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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.

Pre-Determination Of Benefits

To promote cost-effective care, GHI has developed a Pre-Determination of Benefits procedure for services received from a participating provider or a non-participating provider. A Pre-determination of Benefits is recommended for any non-emergency dental surgery, prosthetic or orthodontic procedure. A treatment plan describing the proposed course of treatment and the estimated costs should be submitted to GHI before the course of treatment is begun.

Treatment plans should be sent to GHI at:

GHI Dental Claims
P.O. Box 2838
New York, NY 10116-2838

GHI will notify the dentist and the enrollee of the benefits certified as payable, based upon the course of treatment to be rendered. In determining the amount of benefits payable, consideration will be given to alternate procedures, services or courses of treatment that may be performed for the dental condition in order to accomplish a satisfactory result. When a more costly material or service is substituted for a less costly material or service having the same function, the Plan will pay the allowance for the less costly item.

If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, GHI reserves the right to make a determination of benefits payable taking into account alternate procedures, services or courses of treatment, based on accepted standards of dental practice. To the extent that verification of covered dental expenses cannot reasonably be made by GHI, the benefits for the course of treatment may be a lesser amount than otherwise payable.