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.
1. No Assignment. You cannot, without GHI's consent, assign any benefits, payments, causes of action or rights to appeal benefits or claims determinations under this plan to any person, corporation, or other organization. Any assignment by you will be void. Assignment means the transfer to another person or organization of your right to the services provided or your rights under this plan.
2. Your Dental Records. To process your claims it may be necessary for GHI to obtain records and data from practitioners who treated you. When you become covered, you give GHI permission to obtain and use these records. The information will be kept confidential.
3. Recovery of Overpayments. If GHI pays benefits under this plan for services incurred on your account and it is found that GHI paid more benefits than should have been paid because you were: (a) not covered; (b) the services were not covered; (c) payment was in an amount greater than that to which you are entitled under this plan; or (d) payment was in an amount greater than that to which you are entitled because you were repaid for all or some of those expenses by another source; then GHI will have the right to a refund from you. You must return the amount of the overpayment within sixty (60) days of GHI's request.
4. Right to Develop Guidelines. GHI reserves the right to develop or adopt standards and criteria which set forth in more detail the circumstances under which it will make payment.
5. Lawsuits. A lawsuit against GHI regarding this Certificate must be started within two (2) years from the date on which GHI issued the notification of covered benefits.
6. Suits against GHI for Actions of Others. You cannot sue GHI for the actions of any person or organization which renders covered services to you.
7. New York Law. This Certificate is in all respects governed by the laws of New York State.
8. Who Receives Payment Under This Plan. Payments for covered services rendered by a participating provider will be made directly to that provider. If you receive covered services from a Non-Participating Provider, GHI will reimburse you for covered services based on the Reimbursement Schedule.
9. Patient's Relationship with the Dentist or Provider. Nothing in this Certificate shall force a Dentist or Provider to accept you as a patient. This Certificate is not meant to change the normal relationship between the provider and patient. At all times, the provider's usual rules will govern the service provided to the patient. GHI cannot guarantee receipt of any particular service or accommodation.
Filing A Claim
When you receive care from a participating dentist, the dentist accepts GHI's allowance as payment-in-full (subject to the annual and lifetime-orthodontic benefit maximums) and bills GHI directly. Therefore, when you use a participating dentist, you do not have to file a claim.
For covered services rendered by non-participating dentists, a claim must be filed for you to receive reimbursement. This section explains the steps you must complete in filing a claim with GHI.
Proof Of Claim
GHI reserves the right to accept or to require verification of any alleged fact or assertion pertaining to any claim for dental expense insurance benefits. As a part of the basis for determining benefits payable, GHI may require submission of x-rays and other appropriate diagnostic and evaluative materials. When these materials are unavailable, and to the extent that verification of covered expenses cannot reasonably be made by GHI, based on the information available, benefits for the course of treatment will be determined by GHI and may be for a lesser amount than otherwise payable.