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6.05 The amounts payable by CDS with respect to services provided by a Dentist in another state or country who cooperates with CDS in the administration of the program shall be the applicable percentage specified above of fees charged up to the Customary fee in California. 6.06 Payment for services provided by a Participating Dentist shall be made directly to the Dentist. CON- TRACTS BETWEEN CDS AND ITS PARTICIPATING DENTISTS PROVIDE THAT, IN THE EVENT CDS FAILS TO PAY THE DENTIST, THE ELIGIBLE PERSON SHALL NOT BE LIABLE TO THE DENTIST FOR ANY SUMS OWED BY CDS. 6.07 Payment for services provided by a Dentist who is not a Participating Dentist may be made to an Eligible Person, and shall not be assignable. IN THE EVENT CDS FAILS TO PAY A DENTIST WHO HAS NOT CONTRACTED WITH CDS AS A PARTICIPATING DENTIST, THE ELIGIBLE PERSON MAY BE LIABLE TO THE DENTIST FOR THE COST OF SERVICE. 6.08 CDS shall not be obligated to pay claims submitted more than six (6) months after the date of providing the service. If a claim is denied due to a Participating Dentist's failure to make timely submission, the Eligible Person shall not be liable to such Dentist for the amount which would have been payable by CDS, provided that the Eligible Person advised the Dentist of his eligibility for Benefits at the time of treatment. 6.09 CDS shall prepare and furnish to each Participating Dentist and to any other Dentist or Eligible Person on request a standard form to make a claim for payment for services covered by this Contract. In order to make a claim for pay- ment, such form, duly completed in accordance with the terms thereof by the Dentist who provided the services and by the Eligible Person (or the patient's parent or guardian if such patient is a minor), shall be submitted to CDS at the address shown thereon. 6.10 CDS shall notify each claimant who submits a claim in accordance with paragraph 6.09 above if such claim is denied, in whole or in part, stating the reason or reasons for the denial. Within sixty (60) days after receipt of such notice a claimant may make a written request for review of such denial, by addressing such request to CDS, P.O. Box 7736, San Francisco, California 94120, Telephone (415) 864-9800, Attention: Benefit Services Department, stating the reasons the claimant believes that the denial of the claim was in error and requesting any pertinent documents which the claimant wishes to review. The Benefit Services Department of CDS will review the claim. If the review involves a determination as to the quality of services provided or the appropriateness of fees charged, and the matter cannot be resolved by CDS to the satisfaction of the claimant, it will be referred to a peer review committee of the appropriate dental society or association which will accept jurisdiction, and CDS agrees to be bound by the determination of such peer review committee. Unless reference to a peer review committee is required or other unusual circumstances arise, a decision on a request for review shall be provided and communicated to the claimant in writing within 120 days after receipt of a request for review. ARTICLE VII - OTHER CDS OBLIGATIONS 7.01 CDS shall advise Participating Dentists as follows: A. To complete and submit a standardized Attending Dentist's Statement, (ADS), prior to providing service, showing the Eligible Person's dental needs and the treatment necessary in the professional judgment of the Dentist. B. To notify the patient of all actions taken by CDS with respect to such Attending Dentist's Statements, and C. That such ADS need not be submitted prior to providing of services in the case of emergency services or in the case of brief, routine procedures. 7.02 CDS shall authorize such ADS for Benefits when satisfied from the ADS and other data submitted by the Dentist that (a) the patient is an Eligible Person hereunder, (b) the services proposed are Benefits under this Contract, and (c) that the total fees to be charged for such services to both CDS and the Eligible Person do not exceed the Participating Den- tist's Usual, Customary and Reasonable fees. Such authorization shall be for a reasonable period up to a maximum of sixty (60) days, but shall not be required to extend beyond termination of the patient's eligibility, and may be revoked upon notice of such termination. In no event shall an authorization period exceed the termination date of this Contract. -9- 11 77 AD/RET/PSE