Claim forms
The carrier, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If claim forms are not furnished within 15 days after the giving of notice, the claimant shall be deemed to have complied with the requirements of this contract as to proof of loss upon submitting, within the time fixed in the contract for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.
Proof of loss
Claims for covered Emergency Dental Services or authorized Specialized Services should be sent to us within 90 days of the end of treatment. Valid claims will be reviewed after 90 days if you can show that it was not reasonably possible to submit the claim within that time. Late claims must be submitted as soon as possible. All claims must be received within one year of the treatment date except in the absence of legal capacity of the claimant.
Time of payment of claims
We will acknowledge receipt of a claim within 20 working days unless payment of the claim is made within that time. Within 30 days after receipt of a claim, we will pay or deny the claim, in whole or in part, unless more time is required to make a determination. If more time is required, we will notify the Dentist within 30 days of receipt of the claim indicating that additional information is needed in order to process the claim and listing the specific information necessary to complete the processing of the claim.
If during the term of this Contract, none of the Contract Dentists can render necessary care and treatment to the Enrollee due to circumstances not reasonably within the control of ALPHA or the Administrator, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or the disability of a significant number of the Contract Dentists, then the Enrollee may seek treatment from an independent licensed dentist of his/her own choosing. The Administrator will pay the Enrollee for the expenses incurred for the dental services with the following limitations: the Administrator will pay the Enrollee for services which are listed in Schedule A, Description of Benefits and Copayments, as "No Cost", to the extent that such fees are reasonable and customary for Dentists in the same geographic area; the Administrator will also pay the Enrollee for those services listed in the Contract for which there is a Copayment, to the extent that the reasonable and customary fees for such services exceed the Copayment for such services as set forth in the Contract. The Enrollee may be required to give written proof of loss. ALPHA and the Administrator agree to be subject to the jurisdiction of the Maryland Insurance Commissioner in any determination of the impossibility of providing services by Contract Dentists. |
