Members who are enrolled in the Fund’s Exclusive Provider Network (EPN) Plan must obtain all dental care from a dentist that participates in the MPE Exclusive Provider Network (EPN) for covered services to be payable. The Fund’s Exclusive Provider Network (EPN) Plan is administered by DSM Insurance Services, a wholly owned subsidiary of Delta Dental of Massachusetts. Some of the dental procedures offered to members under the MPE Exclusive Provider Network (EPN) Plan are listed in the Paid-In-Full services and you do not pay anything when you receive these services. All diagnostic and preventive dental care is Paid-In-Full under the MPE Exclusive Provider Network (EPN) Plan.
Some dental procedures require payment of a fixed amount of money, which represents a portion of the actual cost of performing the service. These services are Co-Paid Services and are listed in the MPE EPN Plan Co-Paid services table. The MPE EPN Plan has a $1,600* annual plan maximum for each member and each eligible dependent. This is the maximum amount of money which the Fund will pay your dentists during the Plan Year which begins on July 1st of each year. However, payments for covered preventive and diagnostic services are not included in your annual plan maximum, nor are benefits paid for orthodontic services, periodontal scaling and root planing and immediate and complete dentures. Additionally, there is a separate plan maximum for surgical placement of an implant of $1,175.
*Commonwealth of Massachusetts Seasonal Employee annual plan maximum is equal to 50% of stated maximum
How to file claims under the EPN Plan
Your dentist will submit all claims to the MPE Unit at Delta Dental of Massachusetts. You will receive a written Explanation of Benefits statement (also called an EOB) whenever services are paid under the MPE Exclusive Provider Network (EPN) Plan. Please review each EOB statement carefully and immediately report any discrepancy to the MPE Unit at (800) 553-6277. You have the right to appeal any determination in accordance with the procedure noted on your EOB statement and in accordance with the Member Appeal Process.
How to protect yourself from unexpected dental costs
Prior to receiving treatment you should call the Fund Office at (800) 325-5214 to verify that you are enrolled in the MPE Exclusive Provider Network (EPN) Plan. You should also call the MPE Unit at (800) 553-6277 to confirm that the provider you selected still participates in the MPE Exclusive Provider Network. This is necessary since the list of MPE Exclusive Provider Network dentists is subject to change. Be sure to tell your dentist that you are a member of the MPE Exclusive Provider Network (EPN) Plan when you schedule an appointment.
It is your responsibility to confirm your dentist’s participation in the MPE Exclusive Provider Network (EPN) Plan. Failure to do so may result in your paying the dentist’s submitted charge.
If you make a dental appointment and circumstances prevent you from keeping this commitment, you must call the dentist’s office to cancel the appointment at least 24 hours in advance. Your dentist can bill you if you miss an appointment and do not cancel it at least 24 hours in advance.
Before undergoing any treatment which you consider costly, you should obtain prior approval by requesting that your MPE Exclusive Provider Network (EPN) dentist submit a pre-treatment estimate to the MPE Unit at Delta Dental of Massachusetts.
Call the MPE Unit to make sure that 6 months have passed since your last exam or cleaning and to check your proposed treatment costs against your annual limit.
How to receive dental services from a dentist that does not participate in the MPE EPN Plan
There is no out-of-network benefit under the MPE EPN Plan. This means that if you are enrolled in the MPE EPN and receive services from a provider that does not participate in the MPE EPN, there is no coverage for these services. In very specific situations (Approved Referral), the Fund may pay for covered services received from an out-of-network provider. Under an Approved Referral, a referral must be made by your MPE EPN dentist and that referral for specific services must be authorized by the MPE Unit prior to treatment. The following steps must also be followed for coverage to be provided under an Approved Referral:
- You must be a patient of record, as defined by the Fund, with a general dentist within the MPE Exclusive Provider Network (EPN). A patient of record is defined by the Fund as a general dentist who you have visited during the past 12 months for treatment and/or evaluation.
- Your MPE Exclusive Provider Network (EPN) dentist will refer you to a specialist for either (1) a consultation or evaluation, or (2) a specific service(s). If there is a specialist that participates in the MPE EPN, you will be required to obtain these services from the participating provider. If there is no specialist in the network, the out-of-network referral must be approved by the MPE Unit prior to receiving treatment.
- There is a six month time limitation on all approved out-of-network referrals. If you receive services after the six month time limit, you will be responsible for the out-of-network provider’s fee.
- If the out-of-network specialist determines that you require additional treatment that was not approved on the initial out-of-network referral, the specialist must contact your MPE Exclusive Provider Network dentist. If your MPE EPN dentist is not able to perform these services, s/he must call the MPE Unit for approval of an out-of-network referral for the specific services prior to treatment.
- Payments made to an out-of-network provider for authorized services when a referral has been approved are subject to a maximum allowable fee. Patients will be responsible for the difference between the maximum allowable fee and the submitted fee and any plan co-payment. You may ask the specialist to submit a pre-treatment estimate prior to receiving services so that you understand your financial responsibility.
- If no referral was made, or if a referral was not pre-approved, you may be responsible for the dentist’s submitted charge.
How to receive dental services in an emergency
To receive services in an emergency, you must:
1. Call a participating MPE Exclusive Provider Network (EPN) dentist. Each office is prepared to handle emergency situations. If one of the MPE EPN dentists cannot deliver prompt emergency service, s/he will refer you to another dentist, and;
2. Confirm that this dentist participates in the MPE Exclusive Provider Network (EPN) by calling the MPE Unit at (800) 553-6277.
3. If you receive care outside of normal business hours and are unable to contact the MPE Unit, you must verify with the dental office that they participate in the MPE Exclusive Provider Network (EPN) as no benefits are payable to an out-of-network provider. You must also call the MPE Unit at (800) 553-6277 prior to receiving any additional treatment to verify the dentist’s participation in the MPE Exclusive Provider Network (EPN) and to inquire about your co-payment.
4. If you are out of state and have an emergency, you must call the MPE Unit at (800) 553-6277 and they will advise you on how to proceed. The maximum amount payable to an out-of-network dentist in an emergency situation will be for Palliative Treatment.
If you do not follow these procedures, you will be responsible for the dentist’s submitted charge. No benefits will be payable for services received from an out-of-network provider unless you have received both a referral for specific services from an MPE Exclusive Provider Network (EPN) dentist and an approval of that referral by the MPE Unit at (800) 553-6277.
