% for that procedure, your spouse will receive a $70 benefit (70% of $100). Also assume that your Cigna Dental PPO plan option (which we will assume is your spouse s secondary coverage) would pay 80% for this clinically necessary procedure. In this case, your spouse normally would receive an $80 benefit (80% of $100) from the Cigna Dental PPO plan option. Because your spouse already received $70 from his/her primary plan, he/she would receive the balance ($10) from the Cigna Dental PPO plan. Standard Coordination of Benefits Cigna DHMO Plan If you and your eligible dependents are covered under more than one group plan, the primary plan (the one responsible for paying benefits first) needs to be determined. If the Cigna DHMO Plan is paying secondary, your Cigna DHMO Plan coverage will ensure that, in total, you do not receive benefits in excess of 100% of what you would have received with Cigna as your only source of coverage, based on the primary plan s covered benefits. A summary of coordination rules (e.g., how Cigna coordinates coverage with another group plan to ensure standard coordination of benefits) is provided below. If you have questions, contact Cigna s Member Services at for help. Example: Assume your spouse has a clinically necessary procedure with a maximum reimbursable charge (MRC) of $100. If your spouse s plan (which we will assume is

19 Cigna Dental HMO Plan and Cigna Dental PPO Plan 16 primary) pays 70% for that procedure, your spouse will receive a $70 benefit (70% of $100). Also assume that your Cigna DHMO Plan option (which we will assume is your spouse s secondary coverage) would pay 80% for this clinically necessary procedure. In this case, your spouse normally would receive an $80 benefit (80% of $100) from the Cigna DHMO Plan option. Because your spouse already received $70 from his/her primary plan, he/she would receive the balance ($30) from the Cigna DHMO Plan for a total benefit of 100% ($70 + $30 = $100). Determining Primary Coverage To determine which dental plan pays first as the primary plan, here are some general guidelines: As an active employee, the Cigna Dental HMO plan or the Cigna Dental PPO plan will consider claims for your dental expenses first. If your covered dependent has a claim, the plan covering your dependent as an employee will pay first. If your claim is for a covered dependent child, the plan covering the parent who has the earlier birthday in a calendar year will pay first. In the event of divorce or legal separation, and in the absence of a qualified medical child support order, the plan covering the parent with court-decreed financial responsibility will pay first. If there is no court decree, the plan of the parent who has custody of the covered dependent child will pay first. Please refer to the SPD for the Visa Welfare Benefits and Cafeteria Plan for more information regarding a qualified medical child support order. If you are a retiree employed elsewhere and covered under another employer s plan, that plan will be responsible for paying claims first for you and your dependents. If your other dental plan does not have a coordination of benefits provision, that plan will pay first for you and your covered dependents. If payment responsibilities are still unresolved, the plan that has covered the claimant the longest pays first. After it is determined which plan pays benefits first, you will need to submit your initial claim to that plan. After the first plan pays your benefits (up to the limits of its coverage),

20 Cigna Dental HMO Plan and Cigna Dental PPO Plan 17 you can then submit the claim to the other plan (the secondary plan) to consider your claim for any unpaid amounts. You will need to include a copy of the written explanation of benefits (EOB) from your primary plan. HOW TO REACH THE PLAN Here is how you can reach your dental plan provider: Plan Phone Number Web Site Address Cigna Dental PPO plan Cigna Dental HMO plan Visa Benefits Help Line

21 Cigna Dental HMO Plan and Cigna Dental PPO Plan 18 CLAIMS PROCEDURES FOR CIGNA DENTAL PPO PLAN Filing a Claim If you are enrolled in the Cigna Dental DHMO Plan, you do not have to file a claim when you use a Network General Dentist. If you are enrolled in the Cigna Dental PPO plan, you do not need to file a claim if you use a network dentist. To receive benefits for care obtained from a dentist who is not part of the network, you should mail your completed claim form and original itemized bills to the address below. Please refer to to obtain the appropriate claim form. Send your claims to Cigna Dental - Sherman P.O. Box Chattanooga, TN Time Frame for Initial Claim Determination For urgent care claims (see definition on page 18) and pre-service claims (claims that require approval of the benefit before receiving care), the plan s claims administrator will notify you whether your claim for benefits under the plan is approved or not within the following time frames: As soon as possible, taking into account the exigencies, but not later than 72 hours after receipt of a claim initiated for urgent care (a decision can be provided to you orally, as long as a written or electronic notification is provided to you within three days after the oral notification) Within a reasonable period of time appropriate to the circumstances, but not later than 15 days after receipt of a pre-service claim. For post-service claims (claims that are submitted for payment after receiving care), the claim administrator will notify you in writing or electronically of an adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of a claim. An adverse benefit determination is any denial, reduction or termination of a benefit, or a failure to provide or make a payment, in whole or in part, for a benefit.

22 Cigna Dental HMO Plan and Cigna Dental PPO Plan 19 For urgent care claims, if you fail to provide the claim administrator with sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan, the claim administrator will notify you within 24 hours of receiving your claim of the specific information needed to complete the claim. You then have 48 hours to provide the information needed to process the claim. You will be notified of a determination no later than 48 hours after the earlier of: The claim administrator s receipt of the requested information The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. For pre- and post-service claims, a 15-day extension may be allowed to make a determination, provided that the claim administrator determines that the extension is necessary due to matters beyond its control. If such an extension is necessary, the claim administrator will notify you before the end of the first 15- or 30-day period of the reason(s) requiring the extension and the date it expects to provide a decision on your claim. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will also specifically describe the required information. You then have 45 days to provide the information needed to process your claim. If an extension is necessary for pre- and post-service claims due to your failure to submit necessary information, the period for making a benefit determination is stopped from the date the claim administrator sends you an extension notification until the date you respond to the request for additional information. In addition, if you or your authorized representative fail to follow the plan s procedures for filing a pre-service claim, you or your authorized representative will be notified of the failure and the proper procedures to be followed in filing a claim for such benefits. This notification will be provided within five days (24 hours in the case of a failure to file a pre-service claim involving urgent care) following the failure. Notification may be oral, unless you or your authorized representative requests written notification. This paragraph only applies to a failure that:

23 Cigna Dental HMO Plan and Cigna Dental PPO Plan 20 Is a communication by you or your authorized representative that is received by a person or organizational unit customarily responsible for handling benefit matters and Is a communication that names you, a specific clinical condition or symptom, and a specific treatment, service or product for which approval is requested. Urgent Care Claims Urgent care claims are those which, unless the special urgent care deadlines for response to a claim are followed, either: Could seriously jeopardize the patient s life, health or ability to regain maximum function or In the opinion of a physician with knowledge of the patient s clinical condition, would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested in the claim for benefits. An individual acting on behalf of the plan, applying the judgment of a prudent layperson who has an average knowledge of health and medicine, can determine whether the urgent care definition has been satisfied. However, if a physician with knowledge of the patient s clinical condition determines that the claim involves urgent care, it must be considered an urgent care claim.

24 Cigna Dental HMO Plan and Cigna Dental PPO Plan 21 Concurrent Care Claims Request to Extend Treatment If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent care claim as defined earlier, your request will be decided and you will be notified of the decision within 24 hours of the claim administrator s receipt of the claim, provided your request is made at least 24 hours prior to the end of the approved treatment. If the request is not made within 24 hours before the end of the approved treatment, the request will be treated as an urgent care claim and decided according to the urgent care claim time frames described earlier. If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend treatment is a non-urgent circumstance, your request will be considered a new claim and decided according to pre-service or post-service time frames described above, whichever applies. Note: Any reduction or termination of a course of treatment will not be considered an adverse benefit determination if the reduction or termination of the treatment is the result of a plan amendment or plan termination. If You Receive an Adverse Benefit Determination The claim administrator will provide you with a notification of any adverse benefit determination, which will set forth: The specific reason(s) for the adverse benefit determination References to the specific plan provisions on which the benefit determination is based A description of any additional material or information needed to process the claim and an explanation of why that material or information is necessary A description of the plan s appeal procedures and the time limits applicable to those procedures, including a statement of your right to bring a civil action under ERISA after an appeal of an adverse benefit determination

25 Cigna Dental HMO Plan and Cigna Dental PPO Plan 22 Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination or a statement that a copy of this information will be provided free of charge to you upon request If the adverse benefit determination was based on a clinical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your clinical circumstances, or a statement that such explanation will be provided free of charge upon request If the adverse benefit determination concerns a claim involving urgent care, a description of the expedited review process applicable to the claim. Procedures for Appealing an Adverse Benefit Determination If you receive an adverse benefit determination, you may ask for a review. You, or your authorized representative, have 180 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination. You have the right to: Submit written comments, documents, records and other information relating to the claim for benefits Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits. A review that takes into account all comments, documents, records and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination A review that does not defer to the initial adverse benefit determination and that is conducted neither by the individual who made the adverse determination, nor that person s subordinate A review in which the named fiduciary consults with a health care professional who has appropriate training and experience in the field of dentistry involved in the judgment, and who was neither consulted in connection with the initial adverse benefit determination, nor the subordinate of any such individual. This applies only if

26 Cigna Dental HMO Plan and Cigna Dental PPO Plan 23 the appeal involves an adverse benefit determination based in whole or in part on a judgment (including whether a particular treatment, drug or other item is experimental) The identification of dental or vocational experts whose advice was obtained in connection with the adverse benefit determination, regardless of whether the advice was relied upon in making the decision In the case of a claim for urgent care, an expedited review process in which: You may submit a request (orally or in writing) for an expedited appeal of an adverse benefit determination All necessary information, including the plan s benefit determination on review, will be transmitted between the plan and you by telephone, facsimile or other available similarly prompt method. A decision regarding your appeal will be reached: As soon as possible, taking into account the exigencies, but not later than 72 hours after receipt of your request for review of an urgent care claim Within a reasonable period of time appropriate to the circumstances, but not later than 30 days after receipt of your request for review of a pre-service claim Within 60 days after receipt of your request for review of a post-service claim. The claim administrator s notice of an adverse benefit determination on appeal will be provided in writing or electronically and will contain all of the following information: The specific reason(s) for the adverse benefit determination References to the specific plan provisions on which the benefit determination is based A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records and other information relevant to your claim

27 Cigna Dental HMO Plan and Cigna Dental PPO Plan 24 A statement describing any voluntary appeal procedures offered by the plan and your right to obtain the information about such procedures, and a statement of your right to bring an action under ERISA Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination; or a statement that a copy of this information will be provided free of charge to you upon request If the adverse benefit determination was based on a clinical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your clinical circumstances or a statement that such explanation will be provided free of charge upon request. What To Do If There Is A Problem with your Cigna Dental HMO Plan Most problems can be resolved between you and your dentist. However, we want you to be completely satisfied with the Dental Plan. That is why we have established a process for addressing your concerns and complaints. The complaint procedure is voluntary and will be used only upon your request. A. Your Rights to File Grievances With Cigna Dental We want you to be completely satisfied with the care you receive. That is why we have established an internal grievance process for addressing your concerns and resolving your problems. Grievances include both complaints and appeals. Complaints may include concerns about people, quality of service, quality of care, benefit interpretations or eligibility. Appeals are requests to reverse a prior denial or modified decision about your care. You may contact us by telephone or in writing with a grievance. B. How to File a Grievance To contact us by phone, call us toll-free at Cigna 24 or the toll-free telephone number on your Cigna identification card. The hearing impaired may call the state TTY toll-free service listed in their local telephone directory.

28 Cigna Dental HMO Plan and Cigna Dental PPO Plan 25 Send written grievances to: Cigna Dental Health P.O. Box Chattanooga, TN We will provide you with a grievance form upon request, but you are not required to use the form in order to make a written grievance. You may also submit a grievance online through the following Cigna website: If the Member is a minor, is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative, or other legal representative acting on behalf of the Member, as appropriate, may submit a grievance to Cigna Dental or the California Department of Managed Health Care (DMHC or Department ), as the agent of the Member. Also, a participating provider may join with or assist you or your agent in submitting a grievance to Cigna Dental or the DMHC. 1. Complaints If you are concerned about the quality of service or care you have received, a benefit interpretation, or have an eligibility issue, you should contact us to file a verbal or written complaint. If you contact us by telephone to file a complaint, we will attempt to document and/or resolve your complaint over the telephone. If we receive your complaint in writing, we will send you a letter confirming that we received the complaint within 5 calendar days of receiving your notice. This notification will tell you whom to contact should you have questions or would like to submit additional information about your complaint. We will investigate your complaint and will notify you of the outcome within 30 calendar days. 2. Appeals If your grievance does not involve a complaint about the quality of service or care, a benefit interpretation or an eligibility issue, but instead involves dissatisfaction with the outcome of a decision that was made about your care and you want to request Cigna Dental to reverse the previous decision, you should

29 Cigna Dental HMO Plan and Cigna Dental PPO Plan 26 contact us within one year of receiving the denial notice to file a verbal or written appeal. Be sure to share any new information that may help justify a reversal of the original decision. Within 5 calendar days from when we receive your appeal, we will confirm with you, in writing, that we received it. We will tell you whom to contact at Cigna Dental should you have questions or would like to submit additional information about your appeal. We will make sure your appeal is handled by someone who has authority to take action and who was not involved in the original decision. We will investigate your appeal and notify you of our decision, within 30 calendar days. You may request that the appeal process be expedited, if there is an imminent and serious threat to your health, including severe pain, potential loss of life, limb or major bodily function. A Dental Director for Cigna Dental, in consultation with your treating dentist, will decide if an expedited appeal is necessary. When an appeal is expedited, Cigna Dental will respond orally and in writing with a decision within 72 hours. C. You Have Additional Rights Under State Law (CIGNA Cigna HMO Plan) Cigna Dental is regulated by the California Department of Managed Health Care (DMHC or the Department ). If you are dissatisfied with the resolution of your complaint or appeal, the law states that you have the right to submit the grievance to the department for review as follows: The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at Cigna 24 and use your health plan s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or

30 Cigna Dental HMO Plan and Cigna Dental PPO Plan 27 urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line ( ) for the hearing and speech impaired. The department s Internet Web site has complaint forms, IMR application forms and instructions online. You may file a grievance with the DMHC if Cigna Dental has not completed the complaint or appeal process described above within 30 days of receiving your grievance. You may immediately file an appeal with Cigna Dental and/or the DMHC in a case involving an imminent and serious threat to the health, including, but not limited to, severe pain, the potential loss of life, limb, or major bodily function, or in any other case where the DMHC determines that an earlier review is warranted. D. Voluntary Mediation If you have received an appeal decision from Cigna Dental with which you are not satisfied, you may also request voluntary mediation with us before exercising the right to submit a grievance to the DMHC. In order for mediation to take place, you and Cigna Dental each have to voluntarily agree to the mediation. Cigna Dental will consider each request for mediation on a case by case basis. Each side will equally share the expenses of the mediation. To initiate mediation, please submit a written request to the Cigna Dental address listed above. If you request voluntary mediation, you may elect to submit your grievance directly to the DMHC after participating in the voluntary mediation process for at least 30 days. For more specific information regarding these grievance procedures, please contact our Member Services Department.

31 Cigna Dental HMO Plan 28 APPENDIX A CIGNA DENTAL HMO PATIENT CHARGE SCHEDULE Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Cigna Dental DHMO Plan including covered procedures and patient charges. Important Highlights This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist, Orthodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Member Services at Cigna 24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child s 7th birthday. Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient s responsibility at the dentist s usual fees. The administration of IV sedation, general anesthesia, and/or Nitrous Oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract. All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.