Government of Guam Self- Insured Dental Plan
INFORMATION & NOTIFICATION
Enrollment/Eligibility

We have successfully processed and loaded all Government of Guam subscriber and dependent eligibility information into our administrative and benefit system. We welcome over 23,000 GovGuam members under the Self Insured Dental Plan administered by NetCare Life & Health Insurance Company.

Member ID Cards

We are currently processing and printing all Member ID Cards for distribution within the next two weeks. You can call our customer service center at (671)472-3610 or via email at csr@netcarelifeandhealth.com. to obtain your member ID number in order to print a temporary card. You are also welcome to call customer service for eligibility verification prior to your scheduled dental appointment.

Locating a Provider

To locate a participating dental provider, please access our website at www.netcarelifeandhealth.com and click on the GOVGUAM link. You can view NetCare’s Participating Dental Providers on Guam and outside of Guam.

Referrals are required to access a participating dental provider in the Philippines and/or U.S. Please be informed that failure to obtain an approved referral from NetCare to access an off-island dental provider will result in services being denied and not covered.

Health Risk Assessment (HRA)

We invite you to complete a Health Risk Assessment (HRA) by visiting www.netcarelifeandhealth.com. Good oral health can have a positive or negative impact on your medical health. In order to access the HRA portal, you will need to insert the assigned GovGuam HRA number which is #8383777.

Summary of Plan Description (SPD)

NetCare will issue a Summary of Plan Description (SPD) outlining the covered and non-covered dental benefits and how we will administer the self- insured dental plan for the Government of Guam. The SPD will be available on the GovGuam page at www.netcarelifeandhealth.com or you can call our customer service center at (671)472-3610 to have a copy mailed to your address.

Contacting Customer Service

NetCare’s Customer Service Center is open Monday through Friday at 8:00am to 5:00pm. Our customer service center is located at the Julale Center in Hagatna, suite 200, second floor. We welcome you to come by and visit with us…no appointments are necessary

Our capable customer service representatives are able to assist you with understanding your benefits, locating a participating dental provider, facilitating off-island referrals outside of Guam and updating eligibility information and changes.

Our customer service helpline is (671)472-3610 or via facsimile at (671)472-3615 or via email at csr@netcarelifeandhealth.com.

Policy:

NetCare is required by Guam law to offer certain appeal and grievance procedures. These procedures are listed below. NetCare does have the option to impose time limitations on filing the appeals or grievances. These specific plan limitations, as well as any other plan specific information, are listed below.

Process:

Plan members have two (2) separate appeal routes. One takes place when the member contests a decision to deny or limit health care services "non-certification decision" or for experimental or investigational treatment. This is called an APPEAL. The other appeal route occurs when a member is unhappy with other aspects of the plan’s operations. A complaint about other operations of the plan is called a GRIEVANCE.

Members have the right to two (2) levels of review, for both appeals and grievances. The first level of review has a different name and a slightly different process depending on whether it is a first-level appeal or first-level grievance review. However, the second-level review is the same regardless of whether the dispute is a denial of services or another problem with the plan’s operation. This is referred to as a second-level grievance hearing or an external hearing.

Members who contest non-certification decisions (denials of services or procedures) have a right to ask for expedited review if the normal time limits could hurt the person’s health. Otherwise, the normal time limits apply. There is not an expedited process for first-level grievance decisions, because first-level grievance hearings do not deal with non-certification decisions (these are handled at the first level appeals).

Informal Reconsideration: NetCare has an informal process where it can resolve disputes quickly. The informal process is voluntary.

Appeal

• First Level Appeal: Members can file an appeal on their own behalf. In addition, a physician or other person acting on the member’s behalf can file an appeal. NetCare offers at least two levels of appeals. A physician who was not involved in the original decision must hear the first appeal. In this level, normally the physician has thirty (30) days for post-service claims or fifteen (15) days for pre-service claims to decide and inform the member of its decision of the appeal. All appeals from a member or physician acting on behalf of a member must be made in writing.
  
  NetCare must provide a written decision to the member and the member’s provider. The decision should contain the qualifications of the person reviewing the appeal, the reviewer’s decision including the medical rationale and evidence used as the basis for the decision, and instructions on how to file a second-level grievance hearing.
• First Level Expedited Appeal: Members can request an expedited appeal if their health would be harmed by the 30-day or 15-day delay. In an expedited appeal, the physician has up to thirty-six (36) hours to make a decision. However, members can request the decision be made immediately if there is a more immediate health care need. Members will have their health services covered until the member is notified of the expedited review decision, if the appeal involves concurrent review such as continued stay in a hospital. Members are not entitled to expedited review if the health care services have already been provided and the issue is whether the care was appropriate.
• Second Level Expedited Appeal: Members can request an expedited second-level review if their health could be harmed because of any time delays. Members may request an expedited second-level review even if the first-level appeal or grievance review was not expedited. In this level review, the Plan has thirty-six (36) hours to make a decision. If necessary, NetCare may conduct the hearing over the phone or through submission of written information.

Grievance

• First Level Grievance Hearing: The member, his representative or the provider may submit a first-level grievance. NetCare must provide the member with information on how to submit written materials, within seven (7) business days after receiving notice of the grievance. The person reviewing the grievance cannot be the same person who initially handled the grievance. If the issue is a clinical one, at least one of the reviewers must be a medical physician with appropriate expertise. NetCare must make a grievance decision within thirty (30) days after receiving the complaint. The notice of the decision must include the same information as provided in first-level appeal decisions.
• Second Level (External) Hearing: NetCare also has second-level grievance reviews for members who are dissatisfied with the decision of the non-certification appeal or first level grievance review. NetCare must notify the member of the name and telephone number of the grievance coordinator, as well as information about the second-level grievance process within five (5) business days of receiving a request for a second-level grievance. Members have more extensive due-process rights at the second-level grievance review.
  
  The member may request for an external review where NetCare will convene a hearing panel that will comprise of people who are not employees of NetCare or utilization review organization, who were not previously involved in the decision, and who do not have a financial interest in the outcome of the review. All people reviewing a second-level appeal involving a non-certification or clinical decision should be providers who have appropriate expertise in the health issue in dispute. If the review involves a grievance, the people should be members of the community who have appropriate expertise in the issue in dispute.
  
  The member can attend the second-level grievance-hearing, request and receive all information relevant to the case in order to prepare for the hearing. Members may present his or her case to the review panel, submit supporting materials before and at the review meeting, ask questions of any member of the review panel and bring another person to help in the review hearing. These could include a family member, employer representative or attorney. If the member chooses to bring an attorney, then an attorney may also represent NetCare. The review panel has up to fifteen (15) business days to hold the hearing, and up to ten (10) business days thereafter to make a decision. This decision is a recommended decision to NetCare.
  
  NetCare may provide expedited access or process of the external hearing if the member’s health or issue will be harmed by the thirty (30) day time delay. Expedited access to the External hearing level will follow the same process as the Expedited Appeal.
  
  NetCare must provide a written decision to the member and the person’s provider (if appropriate). The decision should contain the qualifications of the people reviewing the grievance, the reviewer’s decision, including the medical rationale for the decision and the evidence used as the basis for the decision. The account states that the decision is the insurer’s final determination in the matter.

Appeals and Grievances Procedures (PDF version)
Grievance Complaint Form

To access these files, you must have the LATEST ADOBE READER installed. To install the Adobe Reader for FREE, please click here.

NetCare’s Customer Service Center is open Monday through Friday at 8:00am to 5:00pm. Our customer service center is located at the Julale Center in Hagatna, suite 200, second floor. We welcome you to come by and visit with us…no appointments are necessary. Our customer service helpline is (671)472-3610 or via facsimile at (671)472-3615 or via email at csr@netcarelifeandhealth.com.

As a member under the GovGuam Self Insured Dental Plan, you have the right to:

• Receive information regarding the Plan including services, benefits, and limitations.
• Information on your rights and responsibilities and any charges you may be responsible for.
• Obtain evidence of dental credential of a Participating Provider.
• Receive courteous and personal attention and be treated with respect and dignity. NetCare personnel, network doctors, other health care professionals and their staff will respect your privacy.
• Privacy and confidentiality of your dental and medical history, enrollment file and any Protected Health Information (PHI).
• Voice concerns about the service and care received.
• File a grievance for an administrative or dental care complaint and hearing procedures without retribution from the NetCare as your TPA.
• Have coverage denials reviewed by appropriate and qualified professionals consistent with NetCare’s review procedures. Informal and formal steps are available to you to resolve all complaints/grievances/appeals.
• Choose a primary dental provider which enables you to participate in the management of your total health and dental care needs, including the right to refuse care from a specific provider.
• Change Primary Care Physician (PCP) if so desired. Limited to one request for change per day.
• Receive information from health care professionals about your medications, including what are the medications, how to take them, and possible side effects.
• Openly discuss with your dentist the appropriate and necessary treatment options for your condition, regardless of cost or benefit coverage.
• Be informed if a dental provider or professional plans to use an experimental treatment or procedure in your care. You have the right to refuse to participate in research projects.
• Complete an Advance Directive, Living Will or other directive and give it to your health care professionals.
• Receive urgently needed medically necessary care.
• Privacy and confidentiality regarding your dental care and records. NetCare will not release personal health information to an employer, or its designee without a signed Authorization for the Use or Disclosure of Protected Health Information by you. Reference Notice of Privacy Practices for a description of how NetCare Health protects your personal health information.
• Access to dentists, dental care professionals and other health care facilities.
• Participate in decisions about your care with your dentist and other health care professionals.
• Receive information about NetCare Health, our services, and provider network.

Members’ Rights and Responsibilities

• Know your benefit coverage and its limitations.
• Contact an appropriate dental care professional when you have a dental need or concern.
• Show your member ID card before receiving dental care services.
• Never authorize anyone else to use your ID card.
• Use emergency room services only for injury and illness that, in the judgment of a reasonable person, requires immediate treatment to avoid jeopardy to life or health.
• Provide complete and accurate information to the providers rendering care.
• Follow agreed-upon instructions and guidelines of dentists and health care professionals.
• Participate in understanding your dental health problems and developing mutually agreed-upon treatment goals.
• Notify NetCare of changes in Name, Address, Contact information, family status, loss of an identification card, selection of a Primary Care Physician (PCP) or other medical insurance coverage that you or your family members may have.
• Schedule appointments, arrive on time for scheduled visits, and notify your dental provider if you must cancel or be late for a scheduled appointment.
• Contact NetCare within 48 hours upon receiving emergency care outside NetCare’s service area.
• Contact Primary dental provider before seeking any specialty dental service.
• Log in to MyNetCare portal or call Customer Service when you have a question about your eligibility, benefits, claims and more.
• Log in to www.netcarelifeandhealth.com or call Customer Service before receiving services to verify that your provider or health care professional participates in NetCare Health’s provider network.
• Maintain a relationship with a general dentist, as the provider will act as the coordinator for all of your dental care needs.
• Pay any necessary co-insurance, deductibles, co-payments in accordance to the “Schedule of Benefits” at the time treatment/service is received.
• Be courteous and respectful of NetCare employees, providers, and their staff.

New User Sign Up

Once you logon to the website, click on the GOVGUAM page (top right corner of your screen). Then click on MyNetCare Portal (top right corner of your screen). This will take you to the secured NetCare Member Portal page. Then click on New User Registration (top left corner of your screen).

You will then be linked to the New Account Setup Form. Please complete all applicable fields on the New Account Setup Form (which include creating your own User ID and Password). Once completed, select the Submit button at the bottom of the screen. If pertinent information is missing, you will be asked to complete the highlighted fields until completed. Please allow 48 hours from submission to access your account.

Existing User Sign In

Once you have completed the steps to sign up, you will now be able to access your online member services that would include 24 hour access to your paid claims & eligibility, view & submit inquiries regarding your benefits or eligibility, paperless enrollment, medical information, messaging services, and much more!

Don’t remember your User ID?

If you do not remember your user I.D, you may contact our customer service department at 671-472-3610 or email csr@netcarelifeandhealth.com to obtain your I.D. If you do not remember your password, click on the Forget Password link which will allow you to reset your password.

Member Portal Features include:

• Personal Data/Eligibility
• Dependent Status
• Benefits
• Claims Status
• Provider Listings & Update
• Print a temporary Member ID Card

Affidavit of Lawful Marriage
Affidavit of Natural Child
Affidavit of of Step Child
Affidavit of Domestic Partnership
Affidavit of Child Disability