This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.
How To Read Your Dental Explanation of Benefits
This document explains the GHI determination of benefits for dental services a patient received. A separate statement will be prepared for each patient. If you use a Participating Dentist, you will receive notification of payment made to the dentist. If you use a non-participating dentist, you will receive your GHI Payment Check attached to your Explanation of Benefits.
- Services Rendered: This column describes the kind of service received.
- ADA (American Dental Association) Code: This column contains the ADA procedure code for the services rendered.
- Tooth Number: The specific tooth your dentist treated. (This will appear as an alphabetical code for certain situations, e.g., FM = full mouth.)
- Date(s) of Service: The actual date(s) of service for the specific treatment listed.
- Charge: The amount charged by your dentist.
- GHI Allowance: If the service is covered, the GHI allowance for that specific service.
- Payment Summary: This area shows the total payment of all services listed for this claim.
- Note: You will see a number in the "note" column, if part or all of your claim was denied, or additional information is needed about the service rendered. An explanation of the code number will be printed on the bottom of the statement.
- Benefits Paid Toward Maximum: The total amount of benefits paid toward your applicable annual maximum.
If you have any questions concerning your claim, call GHI for assistance: 1-800-947-0101.
