When a member becomes effective with Dominion and is currently in treatment, Dominion will pay a total of $500 to the orthodontist for the remaining treatment, or the balance remaining from the previous insurer’s agreed-upon payment amount, whichever is lower. The member will be responsible for paying the difference remaining between the previous insurer’s payment, Dominion’s payment of $500, and the previous insurer’s total allowable. Dominion’s payment will be paid in one lump sum upon receiving the claim.
Claim submitted 2/1/2016
18 months of treatment remaining
Previous insurer’s total allowable: $4,000 (Total allowed: amount which would have been paid to the orthodontist over the lifetime of the case by both the previous insurer and the member had coverage remained effective with the previous insurer for the full duration.)
Previous insurer payment: $1,000
Dominion’s total payment: $500
Member responsibility: Agreed-upon amount – (Previous insurer payment + Dominion Payment)
$4,000 - ($1,000 + $500) = $2,500