A. Dental Plan Administration • Design, implement, and manage dental insurance plans, including PPO, Indemnity and DHMO plan options as specified. • Enrollment processing for active employees, retirees, dependents and COBRA beneficiaries. • Plan communication and education materials for members, including custom or personalized communications when needed. • Ongoing plan management, including updates and modifications. B. Claims Processing and Management • Efficient and accurate claims adjudication and reimbursement. • Handling of pre-authorizations, referrals, and coordination of benefits. • Management of denied claims and appeals process. C. Provider Network Management • Development and maintenance of a broad, accessible network of licensed dental providers. • Credentialing, contracting, and ongoing provider relations. • Provider directory maintenance and updates. D. Member Services • Call center support for member inquiries and assistance. • Member portal access for plan information, claims status, and provider search. • Educational resources on dental health and preventive care. E. Compliance and Reporting • Must be registered with the Secretary of State to do business in the State of California. • Ensure compliance with all applicable federal and state regulations. • Regular reporting on plan utilization, financials, and member satisfaction. • Data security and confidentiality in accordance with HIPAA and other relevant laws.
