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Dental Preferred Provider Organization (PPO) Plan
| How the United Concordia PPO Program Works | | Members may utilize participating and/or nonparticipating providers. | | There is a deductible of $50 per person/$150 per family per contract year, excluding Class I—Diagnostic and Preventive Services and Class IV—Orthodontic Services. | | There is a maximum benefit of $1,500 per member per contract year (July 1st-June 30th) for services received under the PPO plan. |
| When care is received from a United Concordia Advantage Plus* network dentist, there are no claim forms to submit and you are only responsible for coinsurance amounts. If you receive services from a nonparticipating provider, claims forms must be submitted and you are subject to balance billing. | | You do not need a referral to receive care from a specialist. | | Orthodontic benefits are available for dependent children. The orthodontia lifetime maximum is $2,000. Orthodontic services are available from participating and nonparticipating providers. | | If you reside in an area that does not have a United Concordia network of DHMO dentists, you must select the PPO plan in order to receive dental benefits from United Concordia. |
PPO Network of Providers
To receive in-network benefits, members must receive services from United Concordia's Advantage Plus* network. You always have the option of receiving care from non-network providers under the PPO plan.
Financial Responsibility of Plan Member
Deductibles and coinsurance are the responsibility of the plan member. Before you receive any services, be sure to review the plan design for your dental plan to ensure that you have anticipated all out-of-pocket costs and liabilities associated with a particular treatment. You are encouraged to discuss major procedures and your financial liability with your dentist. You may also contact United Concordia's Customer Service Department to determine your financial responsibility. If calling Customer Service, please have the ADA procedure code, provider's name and provider's charge available for the Customer Service Representative.
*Advantage Plus network available to Maryland and District of Columbia residents effective July 1, 2008.
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