PDF Dental Reimbursement Form - Hamilton County Schools

Hamilton County Department of Education Dental Plan Request for Reimbursement

Claims must be submitted within 180 calendar days of service date.

Please attach supporting documents behind this page.

PLEASE PRINT OR TYPE ALL ITEMS EXCEPT SIGNATURES

Patient's

Patient's

Name

Social Security Number

Date of Service

Fee for Current Service: $ Other Insurance Paid $

Services and Supplies Provided

Balance Paid:

$

Provider Name and Address: (rubber stamp suggested)

TO BE VERIFIED BY PROVIDER OF DENTAL SERVICES

Check Correct Statement Claim information has not been and will not be furnished to another carrier. Claim information has been or will be furnished to another carrier.

I certify that the services and supplies specified above were provided to the named patient on the date shown and for the fee shown.

Signature of Provider or Facsimile Signature:

Employee's Name

Social Security #

Mailing Address for Check:

TO BE COMPLETED BY EMPLOYEE

Work Location:

This plan is secondary to our medical plan and any other dental plan. Tumors, excision of

impacted teeth, and treatment of accidental injury to natural teeth (including their replacement)

may be covered by your medical plan. For the current services, can you file a valid claim under

our medical plan or another dental plan?

Attach a copy of insurance payment or denial.

Proof of Payment

Cash Receipt Cancelled Check Credit Card Ticket

I certifiy that the information provided on this form is accurate to the best of my knowledge and belief.

Employee Signature

Rev. 6/03 Dental.mab

Send or bring COMPLETED form with proof of payment to:

Hamilton County Department of Education Benefits Department 3074 Hickory Valley Rd. Chattanooga, TN 37421

HAMILTON COUNTY DEPARTMENT OF EDUCATION Dental Expense Reimbursement Program

Purpose

The purpose of the Dental Expense Reimbursement Program is to provide financial assistance for dental expenses for full-time employees and their families. Currently there is no charge to the employee for participation in the plan for either individual or family coverage.

Effective Date of Program

The Dental Expense Reimbursement Program is effective for dental service provided on or after February 1, 1986.

Enrollment and Eligibility

To be eligible, newly hired employees must elect coverage by completing the Enrollment Form within 30 days of date of hire. Coverage is effective the first of the month following 60 days of employment.

Employees who do not elect coverage when first eligible may enroll during the open enrollment period (October) and their coverage will begin on January 1 of the following year.

Coverage ends when the employee is no longer in an eligible class or employment terminates. Coverage may be continued for 18 months through COBRA.

Covered Dependent

Same as defined in our medical plan. An employee need not have dependent health coverage to receive dependent dental coverage.

Dental Expense Reimbursement Schedule

The Dental Expense Program will reimburse 80% of the first $250 of dental expense and then 50% of all additional expenses up to an annual maximum benefit of $1,000 per fiscal year per person for any dental expense not covered under our medical plan or any insurance plan. Reimbursement will be based on date of services and limited to amounts not paid by other plans. The plan is secondary to any other dental plan and to our own medical plan.

Covered Dental Expenses

All dental procedures are covered dental expenses if provided by or under the direction of a dentist licensed by the state in which he or she practices. Tumors, excision of impacted teeth, treatment of accidental injury to natural teeth (including their replacement) may be covered by your medical plan. If these services are provided to a spouse or child not covered by the medical plan, they will not be excluded from the dental plan.

Claim Procedures

An employee must first pay for the dental service and then complete a Dental Reimbursement Request form (available in the Benefits Department or at a County School) and submit this completed form along with a paid cash receipt, charge card receipt, or cancelled check, along with an explanation of benefits from applicable insurance plans. Reimbursement claim must be made within 180 calendar days of dental service in order to be considered for payment. Reimbursement checks will be issued within 20 working days from date of receipt of completed reimbursement form. Please call 498-7087 for detailed instructions for orthodontic claims. Falsification of records will be considered a fraudulent act.

Program Change Subject to agreement of the School Board and the HCEA, we reserve the right to make changes in the benefit levels, annual maximum, or other provisions of the program. Employees will be notified of changes at least one month in advance of the effective date of change.

Rev. 7/17 kmt

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download