When Coverage Begins If You Have to File a Claim You are covered, without a waiting period, from the date you enroll in the plan. Network dentists will send claims directly to Blue Cross Blue Shield. All you have to do is show them your Dental Blue ID card. The payment will be sent directly to Dependent Benefits your dentist as long as the claims are received within one year of the This plan covers dependents until the end of the calendar month in which completed service. theyturnage26,regardlessoftheirfinancialdependency,studentstatus,or employment status. See your plan description (and riders, if any) for exact If you receive care from an out-of-network dentist, you will typically need to coverage details. submit the claim yourself. Before submitting your claim, get an Attending Dentist’s Statement form from Member Service. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your Afteryourdentistfillsouttheform,senditandyouroriginalitemizedbillsto plan sponsor for more information. Blue Cross Blue Shield of Massachusetts, P. O. Box 986030, Boston, MA 02298. All member-submitted claims must be submitted within two years of the date Accumulated Maximum Rollover Benefits of service. ThisdentalplanincludesanAccumulatedMaximumRolloverBenefit.Thisrollover benefitallowsyoutorolloveracertaindollaramountofyourunusedannualdental Ifyouhaveagrievance,seeyourplandescriptionforinstructionsonhowtofile benefitsforuseinthefuture.Therearelimitsandrestrictionsonthisbenefit.Refer a grievance. to the Accumulated Dental Maximum Rollover brochure for further information. Other Information Enhanced Dental Benefits Coordinationofbenefitsappliestoplanmemberswhoarecoveredbyanother EnhancedDentalBenefitsforcertaindentalcareservicesareavailablefor planforhealthcareexpenses.Coordinationofbenefitsensuresthatpayments members who have been diagnosed with qualifying conditions. To learn more from other insurance or health care plans do not exceed the total charges billed aboutspecificconditionsincludedinthisbenefit,reviewyourplandescription for covered services. (and riders, if any) on MyBlue at bluecrossma.org. Your plan description has a subrogation clause, which means that Blue Cross Blue Shield can recover payments if a member has already been paid for the same claim by a third party. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org. LimitationsandExclusions.Thesepagessummarizethebenefitsofyourdentalplan.Yourplandescriptionandridersdefinethefulltermsandconditionsingreaterdetail.Shouldanyquestionsarise concerningbenefits,theplandescriptionandriderswillgovern.Foracompletelistoflimitationsandexclusions,refertoyourplandescriptionandriders. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. April 2023