400N Enrollment Form - Dental Alternatives Insurance Services Inc

Evidence of Coverage and Disclosure Statement
Table of Contents
Who May Enroll .................................................................................. 4
Service Area ...................................................................................... 4
Dependent Coverage .......................................................................... 4
When Coverage Begins ...................................................................... 4
Choice of Provider .............................................................................. 5
Facilities ........................................................................................... 5
New Patient and Routine Services ...................................................... 5
Making an Appointment ...................................................................... 5
Uniform Health Plan Benefits and Coverage Matrix ............................... 6
Specialist Referrals ............................................................................ 6
Changing Your Selected General Dental Office ...................................... 6
Second Opinions ................................................................................ 7
Prepayment Fee ................................................................................. 8
Co-payments ..................................................................................... 8
Other Charges ................................................................................... 8
Coordination of Benefits ..................................................................... 8
Customer Service .............................................................................. 8
Emergency Dental Services ................................................................ 8
Grievance Procedures ....................................................................... 10
Arbitration ....................................................................................... 11
Termination of Benefits .................................................................... 11
Renewal Provisions .......................................................................... 12
Reinstatement ................................................................................ 12
Current Members ............................................................................. 13
New Members ................................................................................. 13
Member Rights ................................................................................ 14
Member Responsibilities .................................................................. 14
Language Assistance ....................................................................... 15
Definitions. ...................................................................................... 16
SG-INDIV-EOC 3
CA 12/07
8/08