Transparency in coverage

Florida Combined Life (FCL) will send enrollees an explanation of benefits (EOB) statement that explains all claim decisions for dental treatments and/or services submitted by a provider on the enrollee’s behalf (or submitted by the enrollees). It is not a bill. If the provider is due a payment for any enrollee’s unpaid cost-sharing or non-covered services per the policy, the provider will bill the insured.

FCL will send the enrollee an EOB within twenty (20) days of our receipt of an electronically filed claim and for a claim filed on a paper claim form within forty (40) days of our receipt.

Please refer to the document How to Read Your EOB for a complete description of each item on the EOB.

Enrollees can choose to receive covered dental services from either a Participating or Non-participating dentist in FCL’s dental network.

FCL has a contracted network of Participating Dentists. These dentists have signed an agreement with FCL to accept the allowance established by FCL for covered dental procedures as payment in full up to the enrollee’s annual Calendar Year Maximum, plus any deductibles, coinsurance, or copayments due from the enrollee per the policy.

Non-participating dentists have not signed an agreement with FCL to accept FCL’s allowance as payment in full and may balance bill an enrollee for any amounts in excess of FCL’s allowance in addition to any deductibles, coinsurance, copayments due (or after the enrollee’s annual Calendar Maximum has been met) from the enrollee per the policy.

Emergency services received from a Non-participating dentist are not exempt from balance billing and any cost sharing as described above.

If dental benefits are obtained from a provider who does not file the claim on the enrollee’s behalf, it is the enrollee’s responsibility to file the claim with FCL.

To file a claim, the enrollee may request a claim form from FCL. The enrollee must obtain an itemized statement from their dentist and attach it to a completed ADA claim form. The itemized statement must contain the following information:

• The date the dental benefit was provided

• A description of the dental benefit

• The actual amount charged by the dentist

• The dentist’s name and address

• The patient’s name

• The policyholder’s name

Claims should be submitted to:

Florida Combined Life Insurance Company, Inc.
P. O. Box 69436
Harrisburg, PA 17106-9436

For Customer Service, please call 1-888-223-4892.

Written notice of the claim must be given to FCL within twenty (20) days after the date of service or as soon thereafter as reasonably possible. If proof of loss is not sent within the time requested, the claim will not be denied if it was not possible to send proof within this time. In any event, the proof required must be sent no later than 15 months after the date of service unless the enrollee was legally incapacitated.

If you are enrolled in an individual BlueDental Choice^SM or BlueDental Copayment Q or QF plan and do not pay your premium on or before the due date, you are entitled to a grace period. FCL allows a three-month grace period to pay each premium after the initial premium.

If you purchased your FCL dental plan directly from Florida Blue (an off-marketplace plan) or on-marketplace but do not receive a subsidy, your coverage will be active during this three-month grace period. To keep your coverage, you’ll need to pay your premium before the end of the three months. If you don’t, your policy will be canceled. You’ll lose coverage back to the last paid-through date and be responsible for any claims for services you received after that date.

If you purchased your plan on-marketplace and receive a subsidy to help pay for your coverage, claims will be paid during the first month of the grace period for all eligible dental services rendered. During the second and third months of the grace period, claims may pend and be denied if past due premiums are not received.

If the premium is not received prior to the end of the grace period, the policy will be canceled.

We continually perform reviews and audits to ensure dental claims are paid correctly. In some cases, we may retroactively deny a claim we have already paid. A retroactive denial occurs when it is discovered that a claim was processed and paid but should not have been paid.

Reasons why a claim may be retroactively adjusted or denied:

• The claim was fraudulent or paid incorrectly and not in accordance with state and federal law

• Nonpayment of your monthly premium

• Your plan ended, and you received services before the provider was notified

How to avoid retroactive denials

• Pay your premiums on time and in full

• Talk to your provider about whether the service performed is a covered benefit

• Receive your dental services from an in-network provider

FCL does not request claim payment refunds for claims paid when a member’s termination date is adjusted retroactively unless the member is terminating coverage with FCL and enrolling in a dental plan with a new insurance company. In all other circumstances, once a termination date is placed on a member’s membership record, claims are processed or denied based on that date moving forward.

However, if a member terminates coverage with FCL and enrolls with a new dental insurance company on the marketplace, FCL will request a refund from the provider for any claims paid after the retroactive termination date. The provider is responsible for refunding the member for payment of any cost shares.

Providers are responsible for billing the new issuer for any covered services incurred and paid after the retroactive enrollment date, and FCL instructs providers that they only collect the cost-sharing for the covered service to reflect the member’s cost-sharing obligation for the service under the new insurance company.

Such an adjustment may result in the member owing the provider additional funds, depending on the new plan’s cost-sharing and benefit structure. FCL advises providers that any refund or credit for excess cost sharing must be provided (or begin to be provided in the case of a credit) within 45 calendar days of the date of discovery of the excess cost sharing.

In the case of premium paid for or on behalf of the member, any refund or credit for any premium paid for or on behalf of the member will be provided (or begin to be provided in the case of a credit) by FCL within 45 calendar days of the date of discovery of the excess premium paid.

Enrollees who believe they have been overbilled for premium by FCL may request a refund.

Requests for refunds of premium overpayments may be made by calling Customer Service at 1-800-352-2583 or in writing to:

Florida Combined Life Insurance Company, Inc.
4800 Deerwood Campus Parkway
ATTN: Membership and Billing
Bldg 200, Suite 600
Jacksonville, FL 32246

All requests for refunds will be investigated within 7-10 business days after receipt by FCL.

If approved, refunds will be processed as follows:

• If the overpayment was made via a bank draft or electronic funds transfer (EFT), the refund will be issued within three business days.

• If the overpayment was made via credit card, the refund will be credited to the card within two business days.

Medical necessity means any services, care, or supplies received while covered, which are determined by FCL to be: 1) consistent with the symptom, diagnosis, and treatment of the insured’s condition; 2) in accordance with standards of good dental or medical practice; 3) approved by the appropriate dental or medical body or board for the condition in question; 4) not primarily for the comfort or convenience of the insured, or dentist; 5) the most appropriate, efficient, and economical dental or medical supply, service, or level of care which can be safely provided; and 6) not cosmetic in nature. FCL will make the final determination as to which services are medically necessary based upon review by our consulting dentists.

NOTE: The fact that a dentist may prescribe, order, recommend, furnish, or approve a service or supply does not, of itself, make it medically necessary for a covered service, nor does it make the charge an allowable expense under this policy, even though it is not specifically listed as an exclusion.

Medically necessary pediatric orthodontic treatment means treatment as a result of a handicapping malocclusion and congenital or developmental malformations related to or developed as a result of cleft palate, with or without cleft lip.

Prior authorization is a process required for specified dental procedures before they are performed. Typically, the dental or healthcare provider will obtain this preauthorization for the insured, but it is your responsibility to ensure it is obtained before the services are performed. Services that are not preauthorized when required are not payable by FCL and will be the insured’s responsibility.

Time frame and required documentation for prior authorization requests

Requests for preauthorization of benefits should be submitted within thirty (30) days of the date of the initial diagnosis or exam. The dentist, health care provider, or the insured must submit for FCL’s review: X-rays, a complete treatment plan, and in some cases, more substantiating material such as a study model.

Coordination of benefits (COBs) is a limitation of benefits for dental benefits under the policy and is designed to avoid the duplication of payment for dental benefits. COB applies when an insured is covered under other dental plans, programs, or policies providing dental benefits that contain a COB provision or are required by law to contain a COB provision. Such other dental plans, programs, or policies may include, but are not limited to:

1. Any group or individual dental insurance, group type self-insurance dental, health maintenance organization dental plan, or other dental plan, program, or policy; or

2. Any group or individual dental plan, program, or policy underwritten or administered by FCL.

FCL’s payment for covered dental benefits depends on whether FCL is the primary payer, as described in the policy. If FCL is the primary payer, FCL’s payment for dental benefits, if any, will not be reduced due to the existence of other coverage and will be made without regard to the insured’s other dental plans, programs, or policies.

In cases where COB applies and FCL is not the primary payer, FCL’s payment for dental benefits, if any, will be reduced so that the combined benefits of both plans will not be more than 100% of the FCL allowance for expenses actually incurred for covered services.

For complete details on the rules for COB, please refer to Section IX in the sample policy documents on the Forms and Documents page of our website.

In order to keep your policy in force and avoid cancellation, it is important to pay your dental premiums when they are due.

Premiums are paid monthly.

FCL allows a three-month grace period to pay your premium after the first payment has been made. During the grace period, your policy will remain active. If the premium is not paid before the end of the grace period, the policy will terminate effective as of the last day for which your most recent premium payment provides coverage.

If you purchased your FCL dental plan directly from Florida Blue (off-marketplace plans) or you purchased a plan on-marketplace but do not receive a subsidy, your coverage will be active during this three-month grace period. To keep your coverage, you’ll need to pay your premium before the end of the three months. If you don’t pay your premium before the end of the three months, your policy will be canceled. You’ll lose coverage back to the last day of coverage based on your most recent premium payment. You will be responsible for any claims for services you received after that date.

If you purchased your FCL dental plan on-marketplace and receive a subsidy to help pay for your coverage, claims will be paid during the first month of the grace period for all eligible dental services rendered. During the second and third months of the grace period, claims may pend and be denied if past due premiums are not received.

Also, please let us know if your mailing address or banking/payment information has changed.