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Summary Plan Description (SPD)
Predetermination of Benefits
Predetermination of benefits is a voluntary review of a proposed treatment plan before the actual dental work begins. The Plan provides this as a service to you so that you will know in advance how much the plan will pay. It is to your advantage to follow predetermination procedures. However, submission of a treatment plan in advance is not required and there is no penalty for not using predetermination procedures.
A predetermination is strongly recommended when your dentist expects treatment costs to exceed $500. In this case, your dentist should submit a dental claim form on which the pre-treatment estimate box is marked and which outlines a plan that includes the following:
- The dentist's recommended services.
- The dentist's charge for each service.
- Supporting x-rays or other diagnostic records where required or requested by the Plan.
The predetermination of benefits statement is an estimate of dental benefits, not a guarantee of payment. The actual payment for any proposed treatment depends on the following:
- The participant’s adherence to all plan provisions and limitation.
- The patient’s continued participation and eligibility in the plan at the time of treatment.
To obtain predetermination of benefits for dental services, contact Southern California IBEW-NECA Claim Administration (Allied Administrators, Inc.) directly at (800) 736-0401.