HRI Dental recognizes the value in sharing information with you so you can make the best decisions based on your individual or family dental needs. This page will give you a brief overview of some important elements of your Individual Marketplace coverage. While much of this information is available in your member policy and/or summary of benefits, this page reviews the basics so you can quickly understand commonly used terms and policies.
HRI Dental offers one of the largest dental networks and is licensed in Ohio, Michigan, Indiana, and Kentucky. When you enrolled in HRI Dental, you selected a dentist for yourself, and for each Member of your family.
Depending on the benefit plan you’ve chosen you may or may not have Out-of-Network Dental benefit coverage. Your member policy and/or summary of dental benefits will clearly state whether or not you have Out-of-Network Dental benefit coverage.
Balance billing occurs when an Out-of-Network dental provider bills a member for charges other than copayments, coinsurance, or the amount remaining on a deductible after HRI Dental has submitted payment on a claim. In-Network dental providers are not permitted to balance bill members.
If you or your family are enrolled in a Dental benefit plan that does not include Out-of-Network Dental benefit coverage, you will be held financially responsible for any services you receive if your selected dentist is Out-of-Network, which could include being balance billed. If a medically necessary covered service or procedure is not available from any Participating Providers (In-Network), you must contact HRI Dental member services prior to requesting coverage and a pre-treatment request from an Out-of-Network Dental provider. It is the Member’s responsibility to make sure procedures and services are provided by a Participating Provider.
HRI Dental Member Services: 800-727-1444
You don't need to submit claims for services received from in-network providers as your dentist and dental office will do so. If you have received services from an out-of-network provider, you may be personally responsible for submitting claims directly to HRI Dental. Some Out-Of-Network Dentist will file the claim as a courtesy to their patients, but they are under no obligation to do so. A member must provider all of the information the Plan needs to process a claim including, an ADA approved claim form, an invoice of the charges and proof of payment.
The member is responsible for the deductible, any out-of-pocket expenses required by the Plan including the co-insurance and the cost of services that are not covered by the Plan, and any charges above the maximum allowable for the service.
If you are required to file a claim yourself, be sure to include the following information on the ADA approved claim form:
Claims should be submitted within 1 year from the date of service to the following address:
HRI Dental
PO Box 659
Evansville, IN 47704
If members do not pay the amount of premium by the date it is due, HRI Dental will apply a grace period. This grace period will allow our members additional time to pay their premium without losing their dental benefit coverage.
The standard grace period is 31-days. If a member’s premium (beyond the initial premium payment) is not paid by the monthly due date, it may be paid during the following 31 days without impacting your coverage. During the 31-day grace period, your policy and coverage will remain in effect.
If you receive advance payments of the premium tax credit and have previously paid at least one full month’s premium during the benefit year, the grace period is extended to three (3) months. If all outstanding premium payment is not paid within the three (3) month grace period, your coverage will terminate and pended claims submitted during the second and third months of the grace period will be denied and you will be responsible for payment to your dental provider.
If you have any questions concerning the grace period, contact the Member Services Department.
Member Services Department: 800-727-1444
Claims will pend when it has been submitted to HRI Dental from a Dental provider and is still being processed by our claims team.
HRI Dental conducts audits on paid claims and may issue denials, when appropriate, making you responsible for payment. Examples to reduce the likelihood of adverse benefit determination include, use of only in-network providers, except in an emergency, understand limitations and exclusions, and paying premiums timely.
If you dispute a premium payment or need to request a refund of premium overpayment, you may contact Member Services for additional assistance.
Acquiring a Pre-treatment Estimate is a quick and easy process that we encourage all of our members to do to help them understand their dental benefit coverage.
A Pre-treatment Estimate is a non-binding estimate of the Benefits available and Member Responsibility for a proposed treatment plan after the application of Policy Limitations, Restrictions, and Exclusions, remaining Plan Annual Maximum and determination of Covered Services. It is suggested that pre-treatment estimates are utilized on services that could cost more than $300. Per your member policy or Summary of Dental Benefits, Pre-treatment Estimates are required for certain procedures/services to be received.
Pre-treatment Estimates are typically processed within 3-5 business days. If services that require a Pre-treatment Estimate are received prior to the Pre-treatment Estimate being submitted, received, approved; those services/claims are subject to being rightfully denied by HRI Dental.
If a medically necessary covered service or procedure is not available from any In-Network dental providers, HRI Dental will make arrangements for an Out-of-Network Dental provider only after initiated by you as the member. If HRI Dental approves of this Pre-Treatment-Estimate, written confirmation will be sent to you and the Out-of-Network Dental provider.
All Eligible authorized services will be covered subject to appropriate Deductible and Copayments/Coinsurance.
Services received without obtaining prior authorization will be denied.
HRI Dental only covers dental services and does not cover prescribed medications.
The Explanation Of Benefit (EOB) provides details about a dental insurance claim that has been processed and explains what portion HRI Dental paid to the dental provider and what portion of the payment, if any, is the patient's responsibility. EOBs are mailed to members after a claim has been received and adjudicated within our system. The EOB is not a bill. Pay special attention to the Claims Detail portion of the EOB which states, You are responsible for this amount. This is the portion of the expense not covered by HRI Dental, and includes deductible, co-pay or coinsurance. The provider will bill the patient and the patient’s payment should be paid directly to the provider. The EOB will also include deductible as well as pertinent messages regarding network providers and a patient’s right for review of denied claims.
The EOB will include the following information:
If you have questions about your EOB, contact Member Services.
Member Services Department: 800-727-1444
If you have more than one Dental insurance plan, those plans need to work together to make sure you’re getting the most out of your coverage. That process is referred to as Coordination of Benefits. Coordinating your benefits helps us process your claims faster and maximizes your benefits, which can lower your out-of-pocket costs. One plan becomes your primary plan and pays your claims first. Then the second plan pays toward the remaining cost.
Please refer to your Member Policy and Summary of Dental Benefits for more detailed information.