Does my plan have coverage for Out-of-Network (OON) services?

HMO and EPO plans do NOT have coverage for OON services. Members must stay in the Solstice network or they will be responsible for 100% of the billed charges. In the case of an emergency, we will reimburse up to $100. PPO plans DO have coverage for OON services. However, if you visit a dentist who is not in the Solstice network, you might owe extra money – this is referred to as balance billing.

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What is balance billing?

When seeing an OON dentist for services on your PPO plan, you may be asked to pay an additional amount by the dentist. This can happen when the dentist’s charge is more than the amount allowed by your insurance plan. For example, 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 I have to submit claims to Solstice?

Dental HMO, EPO, 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 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?

A Grace Period is a period of time a policy will remain in force if payment is not received on or before the due date. Members receiving the Advance Premium Tax Credit are given a three month grace period. All other members received a basic grace period, the length of which can be found in the “Grace Period” section of your Dental Insurance Policy.

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

This typically refers to a claim that is pending because required additional information needed to review the claim was not submitted. Solstice will pay all claims for services rendered during the first month of the grace period if we are in receipt of all required claim information and at minimum the first premium payment. We may pend claims for services rendered in the second and third months of the grace period until additional payment is received, even if a clean claim is submitted.

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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 the member to use on the authorized covered service for 90 days. Claims might be denied if this process is not followed.

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What are the timeframes for processing prior authorization requests?

For standard non-urgent prior authorization service requests, we will typically approve or deny the request within 14 days. For urgent, expedited prior authorization pre-service requests, we will typically approve or deny the request within 72 hours. These timeframes all vary by state. Please contact customer service for specifics on your state.

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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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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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