Appendices to Dental Warranty Service Agreement

APPENDIX A: CLAIMS ADMINISTRATION TERMS & CONDITIONS

A claim may be eligible for Program reimbursement if a covered Treatment requires repair or replacement of restorative materials or maintenance in order to provide its original purpose, and if the repair, replacement or maintenance is physical in nature, and if the Coverage has not expired or been otherwise terminated.

1. DOCUMENTATION REQUIREMENTS: When submitting a request for reimbursement, Practice shall gather and submit all required documentation. Depending on Treatment, and the complexity or total value of the requested reimbursement amount, documentation may include pre-op intraoral images or x-rays, post-op intraoral images or x-rays, intraoral or x-ray showing failed treatment, clinical notes, patient ledger, and models and diagnostic wax ups, etc. Practice acknowledges that processing may be delayed in the absence of all necessary information and documentation.
2. TIMELY SUBMISSION OF CLAIMS: Practice shall submit claims for reimbursement to DWC within 90 days after completing repairs, replacements, or maintenance services or the claim will be ineligible and the Practice will be responsible for the related cost. When applicable, The “Failure” date shall be the first date the claim-related issue is reported to or discovered by the practice, regardless of when the repair or maintenance is completed.
3. COVERAGE EFFECTIVE DATE: The Practice’s eligibility for reimbursement under the Program begins on the date the Patient’s procedure is permanently completed (for example, the seat date for a crown). The Practice will be responsible for any Program related repair, replacement, or maintenance services during the first 90 days.  DWC will begin providing Program related reimbursements after the initial 90 days, or during the first 90 days in the event of i) external trauma to the Patient’s covered treatment, or ii) the Patient must redeem benefits at another dental office per “If a Patient Moves” below.
4. CONTINUING CARE FREQUENCY REQUIREMENT: To stay eligible for Program reimbursement, Patient must return for continuing care visits no less than once every 6 months with a 2-month grace period.
5. REIMBURSEMENT VALUE: Approved reimbursements shall be valued at no more than the Coverage’s original Total Treatment Cost at the time of the Treatment Date as registered with DWC. Repair vs. Replace: If a simple repair will correct damage, DWC requests that the dentist attempt a repair before proceeding to a complete remake of the restoration or appliance. This may result in remaining coverage value for the patient (for example, after one tooth cracks on a $2000 denture, DWC reimburses the practice $300 for repairing the tooth.  The patient’s coverage is still worth $1700).
6. EXCESSIVE CLAIMS: The Program is not insurance, therefore in the event that the Practice’s Program-related claims routinely or through abuse exceed the total Program fees paid to DWC, DWC reserves the right to discontinue cost reimbursement until such time as DWC receives from Practice additional funds sufficient to cover outstanding and unpaid Program-related costs.
7. REPEATED FAILURES: DWC reserves the right to refuse to accept new Warranties or Maintenance Agreements on a Patient’s specific tooth or Treatment that has failed more than two times. e. the third restoration of the same kind or the third attempt to correct the same issue is not eligible for coverage.
8. IF A PATIENT MOVES: If a patient moves or is traveling more than 100 miles from the Practice, or if Practice waives this geographic boundary for a specific Patient, DWC will administer the benefits of the Warranty or Maintenance Agreement though the patient’s new dental practice. Practice will provide DWC with necessary documentation to verify original coverage as needed.
9. REIMBURSING SPECIALISTS: If a failed Treatment is referred to a specialist for repair or replacement, DWC will reimburse either the Practice or the specialist at Practice’s direction.
10. INELIGIBLE CLAIMS: Ineligible claims include but are not limited to issues related to (i) Failed temporary treatments (treatment must be permanent to be eligible for coverage), (ii) Faulty lab work. For Cerec, E4D, and other in-office technology, this includes failure due to Practice’s disregard for manufacturer’s parameters, (iii) Change in cosmetic preferences (for example, a patient consents to a particular shade and then after treatment is completed, requests to have treatment redone in order to change the shade), (iv) Defective materials or using materials outside of manufacturers’ guidelines or directions, (v) Loss of a prosthesis or appliance (denture, retainer, night guard, etc.).  Bad fit of a prosthesis or appliance due to new restorations, or changes in occlusion. (vi) Malpractice, negligence, poor judgment and/or below standard of care work, including but not limited to restorations failing due to open margins or open contacts and/or decay or micro leakage around margins within the first year of placement;
11. INELIGIBLE ENDODONTIC CLAIMS: Endodontic procedures are held to the standard of care of an endodontic specialist. Endodontic procedures are eligible for coverage if the retreatment performed is not another endodontic procedure by the same dentist. (For example, on a failed root canal, an extraction followed by an implant or bridge would be eligible for coverage.) Some root canal failures may be ineligible for reimbursement including but not limited to: (i) Need for retreatment within the first year for any reason other than trauma, (ii) Failure due to poor instrumentation (broken file, perforation, or missed canal), (iii) Poor obturation (inadequate fill, short of apex, over extension, etc.), (iv) Incorrect post placement (inadequate size, angle, depth, or perforation), (v) Failure of the root canal due to patient’s failure to complete a crown on the tooth.
12. ADDITIONAL DOCUMENTATION FOR COVERED IMPLANTS: Please include the following documentation with all implant related reimbursement claims (i) Pre- and post-treatment CBCT imaging for any procedure involving implant placement. If no CBCT imaging was obtained, then DWC will request an explanation as to why this was contraindicated for the procedures involved in the claim.  (ii) Detailed treatment plan notes, including placement criteria (for example, bone and tissue quality, immediate or delayed placement, sinus lift needed, correct A-P spread, implant torque numbers at time of placement, cover screw and curried, healing cap, or abutment/temp and immediate load, proper keratinized attached tissue or mucosa around implant, guided or non-guided surgery, etc.)
13. SLEEP APNEA APPLIANCES: Practice agrees to terms in Appendix B: Sleep Apnea Related Terms and Conditions regarding sleep apnea appliances.
14. LAB WARRANTIES: If practice’s dental lab provides a warranty on their lab work, DWC will coordinate Program benefits directly with the lab.  In some cases this may mean that DWC reimburse the related lab expenses directly to the lab.
15. PEER REVIEW: Practice agrees to accept the final disposition of a peer review to determine reimbursement approval or denial. DWC shall notify practice of approval or denial as soon as reasonably possible.

APPENDIX B: SLEEP APNEA RELATED TERMS AND CONDITIONS

Sleep Apnea related appliances are eligible for reimbursement under the following conditions:

1. Pre-Determined Treatment Value. DWC will reimburse sleep appliances based on a pre-determined value (“Treatment Value”) as agreed upon by Practice and DWC and as registered in dentalwarranties.com, and not based on the value reimbursed by medical insurance.
2. Coordination of Benefits With Manufacturer’s Warranty. If coverage is redeemed during the manufacturer’s warranty period, Dental Warranty will reimburse the difference between the Treatment Value and the usual and customary cost of replacement waived by the manufacturer.  For example, if the manufacturer charges $500 per each appliance, and the Treatment Value is $2000, and the appliance fails during the manufacturer’s warranty period, and the manufacturer will provide a remade appliance to the office at no charge, then Dental Warranty would reimburse $1500 to the practice.
3. Repair vs. Replacement. Practice will seek all viable repair options before resorting to a full remake.
4. Sleep Apnea Appliance Coverage Wait Period. Coverage is available from 60 days after the final delivery date.  No claim submitted on damage discovered within this initial 60-day period will be approved for payment.  The 90-day period referenced in the above general Dental Warranty Service agreement does not apply to Sleep Apnea Appliances.
5. Terms and Conditions of Coverage Eligibility. All conditions of the above Dental Warranty Service Agreement, plus the following conditions including but not limited to:
   1. No coverage for lost appliances
   2. No coverage for failed temporary treatments (if dentist has reasonable doubt that appliance will last for the term of the coverage, coverage should not be offered)
   3. No coverage for faulty lab work or defective materials
   4. No coverage for bad fit of an appliance due to new restorations or changes in occlusion
   5. No coverage for malpractice, negligence, and/or below standard of care work
6. Approved Sleep Appliances. Dental Warranty’s clinical advisors recommend using sleep appliances that offer a minimum 1-year manufacturer’s warranty.  If your sleep appliance does not have at least a 1-year manufacturer’s warranty, please contact Dental Warranty for written approval of your appliance.

APPENDIX C: HIPAA BUSINESS ASSOCIATE ADDENDUM

This HIPAA BUSINESS ASSOCIATE ADDENDUM (Addendum) is incorporated into and constitutes a part of the ADMINISTRATION AGREEMENT BETWEEN DWC AND PRACTICE. DWC and PRACTICE agree as follows:

Definitions

Catch-all definition:

The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.

Specific definitions:

(a) Business Associate.  “Business Associate” shall generally have the same meaning as the term “business associate” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean DWC.

(b) Covered Entity.  “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean the Practice.

(c) HIPAA Rules.  “HIPAA Rules” shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164.

Obligations and Activities of Business Associate

Business Associate agrees to:

(a) Not use or disclose protected health information other than as permitted or required by the Agreement or as required by law;

(b) Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the Agreement;

(c) Report to covered entity any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware;

 (d) In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the business associate agree to the same restrictions, conditions, and requirements that apply to the business associate with respect to such information;

(e) Make available protected health information in a designated record set to the covered entity as necessary to satisfy covered entity’s obligations under 45 CFR 164.524;

 (f) Make any amendment(s) to protected health information in a designated record set as directed or agreed to by the covered entity pursuant to 45 CFR 164.526, or take other measures as necessary to satisfy covered entity’s obligations under 45 CFR 164.526;

 (g) Maintain and make available the information required to provide an accounting of disclosures to the covered entity as necessary to satisfy covered entity’s obligations under 45 CFR 164.528;

 (h) To the extent the business associate is to carry out one or more of covered entity’s obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to the covered entity in the performance of such obligation(s); and

(i) Make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules.

 Permitted Uses and Disclosures by Business Associate

(a) Business associate may only use or disclose protected health information to:

• Maintain Warranty or Maintenance Agreement database records
• Communicate with Practice about such records
• Provide Warranty or Maintenance Agreement information to Practice’s patients at patient’s request
• Provide Warranty or Maintenance Agreement information to other practices when needed to administer Warranty or Maintenance Agreement benefits nationwide

(b) Business associate may use or disclose protected health information as required by law.

(c) Business associate agrees to make uses and disclosures and requests for protected health information consistent with covered entity’s minimum necessary policies and procedures.

 (d) Business associate may not use or disclose protected health information in a manner that would violate Subpart E of 45 CFR Part 164 if done by covered entity except for the specific uses and disclosures set forth below:

(1) Business associate may use protected health information for the proper management and administration of the business associate or to carry out the legal responsibilities of the business associate.

(2) Business associate may disclose protected health information for the proper management and administration of business associate or to carry out the legal responsibilities of the business associate, provided the disclosures are required by law, or business associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies business associate of any instances of which it is aware in which the confidentiality of the information has been breached.

(3) Business associate may provide data aggregation services relating to the health care operations of the covered entity.

Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions

(a) Covered entity shall notify business associate of any limitation(s) in the notice of privacy practices of covered entity under 45 CFR 164.520, to the extent that such limitation may affect business associate’s use or disclosure of protected health information.

(b) Covered entity shall notify business associate of any changes in, or revocation of, the permission by an individual to use or disclose his or her protected health information, to the extent that such changes may affect business associate’s use or disclosure of protected health information.

(c) Covered entity shall notify business associate of any restriction on the use or disclosure of protected health information that covered entity has agreed to or is required to abide by under 45 CFR 164.522, to the extent that such restriction may affect business associate’s use or disclosure of protected health information.

Permissible Requests by Covered Entity

Covered entity shall not request business associate to use or disclose protected health information in any manner that would not be permissible under Subpart E of 45 CFR Part 164 if done by covered entity.

Term and Termination

(a) Term. The Term of this Agreement shall be effective as of the date signed below and shall terminate when business associate no longer processes, transmits or stores EHPI for or on behalf of the covered entity and all EPHI has been returned to the covered entity and securely purged from all business associate systems, or on the date covered entity terminates for cause as authorized in paragraph (b) of this Section, whichever is sooner.

(b) Termination for Cause. Business associate authorizes termination of this Agreement by covered entity, if covered entity determines business associate has violated a material term of the Agreement and business associate has not cured the breach or ended the violation within the time specified by covered entity.

(c) Obligations of Business Associate Upon Termination.

Upon termination of this Agreement for any reason, business associate shall return to covered entity all protected health information received from covered entity, or created, maintained, or received by business associate on behalf of covered entity, that the business associate still maintains in any form.  Business associate shall retain no copies of the protected health information.

 (d) Survival.  The obligations of business associate under this Section shall survive the termination of this Agreement.

Signatures on Practice Service Agreement

The signers of the Practice Service Agreement acknowledge and agree to abide by the terms of this BAA Agreement. This agreement is to remain in force until superseded by an updated contract or until such time as the Business Associate no longer processes, transmits or stores EPHI on received from or on behalf of the Covered Entity.

APPENDIX D: PEER REVIEW PROTOCOL

In the event that the Practice disagrees with the opinion of the Dental Warranty (“DWC”) internal claim reviewing team regarding a claim eligibility decision, the next step is to confirm or disconfirm the opinion by submitting the case to an external panel of dentists for peer review.

It is expected that the review process shall take no more than 30 days.  DWC will communicate progress to Practice as the process proceeds as follows:

1. DWC Collects Documentation.  DWC will gather all documentation that has been submitted related to the claim in question and send a copy to Practice.  If desired, Practice may add additional commentary.
2. DWC Selects Peer Review Panel Members.  Based on the clinical expertise required to evaluate the Treatments related to the claim, DWC selects an odd number of dentists to review the case (the “Panel”).  Practice shall receive a copy of the credentials of the Panel members, but not their names.
3. Case Is Submitted and Reviewed By Panel.  Documentation is submitted to the Panel after removing any identifying information that would link the Practice to the case.  Each Panel member will answer (independently and without conferring with any other Panel member) the question, “Based on the generally accepted standard of care, did a clinical or operator error contribute to the failure of these treatments, and why?”
4. Panel Members Each Submit Their Written Opinion to DWC.
5. A Simple Majority Will Confirm Or Disconfirm Claim Eligibility.  A copy of the result and the written opinions will be submitted to Practice along with any related next steps.