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HOW TO READ YOUR DENTAL EXPLANATIONOFBENEFITS by nqw14076

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									                                              HOW TO READ YOUR DENTAL EXPLANATION OF BENEFITS
                                                 You can access this form in the member section on our website at www.odscompanies.com.

                                     4.              5.              6.            7.           8.                 9.            10.           11.         12.          13.             15.             16.
1. The patient who had                                                                                                                       REMAINING
                                                                                                                                                                                                                 11. A covered charge is
   services performed.         FOR SERVICES    TYPE OF SERVICE    PROCEDURE    TOTAL        DISALLOWED          DEDUCTIBLE      PROVIDER     COVERED       CO-PAY      TOTAL       PATIENT            COMMENTS       the amount allowed
                               FROM TO                            CODE         CHARGES      CHARGES                (-)          DISCOUNT     CHARGES                   BENEFIT     RESPONSIBILITY                    after disallowed
2. This is the claim                                                                                                                                                                                                 charges, the
   number for the             1.                                              2.                           3.                                             14.                                                        deductible and
   services performed.        PATIENT: JUAN CLIENTE                           CLAIM: D55555521-00        PROVIDER: SAM SANDER DMD                         PAYEE: SAM SANDER DMD                                      provider discount are
                              0501 050105     EXAM: INITIAL    D0150                50.00             .00                 .00          .00        50.00          .00    50.00                   .00                  subtracted.
3. The provider who           0501 050105     PROPHY: ADULT    D1110                60.00             .00                 .00          .00        60.00          .00    60.00                   .00
   performed services.        0501 050105     XRAY : FM SERIES D0274                40.00             .00                 .00          .00        40.00          .00    40.00                   .00              12. The co-pay is the
                                                                                                                                                                                                                     difference between the
4. The date the service
   was provided.
                                              TOTALS

                              PATIENT: JUAN CLIENTE
                                                                                   150.00

                                                                              CLAIM: D55555524-00
                                                                                                      .00                 .00

                                                                                                         PROVIDER: SAM SANDER DMD
                                                                                                                                       .00       150.00
                                                                                                                                                              E  .00 150.00

                                                                                                                                                          PAYEE: SAM SANDER DMD
                                                                                                                                                                                                .00
                                                                                                                                                                                                                     covered charge and
                                                                                                                                                                                                                     the amount paid. This

5. The type of service
                              0101 010106     AMAL: 2 SRF PERM
                                              TOTALS
                                                                  D2150            100.00
                                                                                   100.00
                                                                                                     .00
                                                                                                     .00
                                                                                                                        25.00
                                                                                                                        25.00
                                                                                                                                    25.00
                                                                                                                                    25.00
                                                                                                                                             L    50.00
                                                                                                                                                  50.00
                                                                                                                                                            10.00
                                                                                                                                                            10.00
                                                                                                                                                                        40.00
                                                                                                                                                                        40.00
                                                                                                                                                                                              35.00
                                                                                                                                                                                              35.00
                                                                                                                                                                                                      R8             amount is the patient’s
                                                                                                                                                                                                                     responsibility.
   performed.
                                                                                                                          P                                                                                      13. This shows the
6. The code that
   describes the service
                              PATIENT: JOSE CLIENTE
                              0101   010106   EXAM: INITIAL       D0150             50.00       M
                                                                              CLAIM: D55555526-00     PROVIDER: SAM SANDER DMD
                                                                                                     .00                  .00          .00        50.00
                                                                                                                                                          PAYEE: SAM SANDER DMD
                                                                                                                                                                .00     50.00                  .00
                                                                                                                                                                                                                     amount of benefit
                                                                                                                                                                                                                     which has been paid
                                                                           A
   performed.                 0101   010106   PROPHY:ADULT        D1110             60.00            .00                  .00          .00        60.00         .00     60.00                  .00                   by Oregon Dental
                              0101   010106   XRAY: 4 BITEWINGS   D0274             40.00            .00                  .00          .00        40.00         .00     40.00                  .00
                              0101   010106   FLUORIDE: ADULT     D1204             20.00            .00                  .00          .00        20.00         .00     20.00                  .00
                                                                                                                                                                                                                     Service.
7. This is the amount
   charged.                                   TOTALS      S                        170.00            .00                  .00          .00       170.00         .00 170.00                     .00               14. The “Payee” identifies
                                                                                                                                                                                                                     to whom Oregon
                              PATIENT: MARIA CLIENTE                          CLAIM: D55555525-00     PROVIDER: SAM SANDER DMD                            PAYEE: SAM SANDER DMD
8. This is the amount (if                                                                                                                                                                                            Dental Service has
   any) that is being         0101 010106     AMAL: 2 SRF PERM     D2150           100.00            .00                25.00       25.00         50.00     10.00       40.00               35.00     R8             made the benefit
   denied.                                    TOTALS                               100.00            .00                25.00       25.00         50.00     10.00       40.00               35.00
                                                                                                                                                                                                                     payment.

9. This shows any             COMMENTS:                                                                                                                                                                          15. This shows the
   charges which have         *** PAYMENT FOR THESE SERVICES IS DETERMINED BASED ON THE SPECIFIC TERMS OF YOUR DENTAL PLAN OR DELTA’S AGREEMENTS WITH DELTA NETWORK DENTISTS.                                        amount to be paid by
   been applied to your       R8        THE CHARGE EXCEEDS THE AMOUNT ALLOWED.                                                                                                                                       the patient to the
   plan’s deductible. The                                                                                                                                                        Patient deductible                  provider.
   deductible is                   17.                                                                                                                                           for benefit year.
   subtracted from                                                                                                                                                                                               16. Explanations of codes
                                 JUAN CLIENTE              HAS MET $             .00 OF THE $       25.00 PATIENT DEDUCTIBLE FOR THE 2005 BENEFIT YEAR.
   covered charges and is                                  HAS MET $          150.00 OF THE $    1,000.00 MAXIMUM FOR THE 2005 BENEFIT YEAR.
                                                                                                                                                                                                                     in this column are
   the responsibility of                                                                                                                                                         Maximum met for                     listed at the bottom of
   the patient.                                            HAS MET $           25.00 OF THE $       25.00 PATIENT DEDUCTIBLE FOR THE 2006 BENEFIT YEAR.
                                                                                                                                                                                 the benefit year.                   the page under
                                                           HAS MET $           40.00 OF THE $    1,000.00 MAXIMUM FOR THE 2006 BENEFIT YEAR.
                                                                                                                                                                                                                     comments. Additional
10. This shows the               JOSE CLIENTE              HAS MET $             .00 OF THE $       25.00 PATIENT DEDUCTIBLE FOR THE 2006 BENEFIT YEAR.                                                              explanation codes
    amount you saved by                                    HAS MET $          170.00 OF THE $    1,000.00 MAXIMUM FOR THE 2006 BENEFIT YEAR.
                                                                                                                                                                                 Family deductible                   listed on reverse side.
    using an ODS/Delta           MARIA CLIENTE             HAS MET $          25.00 OF THE $        25.00 PATIENT DEDUCTIBLE FOR THE 2005 BENEFIT YEAR                           for the benefit year.
    participating provider.                                HAS MET $          40.00 OF THE $     1,000.00 MAXIMUM FOR THE 2006 BENEFIT YEAR.THE FAMILY                                                           17. If there is a
    You are not                  THE FAMILY
                                                                                                                                                                                                                     deductible, this
    responsible for these
                                                           HAS MET $           0.00 OF THE $         75.00 FAMILY DEDUCTIBLE FOR THE 2005 BENEFIT YEAR.                          This is not a                       section will identify
    provider discounts.                                    HAS MET $           50.00 OF THE $        75.00 FAMILY DEDUCTIBLE FOR THE 2006 BENEFIT YEAR.                          billing. Please save                the amount applied
                                                                                                                                                                                 this copy for your                  toward the annual
                                                                               THIS IS NOT A BILLING. PLEASE SAVE THIS COPY FOR YOUR RECORDS.
                                                                                                                                                                                 records.                            deductible to-date and
                                                                                                                                                                                                                     this section will also
                                                                                                                                                                                                                     show the annual
                                            If you have questions, please call our Dental Customer Service line between 7:30 a.m. and                                                                                maximum met.
                                          5:30 p.m. Pacific Standard Time at 503-265-5680 (Portland area) or toll-free 1-877-277-7280.
                                      Dental Explanation Codes and Comments
EXPLANATION                                                                  EXPLANATION
            COMMENTS                                                                     COMMENTS
   CODES                                                                        CODES
                                                                                             PORCELAIN/RESIN ONLAYS ON POSTERIOR TEETH ARE
    >4     MEMBER NO LONGER ELIGIBILE. PLEASE CHECK ID CARD.                       D92
                                                                                             OPTIONAL. BENEFIT IS PROVIDED FOR METALLIC ONLAY.
           UNABLE TO DETERMINE BENEFITS. CLINICAL                                  L25       MAXIMUM BENEFIT HAS BEEN MET FOR THIS BENEFIT YEAR.
   D04     INFORMATION FROM PROVIDER WAS NOT RECEIVED TO
           SUBSTANTIATE NECCESSITY.
                                                                                   L35       ORTHODONTIC LIFETIME MAXIMUM HAS BEEN MET.
           TOOTH COLORED (COMPOSITE) FILLINGS ON BACK TEETH
   D18     ARE NOT A BENEFIT. ALLOWANCE HAS BEEN MADE FOR A                                  THIS CLAIM HAS PREVIOUSLY BEEN PROCESSED. PLEASE
                                                                                   Q1
           SILVER (AMALGAM) FILLING.                                                         CHECK YOUR RECORDS.

           PORCELAIN CROWNS, IF POSTERIOR TO THE UPPER FIRST                        R0       THIS SERVICE IS NOT COVERED.
   D23     MOLAR AND LOWER SECOND BICUSPID, ARE OPTIONAL.
           BENEFIT IS FOR A FULL GOLD CROWN.
                                                                                    R1       THE FEE CHARGED EXCEEDS THE MAXIMUM ALLOWANCE.
           PAYMENT IS PROVIDED FOR CAST RESTORATIONS,
   D29     PORCELAIN CROWNS AND/OR A PROSTHETIC DEVICE ONCE                                  THE MAXIMUM ALLOWED FOR SERVICES OF THIS TYPE HAS
                                                                                    R5
           IN A FIVE YEAR PERIOD.                                                            BEEN REACHED.

           SPECIALIZED TECHNIQUES, PRECISION ATTACHMENTS,                           R6       THE CHARGE EXCEEDS THE DELTA AMOUNT ALLOWED.
   D30
           IMPLANTS AND COPINGS ARE NOT COVERED.

           AN ALTERNATIVE BENEFIT HAS BEEN PROVIDED BASED ON                        R8       THE CHARGE EXCEEDS THE AMOUNT ALLOWED.
   D40
           THE CONTRACT LIMITATION.
                                                                                             TIMELY-FILING NOT MET. CLAIM SUBMITTED AFTER
                                                                                    S5
           PAYMENT IS NOT PROVIDED FOR ORTHODONTIC SERVICES,                                 CONTRACT TIME LIMIT.
   D62     INCLUDING DIAGNOSIS AND TOOTH GUIDANCE
           APPLIANCES.                                                              S6       DEPENDENT IS OVER MAXIMUM AGE.
           IF PRIMARY INSURANCE DID NOT PAY THE AMOUNT AS
   D76     SHOWN, PLEASE SUBMIT A COPY OF THEIR EXPLANATION OF                     W1        PROVIDER DISCOUNT HAS BEEN APPLIED.
           BENEFITS FOR REVIEW AND/OR AN ADJUSTMENT.
           THE MAXIMUM BENEFIT ALLOWANCE UNDER THE                                 W6        THE CHARGE EXCEEDS THE AMOUNT ALLOWED.
   D81     NON-DUPLICATION PROVISION IS OUR NORMAL BENEFIT
           LESS THE AMOUNT PAYABLE UNDER THE PRIMARY PLAN.
                                                                                             INFORMATION REQUESTED FROM THE MEMBER ABOUT
                                                                                   48B
           BASED ON CONSULTANT REVIEW, NECESSITY NOT                                         OTHER INSURANCE COVERAGE HAS NOT BEEN RECEIVED.
   D88     ESTABLISHED. TREATMENT IS CONSIDERED PART OF THE
           RESTORATION.                                                                      PLEASE SUBMIT A COPY OF THE PRIMARY CARRIER’S
                                                                                             EXPLANATION OF BENEFITS. YOUR CLAIM WILL BE
                                                                                    74
                                                                                             REVIEWED/ADJUSTED WHEN WE RECEIVE THIS
   D89     BASED ON CONSULTANT REVIEW, BENEFIT IS LIMITED.
                                                                                             INFORMATION.

                       If you can not find a specific explanation code listed above, or have further questions, please call the
                            Dental Customer Service line at 503-265-5680 (Portland area) or toll-free 1-877-277-7280.

								
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