SafeGuard DHMO High Plan - Risk Management

Evidence of Coverage and Disclosure Statement
Table of Contents
Who May Enroll ................................................................................. 4
Service Area ..................................................................................... 4
Dependent Coverage ......................................................................... 4
When Coverage Begins ..................................................................... 5
Choice of Provider ............................................................................. 5
Making an Appointment ..................................................................... 5
Specialty Care .................................................................................. 6
Changing Your Selected General Dental Office ..................................... 6
Second Opinions ............................................................................... 6
Prepayment Fee ................................................................................ 7
Co-payments .................................................................................... 7
Customer Service ............................................................................. 8
Emergency Dental Services ............................................................... 8
Grievance Procedures ........................................................................ 9
Appeals ............................................................................................ 9
Arbitration ...................................................................................... 10
Renewal Provisions ......................................................................... 10
Cancellation of Benefits .................................................................. 10
Termination of Contract ................................................................... 11
Termination of Your Coverage ........................................................... 12
Conversion Privilege/Continuation of Coverage ................................. 12
ERISA ............................................................................................ 13
Member Rights ............................................................................... 14
Member Responsibilities ................................................................. 15
Definitions ...................................................................................... 16
SG-GROUP-EOC 3 FL 3/08