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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