If the primary carrier requires that a specific dental office must be used in order for the expenses to be covered and the choice is made not to utilize those services the Fund will not cover those expenses. In essence, when you choose not to use the services of the provider required by the primary carrier you are selecting which carrier will be primary. The “Birthday Rule ” has been established to determine which carrier is primary so that neither the insurer or the insured can be selective in which coverage comes first. If there is some reason that prohibits you from using the designated provider you must take the matter up with the insurer that has established that requirement. The Fund can not help you with another carrier’s rules and regulation.
Some insurer’s have made arrangements with providers that there will be no charge for certain services, such as periodic exams. If the EOB (Explanation of Benefits) that is submitted to the Fund from another insurer states on it that there is no charge to the patient for a particular service the Fund will not make payment regardless of what the provider requests. Remember – the Fund reimburses for expenses that you owe. If the primary insurer states that there is no charge for the service, the provider can not bill you for that service.
