PreSelect Exclusions and Limitations

Specialist Care Referrals
Certain dental procedures require the services of a specialist (i.e. some oral surgery, endodontics, periodontics and pedodontics). In those cases, your general dentist will refer you to a participating specialist. You will be provided a referral form to present to the participating specialist to ensure proper coverage.

What Are Co-Payment Fess?
Co-payments are reduced fees charged by the participating dental offices for some covered dental procedures as specified in the Benefits Schedule. The reduced fees are 30-100% less than the usual, customary and reasonable fees charged in a dental office. Members are financially responsible for co-payment fees, payable to the dental office upon receipt of dental services.

Dependant Eligibility
Eligible dependents include the employee's spouse and/or unmarried children predominantly dependent upon the employee for support until the end of the month in which the child reaches the age of nineteen (19) or until the end of the calendar year in which the child reaches the age of twenty-five (25) provided the child continues to be predominately dependent upon the employee for support and resides in the employee's home or is registered as a full- or part-time student. As used herein, children shall include: all children born to you, whether pre-enrolled or not, from the moment of birth; children legally adopted by you from the moment of placement in your residence or if a newborn, from the moment of birth, if a written agreement to adopt has been entered into you prior to birth; or any stepchildren or foster children under you or your spouse's legal guardianship. Verification or proof of each unmarried child's support, residency and/or student status may be requested by OHS, whose determination of dependent eligibility shall be binding. Coverage will also be extended to any unmarried child over the age of nineteen (19) who is primarily dependent on the employee and otherwise incapable of self support by reason of mental or physical handicap. The employee must submit proof of dependency and incapacity within thirty (30) days of the dependent's attainment of age nineteen (19) and thereafter at the request of OHS for continued coverage.

Terms Of Enrollment
Enrollment in the OHS dental plan is for a minimum of twelve (12) consecutive months while employed by your current employer. Enrollment in the plan will be allowed during open enrollment periods as determined by your employer and OHS.

Cancelling Appointments
The time set aside for a patient is very valuable to the dentist. Therefore, if you cannot keep an appointment, notify the dental office at least 24 hours in advance. If you do not notify the office, charges will be made for broken appointments as stipulated in the Benefits Schedule.

Effective Date Of Coverage

The effective date of coverage is established between your employer and OHS. Upon enrollment you will be notified of your effective date of coverage.

Emergency Care Within The Service Area
In the event of an emergency, contact the participating OHS dental office you selected.

Reimbursement Provision For Out-Of-Area Emergency Care
Members and dependents are covered for emergency dental treatment to relieve pain or prevent worsening of an injury or unforeseen condition, such as a root canal, while temporarily more than fifty (50) miles from their participating dental office. In the event of an emergency, obtain treatment to relieve your pain/discomfort only from a licensed dentist and pay for the services rendered. To receive reimbursement you must submit to OHS, within twelve (12) months of the date service was rendered, the following: 1) receipt; 2) member or dependent¹s name, social security number, address and phone number; 3) member/employee's name and social security number; and 4) all other supporting documentation necessary to process payment.

Mail to:
OHS/CompBenefits
P.O. Box 87539
Chicago, IL 60680-0539
Attn: Claims

OHS will reimburse no less than seventy-five percent (75%) of the usual, customary and reasonable charges for covered services subject to any applicable co-payments but in no event to exceed $100.00 per claim.

Second Opinions
OHS can arrange for second opinions at no additional cost to the member. To coordinate second opinions, members should call OHS¹ Member Support Department. Second opinions not arranged and approved by OHS or rendered by a non-participating dentist will not be covered.

Member Support Grievance Procedure
If you have an inquiry or grievance, OHS encourages you to submit it in writting to:

OHS Dental Services Administrator
5775 Blue Lagoon Drive
Miami, Florida 33126

Or call our Member Support Department, Monday through Friday, 8:00 A.M. to 6:00 P.M. at:

Toll-Free: 800-407-5514

Grievances must be filed no later than one year from the date of the occurence.
Member Support Associates are trained to address and satisfactorily resolve grievances. In the event a resolution cannot be achieved by the Member Support Department, the grievance is referred to the Case Support Department. A Case Support Associate will research the issues and attempt to resolve the grievance in a manner satisfactorily to all affected parties. Members wishing to appeal decisions rendered by the Case Support Department must do so in writing to the Manager of Quality Assurance within sixty (60) days following the date of decision. Grievance appeals will be reviewed by OHS Quality Assurance Committee and/or Dental Advisory committee. The member will receive a final written determination within thirty (30) days after OHS receives the completed grievance appeal form. The final determination of the committee will be binding on the member and provider. A copy of the OHS conflict resolution program policies and procedures is available to each member on request. Members also have the right to submit grievances directly to the Department of Insurance.

Renewals
Your coverage will automatically be renewed each year unless you notify your employer to terminate your coverage. additional information available OHS shall make available to members, upon request, a description of the following:

	Authorization and referral process for covered dental services.
	Process used to analyze the qualifications and the dentists under contract with OHS. Exclusions & Limitations The following dental benefits are not covered or offered under the plan:
	Oral surgery requiring the setting of fractures or dislocations.
	Treatment of congenital malformations.
	Treatment of malignancies.
	Dispensing of drugs.
	Any treatment requiring hospitalization.
	Any work which is not able to be performed because of the general health and physical limits of the eligible member, as indicated by said member¹s personal physician or the OHS dentist.
	Precision attachments or stress breakers.
	Replacement of partial or full dentures within two (2) years after installation unless resulting from the acts or omissions of OHS.
	Any treatment paid for by Workers¹ Compensation or covered or provided for by employer¹s liability laws, by a federal or state government agency, or provided without cost by any municipality, county or other political subdivision.
	Any procedure, implantation and/or any dental procedure considered to be experimental by the providing dentist.
	Surgical treatment of Temporomandibular Joint Dysfunction (TMJ).
	Replacement of lost or stolen prosthetic devices.
	Any dental care provided by a non-participating general dentist or specialist, except when authorized by OHS.
	Services resulting from any act of war, declared or not, or resulting from military service.
	Charges for broken appointments are not covered. The following limitations apply:
	The Participating Dentist shall have the right to refuse treatment to a member who fails to follow a prescribed course of treatment.
	Published member co-payments apply only when treatment is performed at a Participating Dental Office.
	If a member obtains dental services from other than a Participating Dentist/Specialist, the member shall be responsible for all costs. Coordination of Benefits The benefits of this dental plan may be coordinated with an indemnity dental insurance plan. For information on coordination of benefits you should contact your indemnity dental insurance carrier.