How dental claims are submitted

In-network dental providers generally submit claims directly to FCL Dental or its designated claims administrator. Members ordinarily do not need to submit a claim when they receive covered services from an in-network provider.

A member may need to submit a claim when:

• Services are received from an out-of-network provider;
• A provider does not submit claims on the member’s behalf;
• FCL Dental requests additional information;
• A claim must be corrected or reconsidered; or
• The member paid the provider directly and is requesting reimbursement for a covered service.

Submitting a claim does not guarantee payment. All claims are reviewed under the member’s eligibility, benefits, exclusions, limitations, cost-sharing requirements, coordination-of-benefits rules, and other plan terms in effect on the date of service.

Information required for a claim

A dental claim should include, as applicable:

• The member’s full name and identification number;
• The patient’s name, date of birth, and relationship to the subscriber;
• The treating provider’s name, address, telephone number, National Provider Identifier, and tax identification number;
• The date each service was provided;
• The applicable Current Dental Terminology procedure code;
• The tooth number, tooth surface, quadrant, or arch, when applicable;
• The diagnosis, narrative, or clinical reason for treatment, when requested;
• The provider’s charge for each service;
• Proof of payment when reimbursement is requested;
• Appropriate radiographs, periodontal charting, photographs, laboratory reports, treatment notes, or other supporting documentation; and
• Information regarding other dental or health coverage.

FCL Dental may request information reasonably necessary to determine eligibility, coverage, medical or dental necessity, benefit availability, coordination of benefits, or the correct amount payable.

Claim-filing deadline

Claims must be submitted within the filing period stated in the member’s plan documents and within any applicable state or federal deadline.

Unless a different period appears in the controlling plan document, a member-submitted claim must be received within 90 days after the date of service. A claim submitted after the applicable deadline may be denied unless:

• The member demonstrates that submission within the required period was no treasonably possible;
• The claim is submitted as soon as reasonably possible afterward; or
• Applicable law requires FCL Dental to accept the claim.

Contracted providers must comply with the filing deadlines in their participating-provider agreements and applicable Texas law.

Where to submit a claim

Electronic claims may be submitted through:

Payer name: FCL Dental

Electronic payer ID:CX090

Paper claims should be mailed to:

FCL Dental Claims Department

101 Parklane Blvd Suite 301 Sugar Land, TX 77478

Members may obtain a claim form at Claim Form site or by contacting Member Services.

Clean and complete claims

A clean claim is a claim containing the information required to process and adjudicate the claim without obtaining additional information from the provider, member, or another party.

When a claim is incomplete, inaccurate, or missing necessary documentation, FCL Dental may: 

• Request additional information;
• Return or reject the claim;
• Deny the claim with instructions for correction or resubmission; or
• Process portions of the claim that can be adjudicated independently.

FCL Dental processes clean claims within the timeframes required by applicable law and participating-provider contracts.

Claim decisions

After reviewing a claim, FCL Dental may:

• Pay the claim in full according to plan terms;
• Pay part of the claim;
• Apply the charge to a deductible;
• Apply a copayment or coinsurance amount;
• Reduce payment based on the plan’s allowed amount;
• Coordinate payment with another plan;
• Request additional information;
• Deny the claim; or
• Determine that the service is not covered under the plan.

Assignment and payment of benefits

Benefits may be paid to the member, the treating provider, or another authorized party aspermitted by the plan and applicable law.

Payment directly to a provider does not make the provider an agent or representative of FCL Dental. It also does not prevent FCL Dental from recovering an overpayment or correcting an incorrectly processed claim.

Claims questions, reconsiderations, and appeals

Members and authorized representatives may contact Member Services with questionsabout a claim.

A request to reconsider or appeal an adverse benefit determination must be submitted inaccordance with the procedures and deadlines stated in the member’s plan documentsand adverse-benefit notice.

Appeals may be submitted to:

FCL Dental Appeals and Grievances Department

ATTN: Compliance Dept

101 Parklane Blvd, Ste 301

Sugar Land, TX 77478

1-877-493-6282

[email protected]

FCL Dental will provide appeal rights, deadlines, review procedures, and external-reviewinformation when required by applicable law.

FCL Dental’s provider network

FCL Dental uses a dental provider network under which participating providers agree to comply with contractual requirements, including negotiated reimbursement arrangements.

An in-network or participating provider is a provider who has a current agreement with FCL Dental or its designated network administrator for the applicable dental plan.

An out-of-network or nonparticipating provider does not have such an agreement for the applicable plan.

A provider’s network status may differ by location, specialty, tax identification number, or specific FCL Dental product. Members should verify participation before receiving services.

In-network providers generally agree to accept FCL Dental’s contracted allowed amount for

Using an in-network provider

In-network providers generally agree to accept FCL Dental’s contracted allowed amount for covered services, subject to:

• The member’s deductible;
• Copayments or coinsurance;
• Annual or lifetime benefit maximums;
• Frequency and age limitations;
• Waiting periods;
• Alternate-benefit provisions;
• Noncovered services;
• Services exceeding plan limitations; and
• Other amounts permitted under the provider agreement and applicable law.
   

An in-network provider generally may not bill the member for the difference between the provider’s billed charge and FCL Dental’s contracted allowed amount for a covered service. This protection does not eliminate the member’s responsibility for applicable cost sharing or noncovered services

Using an out-of-network provider

Members may use an out-of-network provider when permitted by their plan. However:

• Benefits may be lower;
• The deductible or coinsurance may be higher;
• Certain services may not be covered;
• The plan’s payment may be based on an out-of-network allowed amount rather than the provider’s full charge;
• The provider may require payment at the time of service; and
• The member may be responsible for charges exceeding FCL Dental’s allowed amount.

The amount charged by an out-of-network provider above FCL Dental’s allowed amount is commonly called a balance bill. Except where prohibited by law, that amount is the member’s responsibility and may not count toward the deductible, annual out-of-pocket limit, or other cost-sharing accumulation.

Example

Assume an out-of-network dentist charges $1,000 for a covered service and FCL Dental’s out-of-network allowed amount is $700. If the plan pays 50% of the allowed amount after the deductible:

• FCL Dental’s payment may be $350;
• The member’s coinsurance may be $350; and
• The provider may bill the member the additional $300 above the allowed amount.

In this example, the member’s total responsibility could be $650, plus any unmet deductible or noncovered charges.

This example is illustrative only. Actual benefits depend on the member’s plan, the service provided, accumulated benefits, and applicable law.

Provider-directory information

Members may search for participating providers at:

Find a Dentist 

Members may also contact Member Services for assistance locating a provider.

Because provider participation can change, members should confirm network status with both FCL Dental and the provider before scheduling treatment. A provider’s presence in an online directory is not a guarantee that the provider:

• Is accepting new patients;
• Participates at every office location;
• Participates in every FCL Dental product;
• Will remain in network on the date of service; or
• Is in network for every dentist practicing at the same office.

Network-access concerns

A member who cannot locate an available participating provider within applicable network-access standards should contact Member Services before receiving nonemergency out-of-network treatment.

FCL Dental will assist the member in locating an available participating provider. When an appropriate participating provider is unavailable, FCL Dental will apply the access, authorization, reimbursement, and member cost-sharing rules required by the member’s plan and applicable law.

Members should not assume that out-of-network services will be processed at the in-network benefit level unless FCL Dental provides written authorization or applicable law requires that treatment.

Surprise-billing protections

Federal and state surprise-billing laws primarily address certain medical services and may not apply to routine stand-alone dental services. When a dental service is subject to an applicable surprise-billing protection, FCL Dental will administer the claim in accordance with that law.

Members who believe they received an improper balance bill should contact Member Services and provide a copy of the bill.

What is a grace period?

A grace period is a limited period after a premium due date during which coverage may remain in effect even though the required premium has not been paid in full.

A grace period does not waive the premium. The subscriber remains responsible for all unpaid premiums and applicable member cost sharing.

The grace period does not extend coverage beyond the date coverage would otherwise terminate under the plan or applicable law.

First premium payment

Coverage generally does not become effective until the initial premium, sometimes called the binder payment, has been received in the required amount and within the required
timeframe.

A grace period ordinarily does not apply to the initial premium unless required by law or expressly stated in the plan documents.

Standard premium grace period

After the initial premium has been paid, FCL Dental provides the premium grace period stated in the member’s plan documents and required by applicable law.

For members who are not entitled to a special Marketplace grace period, the grace period is 31 days from the premium due date.

If the full amount due is not paid before the end of the grace period, FCL Dental may terminate coverage effective on the date permitted by the policy and applicable law.

Partial payment does not necessarily prevent termination unless FCL Dental has agreed in
writing to a payment arrangement or applicable law requires otherwise.

Marketplace members receiving advance payments of the premium tax credit

When applicable to the dental product and required by federal law, an eligible Marketplace
member receiving advance payments of the premium tax credit who has paid at least one
full month’s premium during the benefit year may receive a grace period of three consecutive months.

FCL Dental’s administration of claims during that period will comply with federal Marketplace requirements and the applicable state claims-payment requirements for the product.

At a minimum:

• Coverage remains subject to payment of all outstanding premiums;
• FCL Dental will provide required notices regarding premium delinquency and possible termination;
• Claims incurred during the first month of the applicable grace period will be handled as required by federal law;
• Claims incurred during the second and third months of the applicable grace period may be held for processing, also known as pended, until all delinquent premiums are paid in full, in accordance with federal Marketplace requirements, applicable state claims-payment requirements, and the controlling plan documents; and
• Coverage may be terminated retroactively to the date permitted by law if the full
  outstanding premium is not paid before the grace period ends.

Because premium-tax-credit treatment for stand-alone dental coverage can depend on the
Marketplace enrollment arrangement, members should refer to their delinquency notice or
contact Member Services for the rule applicable to their enrollment.

Claims incurred during a grace period

A service received during a grace period is not automatically guaranteed to be covered.

During the first month of an applicable three-month Marketplace grace period, FCL Dental will pay all appropriate claims for covered services rendered to the member, subject to the member’s eligibility, covered benefits, exclusions, limitations, deductibles, copayments, coinsurance, annual maximums, claim-filing requirements, and other terms of the plan.

During the second and third months of an applicable three-month Marketplace grace period, FCL Dental may hold claims for processing, also known as pending or pending claims, until all delinquent premiums are paid in full.

A pending or pended claim is a claim that FCL Dental has received but has not yet approved, denied, or paid. When a claim is pending because premiums are delinquent, no payment will be made to the provider or member for that claim unless the delinquent premiums are paid in full and coverage remains in effect.

If all outstanding premiums are paid in full before the end of the grace period, FCL Dental will process pending claims according to the terms of the plan. If all outstanding premiums are not paid in full before the end of the grace period, coverage may terminate as permitted by law, and FCL Dental will not pay pending claims for services rendered during the second and third months of the grace period.

The member remains responsible for all unpaid premiums. The member also remains responsible for applicable deductibles, copayments, coinsurance, noncovered services, services exceeding plan limitations, and any other amounts that are the member’s responsibility under the plan and applicable law.

Providers may be informed of a member’s premium-delinquency status and that claims may be pending during the second and third months of the grace period when permitted or required by law.

Termination for nonpayment

When coverage terminates due to nonpayment, the termination date may be retroactive as permitted by applicable law.

The member may become responsible for services received after the effective termination date, including claims that were previously processed or paid before eligibility information was corrected.

FCL Dental will send required notices explaining:

• The premium amount due;
• The applicable grace period;
• The deadline for payment;
• The potential termination date;
• The treatment of claims; and
• Available rights or next steps.

Reinstatement

Payment after coverage has terminated does not automatically reinstate coverage. Reinstatement is available only when required by law, permitted under the plan, or
expressly approved by FCL Dental and the Marketplace.

What is a retroactive denial?

A retroactive denial or adjustment occurs when FCL Dental reverses or changes a prior claim determination after the claim was initially processed.

This may result in:

• A reduction or reversal of payment;
• Recovery of an overpayment;
• An additional payment;
• A change in the member’s cost-sharing responsibility; or
• The provider billing the member, when permitted.

Reasons a claim may be adjusted retroactively

A claim may be adjusted when:

• Coverage is retroactively terminated;
• Premiums were not paid as required;
• Eligibility information was inaccurate or later corrected;
• The member had other primary coverage;
• Coordination-of-benefits information changed;
• The claim contained inaccurate, incomplete, duplicate, or misleading information;
• The provider submitted a corrected claim;
• The service was billed under an incorrect procedure code;
• A payment or processing error occurred;
• Benefits exceeded an applicable annual, lifetime, frequency, or age limitation;
• The service was not covered under the applicable plan;
• Payment was induced by fraud or an intentional material misrepresentation; or
• Adjustment is otherwise permitted or required by law.

Recovery of overpayments

FCL Dental may recover amounts paid in excess of its obligations under the plan.

Recovery may be made by:

• Requesting repayment from the provider;
• Requesting repayment from the member or other recipient of the payment;
• Offsetting the overpayment against future amounts payable, where permitted;
• Correcting accumulators or benefit maximums; or
• Using another recovery method permitted by law or contract.

FCL Dental will comply with applicable notice, lookback, appeal, and recovery limitations.

Member responsibility

A member may become financially responsible when coverage is retroactively terminated or a payment is reversed. However, FCL Dental will not transfer responsibility to a member
when prohibited by applicable law or a participating-provider agreement.

Members can reduce the risk of retroactive adjustments by:

• Paying premiums in full and on time;
• Promptly reporting enrollment or household changes to the Marketplace;
• Providing accurate information about other insurance;
• Reviewing eligibility and identification information;
• Presenting the correct identification card to providers; and
• Reviewing Explanation of Benefits statements and promptly reporting errors.

Notice and appeal rights

When a retroactive adjustment creates or increases member responsibility, FCL Dental will
provide an Explanation of Benefits or other notice describing the reason for the adjustment and any available appeal rights.

Premium overpayments

A premium overpayment may occur when:

• More than the required premium was paid;
• Duplicate payments were received;
• Coverage ended and premiums were collected for a later period;
• A Marketplace enrollment correction changed the premium amount;
• A payment was applied to the wrong account;
• A billing or administrative error occurred; or
• Another adjustment created a credit balance.

Requesting a refund

A subscriber may request review of a potential premium overpayment by contacting FCL Dental’s Billing Department:

FCL Dental Billing Department

ATTN: Benefit Administration

101 Parklane Blvd, Ste 301

Sugar Land, TX 77478

1-877-493-6282

[email protected]

The request should include:

• The subscriber’s name;
• The FCL Dental account or member identification number;
• The Marketplace application or enrollment identifier, when applicable;
• The amount and date of the payment;
• The reason a refund is requested;
• Proof of payment; and
• Any Marketplace notice supporting the requested adjustment.

Review of a refund request

FCL Dental may request additional documentation to verify the overpayment, termination date, enrollment record, payment source, or identity of the person requesting the refund.

Refunds are subject to:

• The effective dates transmitted by the Marketplace;
• Applicable premium-tax-credit reconciliation;
• Outstanding premiums or other amounts due;
• Returned-payment activity;
• Chargebacks;
• The controlling plan documents; and
• Applicable law.

FCL Dental will not refund premiums for a period during which coverage was properly ineffect solely because the member did not use dental services.

Method of refund

An approved refund will ordinarily be returned to the original payment method or to the person or entity legally entitled to receive it.

FCL Dental may first apply a credit balance to unpaid premiums or other amounts due when permitted by law.

Refund timeframe

Refund timeframe
FCL Dental will process approved refunds within 30 business days after receiving all information necessary to complete the review, subject to banking, Marketplace, and payment-processing timelines.

Disputed refund decisions

A subscriber who disagrees with a premium-refund decision may request reconsideration by submitting a written explanation and supporting records to the Billing Department or Appeals and Grievances Department.

Dental necessity

A service is dentally or medically necessary when it satisfies the definition and clinical criteria stated in the member’s plan documents and applicable law.

In general, a necessary dental service must be:

• Appropriate for the diagnosis, condition, or treatment of the member;
• Consistent with generally accepted standards of professional dental practice;
• Clinically appropriate in type, frequency, extent, site, and duration;
• Not primarily for the convenience of the member, provider, or another person;
• Not primarily cosmetic; and
• Not more costly than an alternative service expected to produce an equivalent therapeutic or diagnostic result, when the plan contains an alternate-benefit provision.

A provider’s recommendation does not, by itself, establish that a service is covered or dentally necessary under the plan.

Prior authorization

FCL Dental requires prior authorization only for the services identified in the member’s plan documents, provider manual, benefit schedule, or applicable clinical policy.

When prior authorization is required, the provider or member must submit the request before treatment, except in circumstances where retrospective review is permitted or required.

Failure to obtain required authorization may result in reduced benefits or denial, subject to applicable law and participating-provider contract requirements.

Predetermination or pretreatment estimate

A predetermination is a voluntary, advance estimate of how benefits may apply to a proposed course of dental treatment. It is not a guarantee of payment.

FCL Dental recommends requesting a predetermination when:

• The proposed treatment is extensive;
• The expected charge exceeds $300
• Multiple treatment alternatives are available;
• Treatment will occur over more than one benefit year;
• Annual maximum benefits may be affected;
• The service may be subject to frequency, age, or replacement limitations; or
• The member or provider is uncertain whether the service is covered.

Information needed for review

• A prior-authorization or predetermination request should include:
  The proposed procedure codes;
• The treatment plan and estimated charges;
• Relevant clinical history;
• Diagnostic-quality radiographs;
• Periodontal charting;
• Intraoral photographs;
• Tooth numbers and surfaces;
• Narrative justification;
• Dates and details of prior treatment;
• Prosthetic history and replacement dates;
• Laboratory information; and
• Other records reasonably necessary to evaluate the request.

Review timeframes

FCL Dental will decide on prior-authorization requests within applicable federal and state timeframes.

Unless a shorter period is required by law:

• A standard request will be decided within 7 calendar days after receipt of a complete request;
• An urgent request will be decided as soon as the member’s condition requires and no later than 72 Hours and
• A retrospective request will be decided within 7 calendar days after receipt of the information necessary for review.

When additional information is needed, FCL Dental will notify the requesting party and identify the information required.

Effect of a predetermination or authorization

A predetermination or prior authorization is based on information available when the decision is made. It does not guarantee payment.

Final payment remains subject to:

• Continued eligibility on the date of service;
• Premium payment;
• The plan in effect on the date of service;
• Remaining annual or lifetime maximums;
• Deductible and cost-sharing amounts;
• Frequency, age, and replacement limitations;
• Coordination of benefits;
• The services actually performed;
• Accuracy of submitted information;
• Provider network status;
• Applicable exclusions and limitations; and
• Any material change in the treatment plan.

Adverse determinations

When FCL Dental denies or reduces a request based on dental necessity, clinical criteria, or another coverage requirement, it will provide a notice explaining:

• The reason for the decision;
• The plan provision or clinical criterion relied upon;
• How to request relevant documents or criteria;
• How to appeal;
• Applicable deadlines; and
• Expedited-review rights, when available.

Cosmetic and elective services

Services performed primarily to improve appearance and not to restore function or treat disease, injury, or a covered congenital condition are not covered unless specifically included in the member’s plan.

Examples may include elective tooth whitening, decorative dental appliances, and purely cosmetic reshaping. Members should consult their plan documents for the controlling exclusions.

What is an Explanation of Benefits?

An Explanation of Benefits, or EOB, is a statement showing how FCL Dental processed a dental claim. An EOB is not a bill.

The provider may send a separate bill for the amount the member owes.

Information shown on an EOB

An EOB may include:

• The member and patient names;
• The claim number;
• The treating provider;
• Dates of service;
• Dental procedures submitted;
• The provider’s billed charges;
• The FCL Dental allowed amount;
• Network discounts;
• Amounts excluded or not covered;
• Deductible amounts;
• Copayments or coinsurance;
• Amount paid by FCL Dental;
• Amount paid to the member or provider;
• Amount that may be owed by the member;
• Benefit maximum information;
• Coordination-of-benefits information;
• Adjustment or denial codes; and
• Appeal or inquiry instructions.

“You may owe” amounts

The amount identified as member responsibility is based on the information available when the claim was processed. It may differ from a provider’s bill because of:

• Prior payments;
• Services not submitted on the claim;
• Corrected claims;
• Coordination of benefits;
• Payment arrangements;
• Noncovered services;
• Balance billing by an out-of-network provider; or
• A later claim adjustment.

Members should compare the provider’s bill with the EOB before making payment.

Accessing EOBs

EOBs are available through the Member Portal

Depending on the member’s communication preference and applicable law, FCL Dental may send EOBs electronically or by mail.

Members may request a paper copy, accessible format, or language assistance without charge by contacting Member Services.

Reporting an error

Members should contact FCL Dental promptly when an EOB:

• Lists an unfamiliar provider or service;
• Contains an incorrect date or procedure;
• Appears to have been processed under the wrong member;
• Does not reflect other insurance;
• Contains an unexpected denial; or
• Appears inconsistent with the plan documents.

Suspected fraud, waste, or abuse may be reported at:

[email protected]

Hotline: 1-866-202-5898

When coordination of benefits applies

Coordination of benefits applies when a member has dental benefits under more than one plan.

The purpose of coordination of benefits is to determine:

• Which plan pays first;
• Which plan pays second;
• The amount each plan may pay; and
• How duplicate payment is prevented.
   

The plan that pays first is the primary plan. The plan that considers the claim after the primary plan is the secondary plan.

Primary-plan responsibility

The primary plan processes the claim according to its terms without considering benefits that may be available under the secondary plan.

Secondary-plan responsibility

The secondary plan processes the remaining eligible expense according to its coordination-of-benefits provisions.

Payment from all plans will not exceed the amount permitted under applicable coordination rules. The combined payment may be less than the provider’s total charge when:

• One or both plans exclude the service;
• Benefit limitations apply;
• An out-of-network provider charges more than an allowed amount;
• A deductible, copayment, or coinsurance applies;
• An annual maximum has been reached; or
• The plans use different allowed amounts or benefit methodologies.

Order-of-benefit rules

The order in which plans pay is determined under the plan documents and applicable coordination-of-benefits rules. Depending on the circumstances, the determination may consider:

• Whether a person is covered as an employee, subscriber, dependent, retiree, or continuation participant;
• Whether a plan contains valid coordination provisions;
• The birthday rule for dependent children;
• A court decree or custody arrangement;
• Medicare eligibility;
• Active versus inactive employment status;
• Length of coverage; and
• Other rules required by law.

Dependent children

When a child is covered under both parents’ plans, the primary plan is commonly determined by the birthday rule: the plan of the parent whose birthday falls earlier in the calendar year pays first. The parents’ years of birth are generally not considered.

Different rules may apply when:

• The parents are divorced or separated;
• A court order assigns financial responsibility;
• One parent has custody;
• The child is covered through a stepparent;
• The child has coverage in their own name; or
• Applicable law requires another result.

Member responsibilities

Members must provide complete and accurate information about other coverage and promptly report any change.

FCL Dental may request:

• The other plan’s name and contact information;
• The other member identification number;
• The effective and termination dates;
• A copy of the other plan’s EOB;
• Custody or court-order information; and
• Other records needed to determine primary and secondary responsibility.

Failure to provide requested information may delay claim processing.

Right to exchange information

FCL Dental may exchange information with other insurers, plans, providers, clearinghouses, the Marketplace, governmental programs, and other appropriate parties when reasonably necessary to coordinate benefits and as permitted by privacy law.

Right of recovery

When FCL Dental pays more than it should have paid as the secondary plan, it may recover the excess from the member, provider, other plan, or person who received the payment,  subject to applicable law.

FCL Dental provides stand-alone dental benefits and does not include outpatient prescription-drug benefits unless expressly stated in the member’s plan documents. 

Accordingly, a prescription-drug formulary exception process is generally not applicable to FCL Dental’s stand-alone dental plans.

Medications prescribed in connection with dental treatment may be covered under a member’s medical or pharmacy plan. Members should contact the administrator of that coverage for information regarding formularies, prior authorization, step therapy, or exception requests.

When an FCL Dental product includes a covered drug benefit, FCL Dental will publish the applicable exception procedures and review timeframes separately.

FCL Dental does not discriminate

FCL Dental complies with applicable federal and state civil-rights laws. 

FCL Dental does not unlawfully discriminate against, exclude, or treat individuals differently on the basis of race, color, national origin, sex, age, disability, or any other status protected by applicable law.

This protection applies to FCL Dental’s health programs and activities, including enrollment, member services, utilization management, claims administration, appeals, provider-network administration, communications, and access to covered benefits.

Assistance for individuals with disabilities

FCL Dental provides appropriate auxiliary aids and services, free of charge, when necessary to communicate effectively with individuals with disabilities.

Available assistance may include:

• Qualified sign-language interpreters;
• Written information in large print;
• Braille;
• Audio;
• Accessible electronic formats;
• Relay services; and
• Other appropriate communication assistance.

To request assistance, contact:

Accessibility Coordinator

Phone: 1-877-493-6282

TTY: 711

Email: [email protected]

Language assistance

FCL Dental provides language-assistance services free of charge to individuals whose primary language is not English.

Available services may include: 

• Qualified oral interpreters;
• Qualified bilingual staff;
• Translation of important written information; and
• Assistance understanding plan benefits, claims, appeals, and other communications.

FCL Dental will not require an individual to provide or pay for their own interpreter.

To request language assistance, call 1-877-493-6282.

Filing a civil-rights grievance

A person who believes FCL Dental failed to provide required communication or language assistance, or discriminated in another way, may file a grievance with:

FCL Dental Civil Rights Coordinator

101 Parklane Blvd Suite 301, Sugar Land, TX, 77478

Telephone: 1-877-493-6282

TTY: 1-877-493-6282 OR 711]

Email: [email protected]

A grievance should be submitted within 60 calendar days after the person becomes aware of the alleged discrimination, unless an extension is appropriate.

The grievance may be submitted in writing, electronically, or with assistance from the Civil Rights Coordinator. FCL Dental will provide reasonable modifications to the grievance process for individuals with disabilities.

FCL Dental prohibits retaliation against any person who files a grievance, participates in an investigation, or exercises a civil-rights protection.

Filing a complaint with HHS

A civil-rights complaint may also be filed with the U.S. Department of Health and Human Services, Office for Civil Rights: 

Online: Through the HHS Office for Civil Rights Complaint Portal

Mail: U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201

Telephone: 1-800-368-1019

TDD: 1-800-537-7697

Complaint forms and additional information are available from the HHS Office for Civil Rights.

Filing a grievance with FCL Dental does not prevent a person from filing a complaint with a governmental agency. 

Members may request information about their estimated cost sharing for a specific covered dental service from a participating provider.

An estimate may consider:

• The applicable allowed amount;
• Remaining deductible;
• Copayment or coinsurance;
• Annual benefit maximum;
• Frequency and age limitations;
• Waiting periods;
• Alternate-benefit provisions;
• Provider network status; and
• Claims processed before the estimate was prepared.

Cost-sharing estimates are not guarantees of payment because eligibility, accumulated benefits, provider status, submitted procedure codes, and treatment may change before the claim is processed.

Members may obtain available cost-sharing information through by calling Member Services.

FCL Dental submits and makes available Marketplace transparency information in the form, manner, and timeframe required by the Centers for Medicare & Medicaid Services and the applicable state regulators.

This information may include:

• Enrollment data;
• Disenrollment data;
• The number or percentage of claims denied;
• Rating practices;
• Periodic financial disclosures;
• Claims-payment policies and practices;
• Out-of-network cost information; and
• Other required transparency data.

Certain information may be reported in an aggregated format to protect member privacy, confidential business information, and data security.

FCL Dental maintains the privacy and security of members’ personal and protected health information in accordance with applicable law.

FCL Dental may use and disclose information for treatment, payment, health care operations, benefit administration, regulatory reporting, fraud prevention, and other purposes permitted or required by law.

FCL Dental’s Notice of Privacy Practices is available at:

NOTICE OF PRIVACY

Members may request a paper copy by contacting Member Services.

FCL Dental is committed to preventing, detecting, investigating, and correcting fraud, waste, and abuse.

Examples may include:

• Billing for services that were not provided;
• Altering dates, procedure codes, or clinical records;
• Misrepresenting a noncovered service as a covered service;
• Using another person’s identification card;
• Concealing other insurance;
• Paying or accepting an improper inducement;
• Falsifying eligibility information; or
• Submitting duplicate claims intentionally.

Concerns may be reported confidentially through:

Fraud hotline: 1-866-202-5898

Online: www.fcldental.com

Email: [email protected]

Matt: Att: Special Investigation

101 Parklane Blvd Suite 301, Sugar Land, TX 77479

FCL Dental prohibits retaliation against individuals who make good-faith reports.

Member Services

Phone: 1-877-493-6282

TTY: 711

Email: [email protected]

Mail: 101 Parklane Blvd Suite 301, Sugar Land, TX, 77478

Hours: M-F, 8:00 AM to 5:00 PM Central Time.

Claims

Payer name: FCL Denta

Electronic payer ID: CX090

Mail: FCL Dental Claims Department

101 Parklane Blvd Suite 301 Sugar Land, TX 77478

Phone: 1-877-492-6282

Appeals and Grievances

Mail: ATTN: Compliance Dept

101 Parklane Blvd, Ste 301

Sugar Land, TX 77478

Phone: 1-877-493-6282

Email: [email protected]

Billing and Premium Payments

Mail: FCL Dental Billing Department

ATTN: Benefit Administration

101 Parklane Blvd, Ste 301

Sugar Land, TX 77478

Phone: 1-877-493-6282

Email: [email protected]

The applicable State Department of Insurance

Important Disclaimer

This page provides general administrative and transparency information. It is not a contract, quotation, authorization, guarantee of benefits, or guarantee of payment.

Coverage is governed by the member’s applicable policy, Evidence of Coverage, Schedule of Benefits, endorsements, amendments, and applicable law. FCL Dental reserves the right to revise this page to reflect changes in law, regulation, Marketplace guidance, plan design,