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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.

Submission Of Claims

If you use a non-participating dentist, GHI will reimburse you for covered services based on the Reimbursement Schedule. Please review the following steps prior to filing a claim.

  1. Before you go to your dentist, obtain an American Dental Association (ADA) Dental claim form from your Agency Health Benefits Administrator, from GHI, print the ADA Dental claim form now or contact your dentist. Many dentists have ADA Dental claim forms in their office and may be able to submit the form to GHI for you. A separate claim form must be used for each member of your family. Mail your completed claim form to GHI at:
    GHI Dental Claims
    P.O. Box 2838
    New York, NY 10116-2838
  2. Complete the subscriber portion of your Dental claim form. PLEASE PRINT LEGIBLY. Your GHI identification card indicates the necessary Category number. A completed and accurately filled out claim form will speed your payments.
  3. Take your claim form with you to the dentist.
  4. Show the dentist your identification card.
  5. Discuss fees before services are performed.
  6. Ask your dentist to complete and sign the dentist's part of the claim form.
  7. Sign your part of the claim form after the dentist has completed and signed his or her section of the form.
  8. When you visit a non-participating dentist, you must pay the dentist directly. GHI will reimburse you for covered services based on the Reimbursement Schedule.

NOTE: PRESENTATION OF FALSE PROOF IN SUPPORT OF A CLAIM ON A POLICY OF INSURANCE IS UNLAWFUL UNDER NEW YORK'S PENAL LAW.

To receive benefits, you must promptly complete and file an ADA dental claim form. You must file your claim form with GHI within eighteen (18) months of the date upon which a service has been rendered. If you fail to file your claim on time, GHI may still pay the claim if GHI determines that it was not reasonably possible for you to have filed your claim on time. You must file your claim as soon as it becomes reasonably possible to do so.

After GHI receives your claim form, GHI may ask for more information in support of the claim. You must give GHI the information it needs to process your claim.

Determination Of When Services Are Rendered

For payment to be made, services must be completed. Services are considered to have been completed on the date services are performed. Services related to the preparation, supplying or installation of prosthetic or orthodontic appliances, inlays or crowns, or other services requiring more than one session are considered for payment only after insertion or completion.

Your GHI coverage may become effective or terminate while treatment is in progress. GHI will make payment only for services actually performed while coverage is in effect.

Claims Review Procedure

If you have questions about your coverage or claims, please call 1-800-947-0101. If you wish to send a request/inquiry in writing, please forward it to one of the addresses listed below:

Appeals/inquiries pertaining to Utilization Review (e.g., Medical Necessity):

GHI Professional Review Department
P.O. Box 2838
New York, NY 10016-2838

Appeals/inquiries pertaining to non-Utilization Review criteria (e.g., Administration, Benefits, Contractual Interpretation):

GHI
Attn.: NYS Dental Customer Service
P.O. Box 12365
Albany, NY 12212-2365

Please include your identification number and claim numbers as well as any other supporting documentation you may have. If you disagree with the disposition of the inquiry, a written request for review may be made within sixty days of notification of the disposition to the appropriate address listed above depending upon the nature of the inquiry.

Upon receipt of such a request, there will be a review of the entire claims file together with any and all additional material you supply. A written decision will be provided to the enrollee and will include a full explanation of the reason for upholding or modifying the original disposition of the claim. You will receive the written decision, or notification of the receipt of your appeal if further information is needed, within 14 days. Process in legal actions with respect to the provisions of the insurance contract should be directed to:

GHI Legal Department
441 Ninth Avenue
New York, NY 10001-1681