A PPO, or Preferred Provider Organization, has a network of providers like an HMO; however, you don't have to use the preferred provider. If you choose a provider that is not in the preferred network coverage is reduced but not eliminated completely. PPO dental plans have deductibles, co-pays, and premiums as well, and are often a bit more than HMO fees. Basically, you are paying more for the added choices and flexibility in the plan. Many people prefer the PPO dental plans because of the flexibility.

No, you can receive care from any dentist you choose. But remember, you will pay more if the dentist you choose is not a “preferred" provider.

No, it is not necessary to obtain a referral from your dentist to visit a specialist. However, it is always a good idea to discuss treatment options with your dentist before consulting a specialist. Also, be sure to request a predetermination of costs before treatment to know what your out-of-pocket costs might be.

These are all terms that apply specifically to out-of-network claims for both your medical and dental plans. All insurance companies use a national database that tells you what 8 out of 10 providers within a certain area are charging for services. This national database takes into account that the cost of living and cost of services will vary by geographic region.

This NEVER applies if you are using in-network providers. They MUST accept the insurance company’s payment in full (less any deductible or coinsurance you may be responsible for). Out-of-network providers, however, can charge whatever they want. No rules apply to them!

If you go out-of-network, then the insurance company will only pay the “reasonable and customary” reimbursement rate for that service. If a member happens to be using a particularly expensive provider that is charging more than the “reasonable and customary” fees, then the member will be responsible for the deductible and coinsurance amount PLUS any charges in excess of R&C.

R&C (Reasonable and Customary) Example:

• An out-of-network dentist is charging $500 for a root canal.
• Your out-of-network benefits have a $50 deductible and 80% coinsurance.
• If 8 out of 10 dentists in your local area are only charging $400 for root canals, then $400 is the “R&C” amount that the insurance company is going to reimburse your dentist no matter how much he or she charges you. In other words, your dentist is charging $100 over the approved R&C amount - or $100 more than the “going rate” in your area!

The Dental Claim Would Be Paid as Follows:

• The total root canal bill is $500.
• The R&C amount for a root canal is $400.
• Deductible is calculated first: $400 minus your $50 deductible= $350.
• The insurance company will pay 80% of $350 ($280).
• You pay 20% of $350 ($70).
• You also pay the $50 deductible AND the difference between the total bill and R&C ($100).
• Your total cost would be $50 +$100 + $70 = $220.
• Remember that R&C is never an issue as long as the employee uses in-network dentists.

You have an option between Sierra Healthcare Options Dental (SHO), which has  local area network only, and Delta Dental, which is has a national network of dental providers.  Depending on the dental plan you have selected, you can find an in-network dentist by visiting either the directory of Southern Nevada SHO Dental providers, directory of Northern Nevada SHO Dental providers, or the Delta Dental provider search.  

Always remember to confirm with the dental office when you make your appointment AND before you receive services that they still are still an in-network provider your dental PPO plan!  It is your responsibility to make sure you are using in-network dentists if you want to receive in-network benefits!

If your dentist is not currently participating in the network, but would like to know more about the advantages of participation, please ask him or her to call your insurance provider using the number on your ID Card.

Yes. Just ask your dentist to submit a “pre-treatment estimate” – A pre-treatment estimate is a good idea if you are having extensive work done and want to know what your share of the cost will be. Also, you can find out if the procedures are covered, if you will exceed your annual benefit maximum, and how to best plan your payment portion.

Participating dentists will file claims for you. Non-Participating dentists do not have to file your claims for you. Some of them will and some of them will not – it really depends on the (out-of-network) dentist.

If the non-participating dentist will not file your claim, you will have to file for non-network reimbursement.

You can visit another dentist for a second opinion and you will be reimbursed according to your plan benefits. For maximum savings, visit a PPO network dentist.

If you are a Sierra Healthcare Options Dental member, you can call Member Services at the number on the back of your UMR insurance card [(800) 884-0793]and request a new ID Card to be sent to your home, or you can visit the UMR member portal to print a copy for yourself and request that new hard copies be mailed to your home.  Be sure to verify that the carrier has correct information on file such as addresses, telephone numbers, the correct members enrolled, and etc.  If you have Delta Dental, you can call (800) 521-2651, or log into the Delta Dental portal at  www.deltadentalins.com to request a new card.

1. Call the plan administrator at the number on the back of your insurance card and ask the customer service representative to help you understand why the claim was paid the way it was.
   
   
2. Make sure to write down the person's name and ask them if your call is being tracked so that if you ever have to call again, there is a record of the conversation and the information they are giving you!
   
   
3. Confirm that you and your family are enrolled properly into the plan administrator's system.  If there is a problem with your basic enrollment information, contact the COH Benefits team at (702) 267-1944 or MyCOHBenefits@cityofhenderson.com and ask them to correct it for you.
   
   
4. Once the administrative error is fixed, you can call the plan administrator again (when they can see your correct information) and ask them to re-process your claim.
   
   
5. If there is no resolution after calling customer service, get copies of all related paperwork including claims, bills, collection notices, EOB’s (Explanation of Benefits) and anything else that is relevant and call or e-mail Benefits for assistance.  Keep copies of everything in case you ever have to contest a credit rating problem as a result of a collection issue. If you are proactive and address these issues right away, then 99% of the time the issue can be resolved before it goes to collection.

Open enrollment will occur once a year from November 1st - November 30th.  Each year during this Open Enrollment period, you may change your benefit elections. Once you have made your selection, you may not change it until the next year's open enrollment unless you have a qualifying life event (QLE).  QLE's include:

• Marriage
• Divorce or legal separation
• Birth
• Adoption or legal placement of a child
• Death
• Spouse losing coverage at their place of employment
• Child losing coverage due to reaching the age limit

You must notify the Benefits team in writing within 30 days to request a change in your benefit elections.  The Benefits team will need the reason for the change, appropriate documentation, and the effective date of change.