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M/C; Legislature Dental

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

The document below 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.

  1. Services Rendered: This column describes the kind of service received.
  2. ADA (American Dental Association) Code: This column contains the ADA procedure code for the services rendered.
  3. Tooth Number: The specific tooth your dentist treated. (This will appear as an alphabetical code for certain situations, e.g., FM = full mouth.)
  4. Date(s) of Service: The actual date(s) of service for the specific treatment listed.
  5. Charge: The amount charged by your dentist.
  6. GHI Allowance: If the service is covered, the GHI allowance for that specific service is shown at 100% of the Preferred Dental Plan fee schedule. (Note: Under your current coverage Limited and Full Basic Services and Prosthetic Services rendered by a non-participating provider are reimbursed at 80% of the GHI Preferred Dental Allowance).
  7. 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.
  8. Payment Summary: This area shows the total payment of all services listed for this claim, minus the deductible (which applies for certain services under the terms of your contract).
  9. Out of Network Differential: The percentage of the charge which is not covered by GHI for services provided by a non-participating provider. You are responsible for payment of this amount to the provider.
  10. Remaining Deductible: This line shows the remaining deductible (individual and/or family) to date.
  11. 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.