DELTA DENTAL OF TENNESSEE

DELTA DENTAL OF TENNESSEE Mission Statement The mission of Delta Dental of Tennessee is to improve oral health by being the leading dental carrier providing programs of demonstrated value that balance the needs of the customers. Customers Because we believe that you, our customer, are one of our most valued stakeholders, we provide you the highest level of service available. You are the catalyst that inspires us to become more innovative and progressive. Enrollees We treat enrollees with respect in a friendly, courteous manner. We endeavor to assist them in receiving the full value of their benefits by accurately describing their program. We address their questions and concerns promptly and thoroughly.

Table of Contents Section 1 Quick References Who to Call Customer Service 4 Billing Services 4 Service Representative 4 Online Services Featured Employer 5 Featured Subscriber 6 Consumer Toolkit 7 Find a Dentist 8 Defining our Terms 9-10 Section 2 Eligibility & Enrollment Eligibility Who Can Enroll? 12 When Coverage Begins 12 Qualifying Events 12 Rejoining the Plan 12 When Coverage Ends 13 Member Retroactivity 13 Verifying Eligibility Information 13 Enrollment Filling out the Enrollment Form 13 Sample Enrollment Form 14 Sample Change Form 15 Sample ID Card 16 Coordination of Benefits 16 COBRA 16 Section 3 Billing Section 4 Claims ebilling 18-19 Sample Bill 20-25 Billing Procedures 26 Claims at a Glance Claim Filing 28 Explanation of Benefits 28 Identifying Participating Dentists 28 Sample EOB 29 Sample Dentist Search 30 Pre-treatment Estimates 31 Appealing a Claim 31 2

Quick References Welcome to Delta Dental. As plan administrator, you are the primary contact between Delta Dental and your employees. To assist you, we ve created this handbook to serve as a valuable resource to answer your how-to and what-if questions. It provides an overview of Delta Dental s administrative procedures and includes sample forms. You ll also find information on our website at: www.deltadentaltn.com 3

Who to Call Delta Dental s Service Team includes an array of dental benefit professionals, including Customer Service, Billing, Group Services and your Personal Service representative. All of us are at your service if you have a question or concern. Customer Service (615) 255-3175 or 1-800-223-3104 Our Customer Service representatives are available to answer questions from both you and your group s members regarding enrollment, eligibility, benefit coverage and claims. Representatives are available Monday through Thursday 7:00 am to 7:00 pm CST and Friday 7:00 am to 5:00 pm CST. Service Representative Your service representative is available to assist you with eligibility, billing or claims questions and ordering enrollment materials. You should notify your service representative of any change to your company s address, phone number, administrative or billing contact, etc. Your service representative will work with you to ensure that your experience with Delta Dental is an excellent one. To provide better service to our members, Delta Dental provides employees with the assistance of Telelanguage Services. This service allows DDTN to assist non English speaking callers through the translation service in over 150 languages. Please contact our Customer Service Department for further details or assistance. Billing Services (615) 255-3175 ext 298 or 800-223-3104 ext 298 or Fax (615) 244-8108 Call our Billing Department for questions about your monthly invoice and payment status. Group Services (615) 255-3175 ext 295 or 800-223-3104 ext 295 or Fax (615) 256-9731 4

Online Services www.deltadentaltn.com Featured Employer Welcome employers! At Delta Dental, we have a wide array of flexible dental benefit programs that help manage costs without sacrificing quality. Here you will find detailed information about our products. Benefit Manager Toolkit Conveniently submit, update and transfer employee eligibility free of charge. Contact your Service Representative for additional information or login now Electronic Administration Turn the key to access your electronic billing and enrollment/change forms via ecommerce tools. Products Delta Dental has developed a wide array of dental benefit programs that help manage costs and care without sacrificing quality. A.M. Best Delta Dental of Tennessee has a Best s rating of A- (excellent). Learn more. Dentist Search Find a participating dentist near you. Contact Delta Dental Please contact us if you have any questions. NEW! Evidence based benefit changes for 2007 Delta Dental of Tennessee believes good oral health is important to overall health and... read more Read all the headlines in our archive. Document Library Administrative Manual As a plan administrator, you are the primary contact between Delta Dental and your employees. To assist you, we have created this handbook to serve as a valuable resource to answer your how to or what if questions. The Delta Difference Learn about Delta's leadership, cost containment, network, customer service, and more. Value Added Benefits Delta Dental of Tennessee offers members a discount vision plan through EyeMed Vision Care. Oral Health & Wellness Resources Get the latest health news from Delta Dental. 5

Featured Subscriber Welcome subscribers! Delta Dental provides you with resources to make managing your dental benefits easy. Here you can access our online dentist directory and learn about your oral health. Click on the Consumer Toolkit link to review benefit and claims information for individuals covered by Delta Dental. Dentist Search Find a participating dentist near you. Consumer Toolkit Find claim and benefit information along with helpful tips and valuable oral health information by logging on to the Consumer Toolkit today. Contact Delta Dental Please contact us if you have any questions. Privacy Notice your privacy is important to us. Making the Most of Your Benefits As a Delta Dental member, we want to help you get the most benefit from your dental plan. Our list of Frequently Asked Questions may also provide you with the answers you are looking for. Translation Services Our Customer Service can help you in virtually any language. Call 1.800.223.3104, press 6, and ask your representative for translation assistance. Value Added Benefits Special bonus offers for you, our valued subscribers. Oral Health & Wellness Resources Get the latest health news from Delta Dental. 6

This area of our website was created exclusively for subscribers, to meet their needs and answer specific questions. The Consumer Toolkit provides members with instant online access to their specific benefit and eligibility information, 24 hours a day, 7 days a week. Welcome Consumer This site has been developed for your use only because we are committed to safeguarding your protected health care information and to meeting the privacy requirements of federal law. For more information, click here. If you are a dentist or work in a dental office, go to the Dental Office Toolkit. If you are a benefits administrator or manager, go to the Benefit Manager Toolkit Subscriber Member Number Relationship Subscriber Date of Birth Log In Once you log in you will see: Welcome to your Consumer Toolkit, X The Consumer Toolkit will allow--in a very secure environment--our covered members and their spouses to easily: Verify eligibility of subscriber and dependents; Review up-to-date benefits information (such as how much of your yearly benefit has been used to date, how much is still available to use, and levels of coverage for specific dental services); Review specific claims transactions, reimbursements, and payments; and Print your own member ID cards. The privacy of your benefits information is assured. We employ state-of-the-art, ultra-secure computer technology to protect your personal information. 7

Find a Dentist There are more than 171,000 participating dental locations in the nation. To verify participation status, please search on our website or simply ask your dentist if he/she is a participating dentist with Delta Dental. Welcome to the DeltaDental.com Dentist Search. Delta Dental has a national network of dentists across the U.S. and Puerto Rico. To locate a dentist in your area, please complete the following information. Required fields are indicated with an asterisk (*) Search Tips and Disclaimers! 1. Product Selection ( Unsure of your coverage? Click Here ) *Your Dental Plan: Delta Dental Premier Delta Dental PPO DeltaCare USA (formerly (formerly DeltaPremier USA) DeltaPreferred Option USA) 2. Your Location Your Address: *Your City: *Select a State: Select a State - OR - *Your Zip Code: 3. Sorting, Distance and Number of Results Sort Results By: Maximum distance willing to travel: Distance 5 10 15 20 30 40 50 Number of Results: 50 Changing this value will limit the number of Dentists returned. 4. Additional Search Criteria Dentist Last Name: Practice Name: Specialty: General Dentist Search for a Dentist 8

Defining Delta Dental Terms Account Summary The first section of the monthly billing, which details prior and current billings and payment information (see pages 22-25 for a sample bill). Maximum Plan Allowance (MPA) This is the maximum amount we reimburse a participating dentist per procedure. Annual Maximum The maximum amount we will pay for covered services in a calendar year, per member. Billing Code A two-digit code indicating changes in the member s status that affect the monthly bill. Coinsurance The percent a member pays for covered services, after the deductible (if any) is met. The amount of coinsurance varies with the type of covered services. Coordination of Benefits (COB) When a member has coverage with another insurance policy, benefits are coordinated to determine the appropriate share of the claim to be paid by each insurance carrier. Date of Service The actual date the service was rendered. With multi-stage procedures, except orthodontics, the Date of Service is the final completion date. Example: the insertion date of a partial denture, the cementation of a permanent crown. Deductible The amount of money a member pays for covered services before Delta Dental begins to pay for the service. Deductibles vary by type of benefits and are specific amounts for each subscriber and/or dependent per year or per lifetime as specified. Example: A company s dental plan includes a $50 deductible. Each year a member must pay the first $50 for dental services before Delta Dental begins to pay for the services. Dentist This is any person duly licensed as a Doctor of Dental Medicine (DMD) or Doctor of Dental Surgery (DDS) practicing within the authority of his or her license. The term dentist includes an oral surgeon. Dependent This refers to a spouse and any unmarried dependent children to age 24. Adopted children, step-children and children under a member s own or spouse s legal guardianship who are permanently residing in the member s household in a normal child-parent relationship and chiefly dependent on the member for support, are also considered dependent children. This also includes unmarried children over age 24 that are mentally or physically handicapped and incapable of earning a living. Married children are not considered dependents, regardless of their age. Effective Date The date as shown in our records on which a member s coverage begins. Enrollment Forms The form used to add a member and record all changes to a member s personal data, eligibility status and coverage. (See page 11 for a sample enrollment form). Explanation of Benefits (EOB) Delta Dental s notification to the subscriber and dentist detailing the dentist s total fees, any deductibles, coinsurance and charges for non-covered services. The EOB also summarizes our payment and any patient financial responsibility. Group A group is considered any company, account, government agency, union or association that meets our underwriting guidelines and contracts with Delta Dental for its dental coverage. ID Card The card issued by Delta Dental of Tennessee to each subscriber, which includes his or her name and group number. Lifetime Maximum The maximum amount of dollars we will allow for covered services during a subscriber s or dependent s lifetime. This provision usually applies only to orthodontic services. Member Member refers to any employee (subscriber) and their eligible dependents (e.g. spouse, child), who are covered under a Delta Dental of Tennessee policy. Non-Participating Dentist A dentist who does not have a contractual agreement with Delta Dental to furnish services to subscribers and dependents. 9

Participating Dentist A dentist who has a contractual agreement with Delta Dental to furnish covered services to subscribers and dependents. Pre-determination A form submitted to Delta Dental by the dentist for certain treatments expected to exceed $300. Delta Dental processes the pretreatment estimate and sends a form to the subscriber and the dentist informing them of what services will be covered and the patient s estimated out-of-pocket costs. Rate Code A two-digit code indicating the subscriber s type of coverage (e.g. individual 01, family 03, or if applicable, two-person 02). This code is found on your monthly bill on both the Subscriber Update Listing and the Subscriber Listing. Sub-group Any of several possible categories or groups within an organization, such as a unique division, office, plant, branch, geographical location or benefit plan. A sub-group is represented by a fourdigit code, following the group number. Example; Group No. 1234-Sub-group No. 0001, 0002, etc. Each sub-group can receive a separate bill. Subscriber A subscriber is usually the employee whose application for coverage has been approved by Delta Dental and who is eligible to receive benefits. Subscriber ID Number A nine-digit number which is usually the subscriber s Social Security number. Subscriber Update Listing The Subscriber Update Listing is the second section of the monthly invoice. The Update Listing details all enrollment changes that have been processed after the previous month s billing cut-off date. Certificate of Coverage (COC) This is the members certificate of coverage detailing their benefits. 10

Eligibility and Enrollment As the Plan Administrator, you may already be familiar with some of our guidelines for enrolling your company or group in Delta Dental. But there are some additional guidelines, such as ongoing group participation requirements, that you may want to refer to from time to time. This section highlights a few of these key underwriting areas for participation, member eligibility and retro activity. 11

Eligibility Participation Requirements refer to the number of employees who enroll in the plan compared to the number of employees who are eligible to enroll, excluding those employees with other coverage (e.g. spouse s plan, other employer group). The group s eligibility requirements and enrollment may be reviewed and audited at least once each year typically prior to the renewal date to ensure compliance with these requirements. Please note: If an employee has dental coverage elsewhere (e.g. through a spouse), that employee may be eliminated from the calculation of the total eligible population. Who Can Enroll? Active Employees: All active employees who are eligible for your group s benefits program and for whom the company contributes all, some or none of the premium charge are eligible for membership in your group s dental benefits plan. Active employees including owners, partners and corporate officers must regularly work 30 or more hours per week and be on your company s payroll. Only employees (and their family members if your company has family coverage) are eligible for coverage. Dependents: Your plan s family coverage includes the following dependent categories: The employee s legal spouse Unmarried children by birth, step children or legally adopted children to age 24 Unmarried children over 24 who are mentally or physically incapable of earning their own living (proof of which must be on the file with Delta Dental of Tennessee). Divorced spouses in accordance with applicable federal and state law. In the case or remarriage, the ex-spouse can no longer be covered under the family plan. When Coverage Begins Please review your Certificate of Coverage for your group s eligibility period (this is in accordance with the contract). If any employees or eligible dependents do not enroll when they are first eligible, they must wait to apply until the next open enrollment period scheduled for your company or when a qualifying event occurs. Qualifying Events The monthly premium rates have been developed assuming all members have committed to a 12-month enrollment period. For a new enrollee to join the program or make a status change, the member must meet an industry-accepted qualifying event. Qualifying Events include: New Hire Marriage Divorce Birth, Adoption, Change of Custody Workers Compensation Family Medical or Disability Leave Spouse s Loss of Coverage Full Time/Part Time Status Change Death of a Member Rejoining the Plan An enrolled member who voluntarily cancels membership in the group may not re-enroll in that group until the first open enrollment following 12 months without coverage. The re-enrollment must occur on the group s anniversary or open enrollment unless a qualifying event occurs. 12

When Coverage Ends Coverage ends on the last day of the month in which the group notifies us that coverage is cancelled by completing the applicable form or online transaction. Please review your contract for detailed participation, enrollment and reenrollment requirements. Member Retroactivity Retroactivity occurs when we are notified of an addition, change or termination after the requested effective date has occurred. Additions: Member additions are made on the first day of the month or as your contract allows. Terminations: Member terminations take effect on the first day of the moth following the last date of coverage or as your contract allows. The maximum credit that can be given is 90 days, provided there are no claim(s) paid on the member during this period. If a claim(s) has been paid, the termination will take effect on the last day of the month in which the claim(s) was paid. Verifying Eligibility Information With our streamlined administration, the same eligibility records are used for both claims processing and monthly billings. This means there is no discrepancy between the two functions and that corrections and updates need only be made once. In addition, a Subscriber List (there is a list for each of your sub-groups) is included with your bill. The Subscriber List displays all your employees who are eligible to receive dental benefits and the type of coverage. You should review these lists carefully to ensure that the information is correct. Filling out the Enrollment/Change Form Enrollment forms need to be completed for new hires. See page 11 for a sample of an enrollment form. This form can be downloaded from our website. When adding a dependent, terminating a dependent, changing an address or terminating the subscriber, please complete a change form. See page 12 for a sample of a change form. Example: On July 8, you request a retroactive termination effective July 1. On July 6, however, the member went to the dentist and a claim was submitted and paid. As a result, the member s coverage will be cancelled August 1. 13

ENROLLMENT FORM Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Telephone 615-255-3175 SOCIAL SECURITY NUMBER GROUP NUMBER SUB-GROUP NUMBER GROUP NAME FIRST NAME M LAST NAME STREET ADDRESS CITY STATE ZIP BIRTH DATE EFFECTIVE DATE SEX M F If enrolling spouse and/or dependents, please list them below FIRST NAME & M.I. (LAST NAME IF DIFFERENT) SPOUSE: CHILD: CHILD: CHILD: CHILD: SEX M F BIRTH DATE I agree to make the required contribution. I certify that the information contained in this form is true and correct to the best of my ability. Signature: Date: DECLINE COVERAGE I have been given the opportunity to apply for group dental insurance coverage through my employer and choose at this time to not take coverage. I understand that by signing this area I am declining this coverage because: I have other dental coverage I do not want at this time Other: Declination Signature: Date: 14

CHANGE FORM Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Telephone 615-255-3175 SOCIAL SECURITY NUMBER GROUP NUMBER SUB-GROUP NUMBER GROUP NAME FIRST NAME M LAST NAME If terminating or adding a dependent(s) ONLY, use Drop (D)/Add (A) box below D A FIRST NAME & M.I. (LAST NAME IF DIFFERENT) SPOUSE: SEX M F BIRTH DATE REASON EFFECTIV E DATE CHILD: CHILD: CHILD: CHILD: CHANGE NAME From: To: CHANGE ADDRESS To: CHANGE SUB-GROUPS: From: To: Effective Date: TO TERMINATE EMPLOYEE COVERAGE, PLACE EFFECTIVE DATE HERE: (Rehired Employees and COBRA enrollees should fill out a new enrollment form) Signature: Date: 15

ID CARDS Delta Dental automatically issues identification cards (ID cards) for all employees covered under your plan. We will mail ID cards within 15 days after enrollment transactions have been completed. Your employees should present their ID card when they visit a dentist outside of the state of Tennessee. To replace lost ID cards your employees can print one from the Consumer Toolkit on our website or call Customer Service. The front of each ID card contains your company s name, Delta Dental group number and the subscriber s name. The back of the card indicates how to contact Delta Dental and outlines claim filing instructions. Coordination of Benefits To enhance benefits and prevent duplication of coverage, Delta Dental coordinates benefits for members covered under a second insurance policy (e.g. through a spouse s plan). This process is known as Coordination of Benefits (COB). Please check your contract to see if your company allows COB. Delta Dental s rigorous performance of dental benefits coordination during claims processing is designed to help your company and its employees control dental care costs. Delta Dental handles COB in accordance with industry standards. We use the Birthday Rule when dependent children are covered by both parents dental plans. The Birthday Rule means covered dependent children are generally covered first (primary) by the plan of the parent whose birthday occurs earlier in the year. COBRA Employee Name Group # John Q Subscriber 0009999-0001 Company Name DENTAL PLAN Visit us at www.deltadentaltn.com How is COBRA processed? Delta Dental does not administer COBRA. The group must pay all premiums. Delta Dental does not accept personal checks from the COBRA participant. This card is to provide group information and is not a guarantee of eligibility or benefits. If you have dependents enrolled, your name and Social Security number must be included on claims to be filed. The amount you are responsible for paying may be greater if services are provided by a non-participating dentist. Send claims to: Delta Dental of Tennessee 240 Venture Circle Nashville, Tennessee 37228 For inquiry, call (615) 255-3175 or (800) 223-3104 16

Billing Your coverage with Delta Dental of Tennessee is a prepaid benefits plan with premiums due on the first of the month. This section explains each part of the monthly bill. If you do not currently have e-billing, pages 18-19 will not apply. If you are interested in receiving e-billing, please contact Billing Services. 17

Billing notification will be sent via email and click on the link for the log-in process. 18

Web-Based Services Account Name and Password: Assigned when E-Billing is requested 19

Delta Dental of Tennessee BILLING STATEMENT Invoice Cover Sheet 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 CONTACT NAME ABC COMPANY 123 ANY AVENUE ANY TOWN, TN 12345-0001 Group Number 000NNNN Contract ID NNNNB1 Sub Group 0001 Net Update Adjustment Current Month Billing Group No. : 000NNNN Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Billing Period : 03-01-2007-03-31-2007 ($24.59) $636.32 CR Sub Group Amount Due $611.73 TOTAL AMOUNT DUE............................ $611.73 1. Retain a copy for your records. Detach and return with payment Group Number: 000NNNN Record Number: NNNNN Due Date: 03-01-2007 Remittance Amount: For Billing questions call toll-free 1-800-223-3104, Ext 298 2. Make checks payable Delta Dental of Tennessee and mail to the following address: Delta Dental of Tennessee P.O. Box 305172 Dept. 35 Nashville, TN 37230-5172 Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 CONTACT NAME ABC COMPANY ANY AVENUE ANY TOWN, TN 12345-0001 BILLING STATEMENT Statement of Account Group No. : 000NNNN Subgroup No. : 0001 Contract ID. : NNNNB1 ProgramType : 10 Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Billing Period : 03-01-2007-03-31-2007 Net Update Adjustment............................................... Current Month Billing............................................... ($24.59) $636.32 CR AMOUNT DUE............................................... $611.73 Detach and return with payment 1. Retain a copy for your records. Group Number: 000NNNN Record Number: NNNNN Due Date: 03-01-2007 Remittance Amount: For Billing questions call toll-free 1-800-223-3104, Ext 298 2. Make checks payable to: and mail to the following address: Delta Dental of Tennessee P.O. Box 305172 Dept. 35 Nashville, TN 37230-5172 Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee BILLING STATEMENT Subscriber Update 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 CONTACT NAME ABC COMPANY ANY AVENUE ANY TOWN, TN 12345-0001 Group No. : 000NNNN Subgroup No. : 0001 Contract ID. : NNNNB1 ProgramType : 10 Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Name of Subscriber Social Security Number Rate Code Effective Date Type of Change Billing Period : 03-01-2007-03-31-2007 Previous Current Total Due Billing Billing Debit Credit PERSON, A 000-00-0000 01 01-01-2007 ADD 0.00 49.18 49.18 PERSON, B 000-00-0000 01 12-01-2006 TERM 73.77 0.00 73.77 Total : Net Adjustments : $49.18 $73.77 0.00 $24.59 Rate Code Definitions Rate 1 - Employee only Rate 3 - Employee, spouse and child(ren) Rate 5 - Employee, one child, no spouse Rate 7 - Employee and less than three children Rate 2 - Employee and spouse Rate 4 - Composite (any family combination) Rate 6 - Employee and more than one child Rate 8 - Children only Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 CONTACT NAME ABC COMPANY ANY AVENUE ANY TOWN, TN 12345-0001 BILLING STATEMENT Subscriber Listing Group No. : 000NNNN Subgroup No. : 0001 Contract ID. : NNNNB1 ProgramType : 10 Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Billing Period : 03-01-2007-03-31-2007 Name of Subscriber Social Security Number Rate Code Total Due PERSON, D PERSON, E PERSON, F PERSON, G PERSON, H PERSON, I PERSON, J PERSON, K PERSON, L PERSON, M PERSON, N PERSON, O PERSON, P 000-00-0000 03 88.92 000-00-0000 02 49.95 000-00-0000 01 25.82 000-00-0000 03 88.92 000-00-0000 03 88.92 000-00-0000 01 25.82 000-00-0000 01 25.82 000-00-0000 01 25.82 000-00-0000 01 25.82 000-00-0000 01 25.82 000-00-0000 01 25.82 000-00-0000 03 88.92 000-00-0000 02 49.95 Current Month Billing : $636.32 Rate Code Definitions Rate 1 - Employee only Rate 3 - Employee, spouse and child(ren) Rate 5 - Employee, one child, no spouse Rate 7 - Employee and less than three children Rate 2 - Employee and spouse Rate 4 - Composite (any family combination) Rate 6 - Employee and more than one child Rate 8 - Children only Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 CONTACT NAME ABC COMPANY ANY AVENUE ANY TOWN, TN 12345-0001 BILLING STATEMENT Subscriber Listing Current Month Rate Code Summary Group No. : 000NNNN Subgroup No. : 0001 Contract ID. : NNNNB1 ProgramType : 10 Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Billing Period : 03-01-2007-03-31-2007 Rate Code Number of Subscribers Rate Total 01 7 25.82 180.74 02 2 49.95 99.90 03 4 88.92 355.68 04 N/A N/A N/A 05 N/A 49.95 N/A 06 N/A 88.92 N/A 07 N/A N/A N/A 08 N/A N/A N/A Total Subscribers : 13 Current Month Billing : $636.32 Rate Code Definitions Rate 1 - Employee only Rate 3 - Employee, spouse and child(ren) Rate 5 - Employee, one child, no spouse Rate 7 - Employee and less than three children Rate 2 - Employee and spouse Rate 4 - Composite (any family combination) Rate 6 - Employee and more than one child Rate 8 - Children only Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228-1699 (615) 255-3175 or (800) 223-3104 BILLING STATEMENT Total Group Subgroup Count Current Month Includes All Subgroups CONTACT NAME ABC COMPANY ANY AVENUE ANY TOWN, TN 12345-0001 Group No. : 000NNNN Run Date : 02-19-2007 Billing Date : 02-19-2007 Closing Date : 02-19-2007 Due Date : 03-01-2007 Rate Code Billing Period : 03-01-2007-03-31-2007 Number of Subscribers 01 7 02 2 03 4 04 05 06 07 08 Total Subscribers : 13 Rate Code Definitions Rate 1 - Employee only Rate 3 - Employee, spouse and child(ren) Rate 5 - Employee, one child, no spouse Rate 7 - Employee and less than three children Rate 2 - Employee and spouse Rate 4 - Composite (any family combination) Rate 6 - Employee and more than one child Rate 8 - Children only Friday, March 02, 2007 559 Page 1 of 1

Delta Dental of Tennessee Phone: 615-255-3175 Revised 02/05 240 Venture Circle 800-223-3104 Nashville, TN 37228-1699 Web Billing is now available. Call the Billing Department for more details. We would like to have your email address so that we may serve you better. Delta Dental Billing Procedures Your Delta Dental bill processes on the 17th of every month and is mailed by the 23rd of every month. The cut off date for receiving guaranteed changes is the 12th of every month. Our billing system adjusts your credits (terminations) and debits (additions) to automatically appear on the following month s Subscriber Update. Please pay the amount due shown on the Cover Sheet. This page reflects the total of all changes plus your current month's listing. Please include the bottom portion of the Invoice Cover sheet along with any changes with your payment. DDTN requires you to pay your premium as billed. Failure to pay as billed may result in the delay of receiving your bill in a timely manner. Payments are due on the 1st of every month. Please remit your payment paid as billed in the envelope provided. TERMINATIONS: Please draw a line through the name of each employee being terminated and write in the effective termination date. Terminations should be reported as soon as possible. It is the responsibility of the group to check their bill each month and report terminations. Failure to do so in a timely manner may cause Delta Dental to pay benefits for an ineligible person. You will be charged for that premium if a claim is paid after the termination date. Credit given is a maximum of 3 months provided there are no claims paid on the subscriber during this period. If the employee chooses COBRA, you must leave the employee on the billing. If he/she is uncertain, please terminate until you are sure they will take COBRA. When DDTN receives COBRA notification DDTN will then reinstate he/she to COBRA. You will be responsible for the premium due for any COBRA participants. You may fax a copy of your billing to Delta Dental each month with terminations indicated before the cutoff date to guarantee your changes before the next month s billing. Please fax the billings to BILLING DEPARTMENT 615-244-8108. NEW HIRES AND CHANGES IN COVERAGE: New hires must complete an Enrollment Form. These can be sent to DDTN anytime prior to one month before their eligible coverage. Please be sure the form is completely filled out. Any form received with missing information will be sent back to the group administrator. This may delay the employees eligibility. Should an employee decide to drop or add family coverage, change their last name, change locations, etc.; please have that employee fill out a Change form. Simply fill in the necessary information as it applies to each individual. This applies only to groups that do not transmit eligibility electronically. Please fax ALL forms to 615-256-9731. Questions about Eligibility? Group Services ext. 295 or e-mail groupservices@deltadentaltn.com Group Services Fax 615-256-9731 Questions about your bill? Billing Dept. ext. 298 or e-mail billing@deltadentaltn.com Billing Fax 615-244-8108 26

Claims One of the most significant benefits to Delta Dental of Tennessee members is that they do not have to file claims when using participating dentists. Participating dentists file claims directly with Delta Dental. Members may need to submit a claim form to Delta Dental when using a nonparticipating dentist. 27

Claim Filing You can find a claim form on our Web-site at www.deltadentaltn.com under the Dentists/Resources for Dentists section under "frequently requested forms". For services performed by a participating dentists As a member of Delta Dental, your employees enjoy distinct advantages when they visit a participating dentist. The dentist agrees to accept our payment as payment in full-minus any applicable deductibles or coinsurance and your employees are protected against being billed for any remaining balance. A participating dentist will also file your employees claims directly with us and handle all of the paperwork. Here s how it works: 1. The member presents his or her ID card at the dentist s office. 2. The dentist calls Delta Dental to verify eligibility and benefits. 3. Once treatment is rendered, the dentist files a claim directly with Delta Dental. For services rendered by non-participating dentists plus any applicable coinsurance, deductibles, etc. Members receive an Explanation of Benefits form for services rendered by both participating and nonparticipating dentists. Explanation of Benefits The Explanation of Benefits (EOB) is used to inform the subscriber when a claim is processed. The EOB also indicates the total charges for the services rendered by the dentists, as well as any amount payable by the employee for deductibles, coinsurance and charges for non-covered services. An EOB is also sent to the participating dentist who performed the treatment. See page 29 for a sample EOB. Identifying Participating Dentists For the most up-to-date information, visit our web site: www.deltadentaltn.com and click on Find a Dentist. This on-line directory is updated weekly. See page 30 for a sample of our on-line Dentist Search. The process for filing and paying claims for services on non-participating dentists is as follows: 1. A non-participating dentist may ask members to file claims. Claims must be submitted within 15 months of the date of service. 2. Members should ask the dentist to complete a standard claim form which is available on our website. 3. Members should mail the completed form to: Delta Dental of Tennessee 240 Venture Circle Nashville, TN 37228 Delta Dental sends payments for claims submitted by non-participating dentists to the subscriber. (The only exception to this is out-of-state, when state laws mandate assignment of benefits or when your group contract specifies assignment of benefits.) It is the member s responsibility to pay the dentist. The member is responsible for the difference between the dentist s full charge and the Delta Dental payment, 28

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Pre-treatment Estimates For certain services (e.g. crowns, bridges, Periodontics, orthodontics), participating dentists are encouraged to submit a pre-treatment estimate to Delta Dental. This will provide members with estimates of the total cost of services and the members out-of-pocket expenses before services are performed. It is important that your employees are aware of this. To help ensure that the process does not unnecessarily delay the delivery of services, Delta Dental quickly responds to pre-treatment estimates submitted by dentists. In addition, Delta Dental encourages members to ask their dentist to file a pretreatment estimate when the cost of the treatment is expected to exceed $300. Once the estimate is reviewed, a pre-treatment estimate form is sent to both the member and the dentist describing the procedures that are covered or not covered. It also estimates how much Delta Dental will pay the dentist and any cost sharing the member will incur. The pre-treatment estimate is not a guarantee of payment. Payment determination is made at the time the actual claim for services is processed based upon eligibility and subject to the applicable coinsurance, deductible and calendar year maximum. If the patient goes ahead with the treatment, this form is submitted as the claim for payment. Appealing a Claim If a payment for services was denied, the EOB will give the reason. If the subscriber disagrees with the denial, he or she must submit a request in writing asking that the claim be reviewed. Such request should include the reason why the subscriber believes the claim was wrongly denied. The request must be received by DDTN within 180 days of the subscriber s receipt of the EOB. DDTN will make a review and may ask for more documents if needed. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after DDTN receives the request for review. If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of Delta Dental. This second level review request must be in writing and received by Delta Dental within a reasonable time after the subscriber receives the first level review decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for second level review. If the subscriber does not agree with the second level review decision, he or she may file civil action in court. 31