Freedom Plans Administrative Manual

SORTCO, INC. GROUP #1043

TABLE OF CONTENTS

Tab 1 General Information----------------------------------------------------------------- 4 Tab 2 NEVADA PACIFIC DENTAL - A New Approach to Dental Care ------- 6 Tab 3 Submitting Enrollee Eligibility--------------------------------------------------- 9

Electronic File Submissions and Transfers -------------------11 NEVADA PACIFIC DENTAL Electronic File structure ------12 Magnetic File Specification -----------------------------------------Appendices Hard Copy or Manual Report ---------------------------------------13 Tape - Diskette Shipping Protocol --------------------------------14

Tab 4 Instructions for New Enrollees --------------------------------------------------16 Tab 5 Glossary of Common Dental Terms -------------------------------------------18 Tab 6 Glossary of Common NEVADA PACIFIC DENTAL Terms --------------23 Tab 7 NEVADA PACIFIC DENTAL Cut-Off Dates-----------------------------------28 Tab 8 NEVADA PACIFIC DENTAL Contacts -----------------------------------------30 Tab 9 Exhibits

Things to Remember -----------------------------------------------------------32 Most Common Questions-----------------------------------------------------33 Enrollment / Change Form ---------------------------------------------------35 Current Provider Directory ---------------------------------------------------Appendices EDI Optimal Layout File Format --------------------------------------------Appendices

GENERAL INFORMATION

General Information

GROUP INFORMATION:

Group Name: Sortco, Inc. Your Group Number(s): 1043 Effective Date: June 1, 2004 WHO TO CALL IN NEVADA: Your Account Representative: Roxanna Whitehead ---------------- (702) 737-6681 NPD Fax #-------------------------------------------------------------------------- (702) 259-0904 Toll-free Number: --------------------------------------------------------------- (800) 926-0925 INSTRUCTIONS FOR MAILING: What To Send: Where To Send It: Electronic Submission PACIFIC DENTAL BENEFITS, INC. Manual Reports/Hard Copy 1390 Willow Pass Road, Suite 800 Enrollment / Change Forms Concord, CA 94520-5240 Premium Payment NEVADA PACIFIC DENTAL, INC. P.O. Box 993

Las Vegas, NV 89125

Other Correspondence NEVADA PACIFIC DENTAL, Inc. 1432 South Jones Blvd. Las Vegas, NV 89146

NEVADA PACIFIC DENTAL A NEW APPROACH TO DENTAL CARE

N EVADA PACIFIC DENTAL – A New Approach to Dental Care In an age of rising dental care costs, NEVADA PACIFIC DENTAL offers an alternative way to provide for you and your family’s dental care needs -- economically and conveniently through NEVADA PACIFIC DENTAL. NEVADA PACIFIC DENTAL was founded on the principle of delivering quality dental care and preventing dental problems before they start. NEVADA PACIFIC DENTAL has contracted with a network of private dental offices. A listing of these Exclusive Network offices is enclosed. As a member of the NEVADA PACIFIC DENTAL Plan you select one office from any of these dental offices for you and your family’s needs. This network of dental offices is composed of established dental practices. It has been found that most people feel more secure if the same dental office is providing for their family’s treatment. Your NEVADA PACIFIC DENTAL FREEDOM PLAN also gives you and your family members the option to receive care at any licensed dentist in the U.S. Please review your Plan materials for information on this option. A deductible, annual maximum, exclusions and limitations will apply. IN-NETWORK PLAN ADVANTAGES No Claim Forms

The dental location you choose provides all primary dental services. There are no claim forms to complete or percentage of usual charges for you to pay. No Deductibles T

here is no required deductible to pay so your benefits begin immediately.

No Maximum T

here is no annual maximum of benefits for you or your eligible dependents.

No Pre-Existing Conditions Restricted The NEVADA PACIFIC DENTAL Plan does not have pre-existing condition exclusion. The only exceptions to this would be work in progress - preparation for crowns/root canals, impressions for dentures, etc., orthodontic treatment in progress or the replacement of long tanding missing tooth/teeth in an otherwise stable dentition. s

Managed Care Plan Saves on Dental Cost Your out-of-pocket savings are substantial. You know the exact cost prior to treatment and this aids in better fiscal planning for you and your family. Your "out-of-pocket" expense (copayment) is the same whether a NPD contracted general dentist or specialist performs the service. Quality Review of Dental Providers On site audits of participating dental locations are performed to ensure that established standards of quality are maintained.

NEVADA PACIFIC DENTAL – A New Approach to Dental Care

Continued Specialty Services The NEVADA PACIFIC DENTAL Plan offers services in dental specialty areas. These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy), and oral surgery procedures. To receive IN-NETWORK benefits, you must be under the care of a NPD Exclusive Provider. Specialty care must be pre-authorized by NPD. OUT-OF-NETWORK PLAN ADVANTAGES May Be Used At Any Dentist You choose your own dentist to receive dental services. Benefit Allowance Fixed In Advance After meeting your deductible, your benefit pays a specific amount, so your dentist can tell you your exact “out-of-pocket” expense, up to your annual maximum.

NEVADA PACIFIC DENTAL – A New Approach to Dental Care

Continued

HOW IT WORKSWhen you enroll in NEVADA PACIFIC DENTAL, select an Exclusive Network dental office from the list in this brochure. This location is now the center for your entire dental needs. After you have enrolled and are eligible for benefits, to receive all necessary dental care covered by the Plan, simply call your chosen dental provider to make an appointment and begin a plan of treatment. To receive your IN-NETWORK benefits, you must contact your selected Exclusive Network dental office. Dental services that are not performed by your Exclusive Network dentist or prior authorized by NEVADA PACIFIC DENTAL Plan will not be covered by the NEVADA PACIFIC DENTAL Plan. WHO CAN JOINIf you meet your employer’s eligibility requirements for dental coverage you can enroll in NEVADA PACIFIC DENTAL. You can also enroll your eligible dependents, which include your lawful spouse and/or unmarried children. Dependent children include: 1) All natural, 2) Adopted, 3) Step-children. Automatic coverage is provided for mentally and/or physically challenged dependent children. You must enroll you and your dependents in the Plan within 31 days of becoming eligible for benefits. If you do not enroll at that time, you will not be able to enroll or add dependents until

your organization’s annual Open Enrollment. Employees may add dependents immediately if there is a “qualifying event” , i.e. birth of child, adoption of child, or marriage. All newly eligible dependents must be added within 31 days of the “qualifying event.” SUMMARY OF BENEFITSThe NEVADA PACIFIC DENTAL Plan provides all reasonable and customary dental care, subject to the master contract provisions, limitations and exclusions, out-of-network deductible, and out-of-network annual maximum. (See Description of Benefits, In-Network Copayments, &

ut-of-Network Allowances.) O Note: This is only a brief summary of the Plan. The Group Subscriber Agreement and Evidence of Coverage must be consulted to determine the exact terms and conditions of coverage.

SUBMITTING ENROLLEE ELIGIBILITY

SUBMITTING ENROLLEE ELIGIBILITY

ENROLLMENT NEVADA PACIFIC DENTAL can facilitate either electronic (EDI) or manual eligibility. If you would like to switch methods of submitting eligibility at any time, please remember that we need 30 days notice if you are going from EDI to manual and 90 days notice if you are going from manual to EDI. Manual For every enrollee, an enrollment card needs to be completed. NEVADA PACIFIC DENTAL can supply these forms. The employee needs to fill out all the information on the upper part of the enrollment card and submit to his/her Human Resource/Benefits department, making sure to select what action is taking place (address change, new enrollment, add dependent, termination, etc.). Please make sure to include the effective date the action should take place. Enrollment cards can be sent in with the bill or separately at any time during the month. A card received by the 20th of the month is guaranteed to make the provider’s eligibility list. The enrollment cards can be sent directly to:

NEVADA PACIFIC DENTAL Enrollment Department 1432 South Jones Blvd.

Las Vegas, NV 89146 Please remember that depending on when the information is received, it may not reflect on the next bill. If the bill does not reflect the changes, please mark the bill appropriately. ADDITIONS: At the end of the bill please list the adds. Please include:

Enrollee’s Social security number Enrollee’s Name (first and last) Number of members in the family being covered Premium rate Month/year for which this enrollee is to be effective

All additions must fill out an enrollment card, if they have not already done so.

TERMINATIONS:

Please draw a line through the person’s name that you wish to terminate. Next to the name, please include the termination date. Enrollees terminated during the month are eligible through the last day of that month unless otherwise specified in your contract.

CHANGES (Name or Social Security):

Please draw a line through the incorrect information and write the correct information next to it.

CHANGES (Rate): Please indicate the new rate and who is being added or terminated. When adjusting the billing total, please remember to determine the difference between the current rate and what the new rate is. Remember to complete an enrollment card when adding and/or deleting a spouse/dependent.

Once all the changes have been noted on the bill, please adjust the total appropriately. Please remember our standard contract only allows for 90 days of retroactivity. The adjusted bill should accompany the payment. This will ensure proper posting of your payment to your account. Please send the payment and the adjusted bill to:

NEVADA PACIFIC DENTAL P.O. Box 993

Las Vegas, NV 89125 NEVADA PACIFIC DENTAL encourages the use of Electronic Data Interface (EDI) as an effective means of delivering the membership/eligibility information. In order to qualify for the electronic method, your company needs to have a minimum of 200 employees enrolled with NEVADA PACIFIC DENTAL. Our Information System (IS) department has the capability to handle multiple media types and file transfer technology including FTP, magnetic media and email. Many of our larger groups are presently utilizing the electronic method to administer their eligibility. NEVADA PACIFIC DENTAL can handle a variety of eligibility submissions, including monthly, semi-monthly, and weekly. The obvious benefit of timely processing has resulted in improved coordination between your group and us. NEVADA PACIFIC DENTAL maintains a standard Eligibility and Enrollment file layout (see Appendix B), which provides a basis for your data’s immediate assimilation into our system. If your system capabilities do not allow for customization to meet our file layout, our analysts will work with your system representative to develop a mutually attainable layout.

Electronic File Submissions and Transfers NEVADA PACIFIC DENTAL encourages the use of Electronic Data Transfer (EDT) as an effective means of delivering our members data. Our Information Systems (IS) Department has the capacity to handle multiple media types and file transfer technologies, including FTP, magnetic media and email. Eighty percent of the enrollment and eligibility administration done by NEVADA PACIFIC DENTAL administrators is presently conducted via Electronic Data Interchange (EDI) with our clients. Formats that report on a variety of eligibility periods (weekly, semi-monthly or monthly) are routinely supported within our administration framework. The benefits of timely processing have resulted in greatly improved coordination between the Client and the Administrator, and provide a much greater measure a data security by eliminating the postal delivery of confidential data.

NEVADA PACIFIC DENTAL, INC., Electronic File Structure

Thank you for choosing electronic file transfer as the means of communicating period eligibility for members who have selected NEVADA PACIFIC DENTAL. We believe this medium to be the most efficient and secure method of moving and sharing data, and hope to be able to serve our members better as a result of getting timely, sanctioned eligibility from you, the authorized administrator. Please review the accompanying file layout in regards to your capacity to deliver eligibility in this, our standard format. Please call our Information Services Department if you have any questions on the file structure. We look forward to working with you. TRANSFER MEDIA The file will be acceptable to NEVADA PACIFIC DENTAL in one of four media types: 1). FILE TRANSFER PROTOCOL (FTP) Files will be posted to a secure FTP site SafeTP is recommended Server/Client software 2. NINE TRACK TAPE EBCDIC 1600 BPI RECORD SIZE : 170 BLOCK SIZE : 10 Records per block 3. E-MAIL ATTACHMENT ASCII file attachment to Internet E-MAIL: EDI@pdbi.com 4. PC DISKETTE Double Sided - 1.2 MB High Density 5 1/4” Standard Double Sided - 1.44 MB High Density 3 1/2” Standard

Hard Copy or Manual Report A hard copy or manual report is a list generated by you each month comprising your eligible enrollees. This list should be sent to NEVADA PACIFIC DENTAL Plan prior to the 15th of the month. NEVADA PACIFIC DENTAL Plan will perform a comparison of the members on our system to the list of members you provided. After the two lists have been compared, NEVADA PACIFIC DENTAL Plan will run a preliminary run which provides the staff the opportunity to

correct any problems before the system is actually updated. Once the preliminary run has been approved by a Supervisor, the NEVADA PACIFIC DENTAL Plan system is updated with the changes. The Enrollment / Change forms may be sent at any time during the month if you wish to expedite our entering the members on our system. These forms should be sent directly to:

NEVADA PACIFIC DENTAL 1432 SOUTH JONES BLVD. LAS VEGAS, NV 89146

Any time you send an enrollment card to NEVADA PACIFIC DENTAL you must ensure that the member is included on the hard copy of the manual report being sent or they will be terminated. Note: Including dependent information on your report is optional. All changes with respect to dependents should be on an Enrollment / Change form.

Tape/Diskette Shipping Protocol

Please note: The tape/diskette should be clearly marked on the outside packaging with the following information:

• Name of Group • Group Number • Eligibility Month • Return Address • Number of Records • Label Type

The tape/diskette should contain complete eligibility. Any employee that appears on our system but is not on your tape will be terminated. However, all terminating employees, whether retroactive or current, should be reported to us once with a term date and then be excluded from future tapes/diskettes. Tapes/diskettes should have NEVADA PACIFIC DENTAL eligibility only and the file names should be consistent.

INSTRUCTIONS FOR NEW ENROLLEES

Instructions for New Enrollees

Customer Service If you have questions about the plan benefits or how to use the NEVADA PACIFIC DENTAL Plan, please call our Customer Service Department toll free at 1-800-926-0927 or (702) 737-8900. Contacting Your Chosen/Assigned Exclusive Network Dental Provider If you have forgotten which dental office you have chosen or if you have transferred to another dental provider, please call (702) 737-8900 or 1-800-926-0925 toll-free to verify your dental provider. Enrollees must go to their chosen dental provider from the NEVADA PACIFIC DENTAL Plan Provider Directory in order to receive the In-Network Benefits under the Plan. You do not need an ID card in order to make an appointment with your dental office. Simply call your dental office and make any necessary appointments to begin a plan of treatment. Specialty Care In-Network benefited specialty care is provided by an Exclusive Network of dental specialists. If specialty care is required, the provider will request authorization from NEVADA PACIFIC DENTAL Plan and will refer the enrollee to the appropriate specialist. All specialty care must be pre-authorized by NEVADA PACIFIC DENTAL. Out-of-Network specialty care will be benefited at the Out-of-Network Schedule of Allowances (please see your Benefit brochure for specific amounts.) Changing Dental Providers Enrollees may change dental providers as needed. This can be done by calling our Customer Service Department at (702) 737-8900 or 1-800-926-0925. The change will be effective on the first day of the following month. Enrollees should not request a change of dental providers if they are in the middle of treatment or owe money to their current NPD provider. The Customer Service Department can advise the enrollee on the definition of the “middle of treatment”.

Instructions for New Enrollees

Continued Claim Forms, Deductibles, Maximums or Pre-Authorizations There are no claim forms, deductibles, dollar maximums or pre-treatment authorizations, with the exception of specialty care, for the NEVADA PACIFIC DENTAL In-Network benefits. Out-of-Network benefits require the submission of a claim form, and also have deductibles to meet, an annual maximum to limit care, and preauthorization is recommended. Pre-Existing Conditions NEVADA PACIFIC DENTAL Plan does not have a pre-existing condition exclusion. However, coverage is not provided for any treatment started after termination of eligibility for coverage; and dental expenses incurred for treatment in progress prior to the enrollee’s eligibility with NEVADA PACIFIC DENTAL (e.g.: teeth prepared for crowns, root canals in progress, orthodontia, fixed and removable prosthetics). Please check your group contract. NEVADA PACIFIC DENTAL will not replace long standing missing tooth/teeth in an otherwise stable dentition. Enrollment / Change Form An Enrollment / Change form is available for the enrollee’s convenience when they wish to update their personal information on the NEVADA PACIFIC DENTAL Plan system. Note: If a member owes the previous dental office a balance for copayments or “no show” fees, the balance must be paid before NEVADA PACIFIC DENTAL Plan will proceed with their transfer to another dental office.

GLOSSARY OF COMMON DENTAL TERMS

Glossary of Common Dental Terms

AbutmentA tooth or implant used to support a prosthesis. AmalgamAn alloy used in dental restorations; includes mercury. AnteriorRefers to the teeth in the forward part of the mouth - incisors and canines. Bitewing RadiographInterproximal view radiograph of the coronal portion of the tooth. BridgeA fixed bridge is a prosthetic replacement of one or more missing teeth usually cemented to the abutment teeth adjacent to the space; removable bridge (partial denture) is a prosthetic replacement of one or more missing teeth on a framework that can be removed by the patient. Caries Correct technical term for decay. CavityLesion or hole in tooth caused by caries. Crown Part of the tooth that is covered with enamel and normally projects beyond the gingival margin; artificial replacement is called by the same name. CurettageScraping or cleaning of the walls of a cavity or gingival pocket. Dental ProphylaxisScaling and polishing procedure performed to remove coronal plaque, calculus and stains. Denture An artificial substitute for natural teeth and adjacent tissues. Fracture A breaking of a part, especially of a bony structure, breaking of a tooth.

Glossary of Common Dental Terms Continued Gingiva Soft tissues overlaying the crowns of unerupted teeth and encircling the necks of those that have erupted, serving as the supporting structure for sub-adjacent tissues. Gingivectomy The excision or removal of gingiva Impacted ToothAn unerupted or partially erupted tooth that is positioned against another tooth, bone or soft tissue so that complete eruption is unlikely. Maintenance PeriodontalTherapy for preserving the state of health of the periodontium. MalocclusionImproper alignment of biting or chewing surfaces of upper and lower teeth. Occlusion Any contact between biting or chewing surfaces of upper and lower teeth. PalliativeAction that relieves pain but is not curative. Partial DentureUsually refers to the prosthetic device that replaces the missing teeth on a framework that can be removed by the patient. Pontic The term used for the artificial tooth on a bridge. ProphylaxisScaling and polishing procedure performed to remove coronal plaque, calculus and stains. QuadrantOne of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth; usually includes five or more teeth.

Glossary of Common Dental Terms Continued

Reline Process of resurfacing the tissue side of a denture with a new base material. Retainer Orthodontic retainer - appliance to stabilize teeth following orthodontic treatment; prosthodontic retainer - a part of a fixed bridge that attaches a pontic to the abutment tooth. Root Canal Therapy Treatment of the pulp cavity to eliminate periapical disease and to promote healing and repair of periapical tissues. Root Planing A procedure designed to remove microbial flora, bacterial toxins on the root surface or in the pocket, calculus and diseased cementum or dentin. Scaling Removal of plaque, calculus and stain from teeth. Study Model Plaster or stone model of teeth and adjoining tissues; also referred to as diagnostic cast. Temporomandibular Joint (TMJ) The connecting hinge mechanism between the mandible (lower jaw) and base of the skull (temporal bone).

GLOSSARY OF COMMON

NEVADA PACIFIC DENTAL TERMS

Glossary of Common NEVADA PACIFIC DENTAL Terms Audit An examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims. Benefit The dental service or procedure covered by the Plan. Benefit Booklet/Schedule A booklet or pamphlet provided to the subscriber which contains a general explanation of the benefits and related provisions of the managed care dental program. Consult the Benefit Schedule for a complete description of your benefits, limitations and exclusions of the plan. Claim Form The form used to file for benefits under a managed care dental program; includes sections for the patient and the dentist to complete. The completed form serves as the basis for payment of benefits. Exclusive Network An Exclusive Network dental benefits plan exists when patients eligible to receive benefits can receive them only if services are provided by dentists who have signed an agreement with the benefits plan to provide treatment to eligible patients. As a result of the dentist reimbursement methods characteristic of an Exclusive Network plan, only a small percentage of practicing dentists in a given geographical area are typically contracted by the Plan to provide dental services. Consolidated Omnibus Budget Reconciliation Act (COBRA) Legislation relative to mandated benefits for all types of employee benefits plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents who would otherwise lose coverage. Contract A legally enforceable agreement between two or more individuals or entities which confers rights and duties on the parties. Common types of contracts include: 1) contracts between a dental benefits organization and an individual dentist to provide dental treatment to members of an alternative benefits plan. These contracts define the dentist’s duties both to beneficiaries of the dental benefits plan and the dental benefits organization and usually define the manner in which the dentists will be reimbursed; and 2) contracts between a dental benefits organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits. Contract Dentist A licensed dentist that contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements.

Glossary of Common NEVADA PACIFIC DENTAL Terms

Continued

Coordination of Benefits (COB) A method of integrating benefits payable under more than one plan. Benefits from all sources should not exceed 100% of the total charges. Copayment Enrollee’s share of the dentist’s fee. Covered Charges Charges for services rendered or supplies furnished by a dentist that qualify as covered services and are paid for in whole or in part by the managed care dental program. May be subject to deductibles, copayments, coinsurance, annual or lifetime maximums or table of allowances, as specified by the terms of the contract. Covered Person An enrollee who is eligible for benefits under a managed care dental program. Customary Fee The fee level determined by the administrator of a dental benefits plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure. (See also Usual Fee and Reasonable Fee). Dependents Includes legal spouse and children of the primary enrollee, as defined by terms of the dental benefits contract. Dual Choice Program A benefits package from which an eligible individual can choose to enroll in either a managed care dental program or an indemnity dental program. Eligibility Date The date an individual and/or dependents become eligible for benefits under a dental benefits contract. Often referred to as effective date. Examination Complete examination - a dentist thoroughly evaluates the state of health of the patient including a thorough examination of the hard and soft tissues of the oral cavity and continguous structures. This includes but is not limited to the use of diagnostic information acquired through interpretation of appropriate dental radiographs; may also include pulp vitality test, transillumination, study models and laboratory tests, when indicated. Limited examination - a dentist thoroughly evaluates the state of health of the patient and includes an

Glossary of Common NEVADA PACIFIC DENTAL Terms

C

ontinued

evaluation of the hard and soft tissues of a portion of the oral cavity. Includes but is not limited to the use of diagnostic information acquired through interpretation of selected dental radiographs; may also include diagnostic information acquired through interpretation of other diagnostic tests as indicated. Exclusions

Dental services not covered under a managed care dental program. Expiration Date 1) The date on which the dental benefits contract expires. 2) The date an individual ceases to be eligible for benefits. Explanation of Benefits A written statement indicating the benefit/charges covered or not covered by the dental benefits plan. Indemnity Plan A dental plan where a third-party provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or by assignment, directly to dentists. Schedule of Allowances, Table of Allowances or Reasonable and Customary plans are examples of indemnity plans. Limitations Restrictive conditions stated in a dental benefits contract, such as age, length or time covered and waiting periods, which affect an individual’s or group’s coverage. The contract may also exclude certain benefits of services or it may limit the extent or conditions under which certain services are provided. (See Exclusions). Managed Care Dental Plan A program that manages patient care through clinically accepted treatment guidelines and phasing of treatment based on the patient's unique dental needs and personal oral hygiene. Medicare A federal insurance program enacted in 1965 at Title XVIII of the Social Security Amendments that provides certain inpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals. The program is administered by the Health Care Financing Administration. Member An individual enrolled in a managed care dental program.

Glossary of Common NEVADA PACIFIC Dental Terms Continued Necessary Treatment A necessary dental procedure or service as determined by a dentist to either establish or maintain a patient’s oral health. Such determinations are based on the professional diagnostic judgment of the dentist and the standards of care that prevail in the professional community.

Open Enrollment The annual period in which employees can select from a choice of benefit programs. Preauthorization Statement by a third-party indicating that proposed treatment will be covered under the terms of the dental benefits contract. (See also Predetermination).

Predetermination An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient’s eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, copayment and/or maximum limitation. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200. Also known as preauthorization, precertification, pretreatment review or prior authorization. Quality Assurance The assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered. Reasonable Fee The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances and therefore, may differ from the dentist’s “usual” fee or the benefit administrator’s “customary” fee. Subscriber The person, usually the employee, who represents the family unit in relation to the managed care dental program. This term is most commonly used by service corporation plans. Also known as: certificate holder or enrollee. Usual Fee The fee that an individual dentist most frequently charges for a given dental service. (See also Customary Fee and Reasonable Fee).

CUT-OFF DATES

NEVADA PACIFIC DENTAL Cut-Off Dates

The following cut-off dates have been established for the year 2004. Please adhere to these dates when submitting enrollment forms or using electronic file submission to ensure that the dental offices are properly notified of your eligible members: SUBMIT FORMS BY TO BE ELIGIBLE BY

January 20, 2004 February 1, 2004

February 20, 2004 March 1, 2004 March 20, 2004 April 1, 2004 April 20, 2004 May 1, 2004 May 20, 2004 June 1, 2004 June 20, 2004 July 1, 2004 July 20, 2004 August 1, 2004 August 20, 2004 September 1, 2004 September 20, 2004 October 1, 2004 October 20, 2004 November 1, 2004 November 20, 2004 December 1, 2004

NEVADA PACIFIC DENTAL CONTACTS

NEVADA PACIFIC DENTAL Plan Contacts

Our systems are designed to accommodate all routine and non-routine situations. Please consult the following listing to determine the appropriate department that can best assist you when contacting our office. If you feel it necessary to bypass our automated routine system, or if your request requires special handling, please contact your Account Executive or Marketing Services: Administrative Services Roxanna Whitehead, (702) 737-8900,

Ext.213 Cathie Davenport, Ext 211

Ted DeCorte, Ext. 210 Routine Benefit Determination Customer Service, (702) 737-8900 Member Transfers Customer Service, (702) 737-8900 Routine Quality Assurance Grievances Susy Storms, Ext. 212 Routine Claims, Pre-Authorizations Customer Service, (702) 737-8900 Emergency Referrals Customer Service, (702) 737-8900 Eligibility Processing (Bills, Tapes, Hard Membership/Enrollment Department Copies) and Reconciliations 1-800-999-3367 Eligibility Problems or Issues Administrative Services, (702) 739-6681 Electronic File Submission Questions or Enrollment/Eligibility Layout Changes Carin Olson, 1-800-999-3367

Ext. 6062 Re-Issuing of Bills Membership/Enrollment Department 1-800-999-3367 Call us between the hours of 8:00 AM and 5:00 PM at our toll free numbers:

(800) 926-0925 or (702) 737-8900 /Customer Service (800) 926-0925 or (702) 737-6681 / Administration

NPD Fax Number(s): (702) 259-0904 - Enrollment Department Customer Service/Claims Department

Marketing Department Plan Information Can Be Found On the Web @ www.npdofnevada.com

EXHIBITS

Things to Remember

1. Timing is critical to ensure that your eligible members appear on the dentist’s eligibility

list and your following month’s NEVADA PACIFIC DENTAL Plan billing. 2. Submit your electronic file to NEVADA PACIFIC DENTAL Plan by the 15th of each

month. 3. Enrollment cards can be sent to NEVADA PACIFIC DENTAL any time during the

month, however, you should refer to the cut-off dates to ensure that the members appear on the doctor’s eligibility list.

4. “NO SHOW” Appointment Fee: If a member fails to keep a scheduled appointment

without 24 hours notice, they will be charged a “no show” appointment fee. The member will be required to pay this “no show” fee before they can set up any further appointments with the dental office, or transfer to another office.

5. NEVADA PACIFIC DENTAL Plan retroactive credits for up to three months providing

the amount of the credit does not exceed 10% of the billed amount. 6. Dental type changes should be made directly on the NEVADA PACIFIC DENTAL

Benefits billing. 7. You must notify NEVADA PACIFIC DENTAL when changing your method of submitting

eligibility. If you send your eligibility electronically, and you are changing your current layout, you must notify NEVADA PACIFIC DENTAL at least a month ahead of time and submit a test file at that time.

8. If submitting a manual or hard copy report, you should identify the additions,

terminations and changes separately to expedite processing. PLEASE NOTE: Enrollment cards must accompany all additions.

9. Enrollment cards should include the group number and effective date of the employee.

10. If a member does not select a dental location, one will be selected for him using his zip code. This can be changed by contacting the Customer Service Department at (702) 737-8900 or 1-800-926-0925.

22 Most Common Questions

Q. Who is NEVADA PACIFIC DENTAL? NEVADA PACIFIC DENTAL is Nevada's largest managed care dental benefit organizations. We have created a Plan that offers our members quality dental health services at significant savings. We have contracted with quality, local dental professionals to provide services to you and your eligible dependents at no cost or for low fixed copayments. Under this Plan, there are no claim forms to complete, no deductibles to be met and no yearly dollar maximum of coverage. An Out-of-Network benefit is also available.

Q. My dentist is not on the list. Can I still use Him?

Not all dentists have contracted with NEVADA PACIFIC DENTAL. To benefit from the significant savings provided with this particular Plan, you must choose a dental office from our list of dental providers. If you use a dentist who is not on our provider directory - your services will be covered under your Out-of-Network schedule of allowances.

Q. Who do I call if I need assistance or if I have questions?

The NEVADA PACIFIC DENTAL Customer Service Department will assist you in all matters pertaining to the NEVADA PACIFIC DENTAL Plan. You may reach a customer service representative at one of the numbers listed on the back of this brochure. You may also call our toll-free number (800) 926-0925 or (702) 737-8900. Our office hours are Monday through Friday from 8:00 AM to 5:00 PM (excluding holidays).

Q. How long does it take to get an appointment with a dentist?

Three to four weeks is a reasonable amount of time to wait for a standard appointment. If you can’t accept the first available appointment or if you require weekend or evening appointments you may have to wait longer for an appointment.

Q. If I have a pre-existing dental condition, may I join NEVADA PACIFIC DENTAL? YES. Pre-existing conditions are not an exclusion under NEVADA PACIFIC DENTAL. Benefits will not be provided for any dental expenses incurred for treatment started after termination of eligibility for coverage; or for treatment in progress prior to becoming eligible under the NEVADA PACIFIC DENTAL Plan. (e.g.: teeth prepared for crowns, root canals in progress, impressions for dentures, fixed and removable prosthetics, orthodontia, etc.) NEVADA PACIFIC DENTAL will not replace long standing missing tooth/teeth in an otherwise stable dentition.

Most Common Questions

Continued Q. Does NEVADA PACIFIC DENTAL Plan provide coverage for specialty services?

YES, for most Plans. NEVADA PACIFIC DENTAL Plan maintains an Exclusive Network of specialists and coordinates all your specialty care needs with your Exclusive Network provider. Should you require benefited specialty services, your Exclusive Network dentist will refer you to a specialist, upon prior authorization. Out-of-Network specialty care is benefited under your Out-of-Network schedule of allowances.

Q. Once I’ve selected a dental provider, may I change Exclusive Network offices?

YES. You may change your eligibility from one NEVADA PACIFIC DENTAL Plan provider to another by phoning or writing NEVADA PACIFIC DENTAL. If you select a provider prior to the 20th of the month, you will be eligible with the new provider office the first day of the following month.

Q. How do I enroll in NEVADA PACIFIC DENTAL?

Once you decide to enroll, complete the enrollment card. Choose a dental provider from the enclosed provider directory. (Contact Nevada Pacific Dental for the most current provider list.) Be sure to write the office number of your chosen dental provider on the enrollment card. Return this card to your employer as directed by your Human Resources Department. Note: If you do not select a dental provider, NEVADA PACIFIC DENTAL will choose a dental office for you in the closest zip code area.

Q. What about missed appointments?

If you fail to cancel an appointment at least 24 hours in advance of the appointment you may be required to pay a “failed appointment fee” ($25.00) and no further appointments will be made until the cancellation fee is paid.

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Enrollment Card – Change Form

The enrollment form is a tool that NEVADA PACIFIC DENTAL uses to obtain vital information for each of your eligible members. It is the responsibility of the employer to ensure that the data is complete and accurate. The following information is required before a member can be nrolled: e

• Group Number • Effective Date • Social Security Number • Member’s Name • Provider Selection

Of course, we encourage you to make sure all the fields have been completed. NEVADA PACIFIC DENTAL will assign an Exclusive Network office to the member if one was not elected. s

Enrollment forms should be sent directly to NEVADA PACIFIC DENTAL and can be sent at ny time during the month. a

NOTE: The enrollment / change form may also be used to submit any changes in status such as an address change, name change, provider change, or the deletion/addition of dependents.

APPENDICES