TIER ONE INSURANCE COMPANY (“TIER ONE”)
Last Revised: 03/27/2025
Introduction
This is Tier One’s Dental Access Plan for the participating provider network servicing covered individuals. The network consists of access to providers contracted with DenteMax, LLC (“DenteMax”), NovaNet, Inc. ("NovaNet," which uses the Connection Dental Network), and Aflac Benefits Solutions, Inc. (“ABS”) (collectively, the “Network”). This Access Plan contains information regarding the accessibility and availability of participating providers within the Network, as well as information on the quality and type of services available to covered individuals. This Access Plan is available online at https://www.aflac.com/aflac-dental-and-vision/aflac-network-access-plans/default.aspx
For more information, please contact ABS’s Vice President of Network Development and Credentialing at 877-864-0625, or write to: ABS Dental & Vision, Inc., Attn: VP of Network Development, 4211 W. Boy Scout Blvd., Ste 295, Tampa, FL 33607.
Network
Tier One has contracted with ABS to provide administrative services including, but not limited to, services related to managing and overseeing the Network, policy administration, and claims administration. In addition, American Family Life Assurance Company of Columbus (Aflac of Columbus) has contracted with SKYGEN USA LLC (“SKYGEN”) to maintain ABS’ provider data management systems and maintain the provider directory. Tier One has access to this agreement as an affiliate of Aflac of Columbus. ABS joined the agreement with SKYGEN for credentialing purposes only. ABS is also contracted with DenteMax and Novanet to access their contracted providers. Tier One insureds have access to all providers in the Network.
Tier One will periodically monitor ABS to ensure the standards agreed upon related to the Network are being met. DenteMax and Novanet are responsible for credentialing their Network providers, and ABS uses SKYGEN for credentialing. All credentialing organizations comply with state regulations. A delegated credentialing audit is performed on an annual basis for each network accessed.
ABS has oversight responsibility to ensure the credentialing and quality assurance standards are consistent, and Tier One retains oversight and accountability for all services delegated to ABS.
Network Adequacy and Corrective Action Process
Criteria Used to Build Network
The Network considers many factors when adding providers. Every provider must be licensed, maintain adequate professional liability insurance, operate in compliance with all laws and regulations, comply with state board orders, complete all credentialing and recredentialing requirements, and comply with provider agreements, policies and procedures.
Network Development and Adequacy
The provider directory is available to applicants prior to issuing coverage. ABS will monitor the availability of providers in the Network, including data related to the location of covered individuals and provider utilization. Monitoring is done monthly by ABS through Geo-Access reports that compare the number of providers to the number of covered individuals in a given county.
Covered individuals may request that Tier One send network provider recruitment information to their current providers. Tier One will communicate any recruitment requests received to ABS and ABS will take appropriate action.
Specialty Care Providers
ABS requires the Network to contract with independent dental specialists to ensure members have adequate access to specialty care. Contracted specialists include oral surgeons, orthodontists, periodontists, pediatric dentists, prosthodontists, and endodontists.
Covered individuals are not required to obtain a referral in order to receive specialty care; however customers should refer to their Policy Schedule to determine which services are covered. The availability of specialty care providers within the Network is monitored to determine if additional specialists are needed.
Network Adequacy Issue and Corrective Action Process
If a network adequacy issue exists, Tier One will provide benefits for covered services at the office of an out-of-network general or specialist dentist at the same plan allowance as if they utilized a network provider.
Covered individuals may call Customer Service for prior approval for network benefits at an out-of-network provider. If a network adequacy issue is confirmed, ABS and the out-of-network provider will negotiate a Single Case Agreement, and the claim will be adjusted to reflect the network benefit cost share.
Claims will be administered using the Usual and Customary Rate as outlined in the policy. The coinsurance percentage amount is the same whether an individual goes in or out of the network.
ABS will provide oversight on the network management and will establish network expansion targets to ensure adequate appointment availability. ABS will exercise contract termination provisions in extreme situations such as appointment discrimination or prolonged failure to comply with corrective action efforts.
Referrals
Individuals with Tier One coverage have the freedom of choice in selection of a provider and are not required to designate or choose a primary dental provider. Tier One does not require a referral to select or change a dentist.
Tier One does not require a referral to see a Network specialist; however, customers should refer to their Policy Schedule to determine which services are covered.
Comprehensive Listing of Network Providers
Tier One ensures covered individuals have access to an updated list of Network general dentists and Network specialists in a variety of ways.
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List of Network Providers
An online Provider Directory is publicly accessible. To locate a provider, covered individuals can visit https://www.aflac.com/about-aflac/providers/default.aspx and select “Go to the Network Dental Providers Page. Searches can be conducted by City/State or Zip Code. The search may be narrowed by selecting a Provider Specialty type or entering in a provider’s name or practice name. The Provider Directory is updated on a regular basis.
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Customer Service
Individuals with Tier One coverage may contact Customer Service at 866-990-2668, TTY/RTT 711 to find a provider or to obtain further information about their coverage.
Ongoing Monitoring
Tier One’s dental network meets Colorado’s adequacy requirements. Tier One’s dental plan provides access to at least one dental provider for at least 90% of our customers within the maximum road travel distance required for each county. Colorado designates each county as one of five geographic types or classifications*:
Geographic Type: Maximum Road Travel Distance
- Large Metro: 10 miles
- Metro: 20 miles
- Micro: 35 miles
- Rural: 60 miles
- CEAC (Counties with Extreme Access Considerations): 85 miles
*The plan provides access to at least one provider for at least 90% of enrollees.
Using Geo-Access reporting through Quest Analytics, ABS measures, tracks, and trends network adequacy against the required access standards on a quarterly basis in each county/state for each provider type. The reports compile information such as the number of individuals with coverage and their geographic distribution, distance to providers in their closest residential proximity, the percentage of providers accepting new patients, after-hours clinic availability and appointment standards, as well as the type of care (emergency, urgent care, or routine care).
Aflac’s national standards with respect to member accessibility to participating providers are:
- Urban - provider within 30 miles from a member’s residence
- Suburban - provider within 60 miles from a member’s residence
- Rural - provider within 90 miles from a member’s residence
This standard may be modified based on a state’s regulation, if more stringent, or on state and local geographic conditions, such as dental specialists and member population in the area. The target of participating providers may be geographically distributed differently depending upon the density of population.
The above listed targets are statewide measures, considering rural, urban, and suburban areas. While these targets take into consideration less populated rural areas where a supply of providers is limited, Aflac may require the Network to exceed these targets in urban areas. Aflac will require the Network to make reasonable efforts to contract with providers in extremely rural areas in any state as well as geographic areas with recognized maldistribution of dental specialists. Service areas are generally approved for an entire state.
Evaluation of performance indicators and diligent monitoring of network and enrollment changes assist ABS in identifying any hotspots where need is high and network concentrations are not in sync. This analysis is the foundation of an informed recruitment strategy, making sure that there is access to optimum high-quality general and specialty dental care.
Provider Directory Audit
To maintain a high degree of data accuracy, the provider directory content is verified and updated at least annually or in accordance with state law. Any necessary updates are completed within 24 hours to two business days of receiving updated information. Members can report a discrepancy in the provider directory by calling ABS Member Services tollfree number on their member ID card or by sending an email to provider.relations@aflac.com. Records of the provider directory audit are retained in compliance with Aflac’s corporate record retention schedule.
Needs of Special Population
ABS has developed various services that are designed to address the special needs of members with limited English proficiency or literacy, diverse cultural and ethnic backgrounds, and with physical or mental disabilities. Our goal is to provide services to members in a manner sensitive to the cultural background, religious beliefs, values and traditions and to those with limited English proficiency or those with physical or mental disabilities. If a member requires special accommodations, they can contact us at the toll-free number on their member ID card or by using RTT 711.
Telehealth Services
Tier One will follow any state law or federal emergency orders requiring teledentistry coverage.
Communication with Covered Individuals
Covered individuals are informed about Tier One coverage through brochures/outlines of coverage, application forms, policy documentation, and a public website.
Individuals may search the public website for a Network provider in their area at any time, or they may also call Customer Service. Dentists are not assigned, and individuals are able to visit any general dentists or specialist without the need for a referral; however, customers should refer to their Policy Schedule to determine which services are covered.
The process for providing and approving emergency care is outlined in the policy documentation. Prior authorization is not required for obtaining emergency services. All general dentists are required to have 24-hour telephone access and the scheduling of emergency appointments within 24 hours. Callers who contact Tier One are instructed to seek assistance from any licensed dentist and if the caller does not have a current provider, the Customer Service Representative will assist the individual in finding a provider.
Information on how to file a complaint, grievance, or appeal is on claim communications and found on myaccount.aflac.com. Individuals may also contact Customer Service at our toll-free number to obtain information about their appeal rights.
Continuity of Care
Provider Contract Termination
Participating providers are contractually obligated to complete procedures in progress in the event of contract termination, for a period not to exceed 90 days.
ABS will make a good faith effort to provide written notice of termination of discontinued providers within fifteen (15) business days, or otherwise as soon as practicable, to all covered individuals who are seen on a regular basis (within the past 12 months) by the provider or that receive primary dental services from the provider. Since dentists are not assigned to covered individuals, covered individuals are encouraged to check the status of a general dentist or specialist before receiving care.
With the exception of collecting copayments, deductibles, and amounts exceeding (a) benefit maximums or (b) for noncovered services as provided for in a member’s benefit plan, participating providers will only be compensated for covered services provided to a member and providers will not seek compensation, remuneration, or reimbursement from covered individuals or persons acting on covered individuals’ behalf, other than for allowable copayments for covered services, even if Tier One for any reason, including insolvency, fails to pay the provider.
Plan for Insolvency or Other Inability to Continue Operations
Tier One is a wholly owned subsidiary of Aflac Incorporated. In the unlikely event Tier One becomes insolvent or otherwise unable to continue operations, it would ensure covered individuals receive uninterrupted dental coverage through the end of the applicable contract period. Tier One would ensure individuals receive advanced written notice of any anticipated change to Tier One’s business operations.
Quality Assurance Standards
ABS has established a Quality Assurance Program to identify, evaluate and remedy potential problems relating to access, continuity, and quality of care. The Quality Assurance Program follows basic principles of quality improvement with a team approach of clinical leaders, subject-matter experts, and day-to-day leadership to measure and monitor processes.
Methods for Evaluating Consumer Satisfaction with Services Provided
ABS monitors member satisfaction through the analysis of member complaints, grievances and appeals. ABS analyzes, tracks, and trends all complaints, grievances, and appeals and works to rectify any company or provider issues that appear to be trending.
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