What is balance billing?

Balance billing applies to Solstice dental PPO plans only, not HMO. If you visit a dentist who is not in the Solstice network, you might owe extra money. This can happen when the dentist’s charge is more than the amount allowed by your insurance plan. If the dentist’s charge is $100 and the allowed amount is $70, the dentist might bill you for $30. Try to prevent balance billing by staying in the network.

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Do HMO members have out-of-network liability? What about emergencies?

Solstice dental HMO plans do not cover out-of-network services. Dental HMO members must stay in the Solstice network to receive coverage. But if you have a dental emergency and are not able to see a network dentist, we will reimburse up to $100.

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Do I have to submit claims to Solstice?

Dental HMO and PPO members do not submit their own claims. This is done by providers. PPO members sometimes need to file a claim for dental care from a non-network dentist. However, many non-network dentists do submit claims for patients. Claim forms with provider information and receipt of procedure codes must be mailed within one year of service date to:

Solstice Benefits
PO Box 21157
Eagan, MN 55121

You can obtain a claim form through your benefits portal, MySolstice.net.   Or download a claim form here.
For questions, please call Solstice Member Services toll-free at 1.855.574.1284.

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What is a grace period?

There is a grace period to pay premium if a member has received advance payments of the premium tax credit. For more information, please verify the “Grace Period” section in your Member Certificate or Member Policy.

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What is the “claims pending” policy during this grace period?

This refers to a claim that is pending because required additional information needed to review the claim was not submitted. Solstice will pay all appropriate claims for services rendered during the first month of the grace period. We may pend claims for services rendered in the second and third months of the grace period.

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What is a retroactive claim denial?

A retroactive denial is the reversal of a previously paid claim. In this case, the member is then responsible for payment. A way to prevent this is to pay premiums on time.

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How can I get a refund of premium overpayment?

Please call Solstice Member Services toll-free at 1.855.574.1284 if you believe you are owed a refund.

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What are my duties for prior authorizations?

Some covered services might require prior approval. This is a process for the insurer to approve a member’s request to access a covered benefit. Some requests are subject to review for medical need. Once approved by Solstice, prior authorizations are valid for 90 days. Claims might be denied if this process is not followed.

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What is an Explanation of Benefits (EOB?)

An Explanation of Benefits (EOB) is a statement that explains what medical treatments or services the insurer paid for on a member’s behalf. An EOB also details the cost paid by the insurer and the member’s financial obligation, if any. Solstice will mail you an EOB after a claim or pre-determination is processed. Download a sample EOB here.

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When is Coordination of Benefits (COB) necessary?

Coordination of benefits (COB) takes place when someone is covered by more than one insurance plan. COB helps determine which benefits are applied first. The purpose of COB is to benefit the member by covering out-of-pocket costs. The primary plan covers a person as an employee, member, subscriber or retiree. The secondary plan would cover you as a spouse or dependent. Dependent children of parents who are married and living together follow the “birthday rule.” The parent whose birthday falls first in a calendar year (month and day) is primary for claims.

Dependent children of parents who are divorced, separated or not living together follow other rules. A parent who has been awarded custody by a court decree is primary for dependent children’s’ claims. Primacy for parents who are separated (whether or not they have been married) or divorced will be determined by the birthday rule for claims on the dependent children. The order of primacy will be determined as follows for cases that involve stepparents: 1) The custodial parent’s plan; 2) the custodial parent’s spouse’s plan; 3) the noncustodial parent’s plan and 4) the noncustodial spouse’s plan. This assumes that all four plans exist and cover the child.

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What are the timeframes for prior authorization requests?

For standard non-urgent prior authorization service requests, the typical timeframe is 14 days. For urgent, expedited prior authorization pre-service requests, the typical timeframe is 72 hours. These timeframes all vary by state. Please contact customer service for specifics on your state.

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If you have any questions that have not been answered here, please contact our Member Services Department at 1.855.574.1284.

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