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PEF Dental Plan

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.

Definitions

  1. Enrollee. An Enrollee is the person to whom this Certificate is issued. He or she is insured by virtue of his or her membership in the group and not by reason of a family relationship. An Enrollee is a person who works at least half time on a regularly scheduled basis and whose position is represented by the Public Employees Federation (PEF).
  2. Member. A Member is an Enrollee or a person who is covered under this Certificate because of their relationship to the Enrollee. Members other than the Enrollee must be enrolled. See Who Is Eligible.
  3. You. To make this document easier to read, we have used the word "you" instead of Enrollee or Member in the text.
  4. Dentist. Dentist means a licensed dentist or physician who renders covered dental care. The dentist or physician must be licensed or certified to perform the service in the jurisdiction in which the service is rendered.
  5. Provider. Provider means a dental clinic or dental facility which is permitted to perform covered services.
  6. Participating Provider. A Participating Provider is any Dentist or Provider who has an agreement with GHI to accept GHI's Schedule of Allowances as payment in full for covered dental services up to the calendar year and lifetime-orthodontic benefit maximums. GHI will pay a Participating Provider directly for covered dental services.
  7. Non-Participating Provider. A Non-Participating Provider is any Dentist or Provider who does not have an agreement with GHI to accept GHI's Schedule(s) of Allowances as payment in full for covered dental services.

    You must pay a Non-Participating Provider's full bill. GHI will reimburse you directly for covered services rendered by a Non-Participating Provider according to the terms set forth in this Certificate. You must file a claim form with GHI to receive benefits.

  8. Schedule of Allowances. A Schedule of Allowances is a listing of GHI's maximum reimbursement to Participating Providers for covered services rendered. GHI's Schedule of Allowances may be amended from time to time. The Schedule of Allowances is on file with the New York State Insurance Department. It is available for inspection at the offices of the New York State Insurance Department and at GHI's offices.
  9. Reimbursement Schedule. The Reimbursement Schedule for covered services rendered by a Non-Participating Provider is based on the Schedule of Allowances and is included with this certificate.
  10. Scheduled Amount. The Scheduled Amount as used in this Certificate refers to GHI's contracted schedule with Participating Providers for covered services or the amount stated in the Reimbursement Schedule for covered services performed by Non-Participating Providers. In the event that the Scheduled Amount for a covered service rendered exceeds the amount billed by the Dentist or Provider for that service, GHI will consider the Dentist or Provider's billed charge to be the Scheduled Amount for that particular service.
  11. Predetermination of Benefits. Predetermination of Benefits is the process whereby GHI approves the treatment plan and estimates benefits before services are rendered. If you are subject to Predetermination of Benefits, a Treatment Plan must be sent to GHI before certain services are performed. GHI will review the plan and send you an estimate of the benefits for covered services. Predetermination of Benefits will allow the provider and member to be aware of the estimated level of benefits prior to treatment.
  12. Treatment Plan. A Treatment Plan is a proposed detailed statement of the dental services to be rendered and the fees to be charged.