400N Enrollment Form - Dental Alternatives Insurance Services Inc

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SafeGuard Network Dentists SafeGuard contracts with dentists who meet our high quality standards, ensuring you the best dental care available. Each dentist is pre-screened and each office is thoroughly evaluated prior to being accepted into our network. Online Directory Instructions Before you enroll... Select a general dentist from the Directory of SafeGuard Participating Dentists You and each of your enrolled dependents may select different general dentists Online Dentist Listing The most current network information can be found in our online directory at www.safeguard.net. Click on “Dental & Vision Directories” Choose "Visitor" and then select “Dental HMO” and state. Select your plan from the scroll down menu (check the Schedule of Benefits in this booklet for the name of your plan). You will be able to search by city, county, zip code, or by a particular dentist's name. After enrollment... To access the directory once you are enrolled, log in to our website and use your Family ID number, Group ID number, or social security number (Family and Group ID numbers are provided on your ID card). If you have any questions, you can call Customer Service at 800.880.1800 or log on to our website at www.safeguard.net/contact.html to email us your questions.
DIRECT REFERRAL DENTAL PLAN* Diagnostic Treatment • Bitewings are limited to 1 per 12 months. • Full mouth x-rays are limited to 1 per 3 years. • Panoramic x-rays are limited to 1 per 3 years. • Orthodontic x-rays are not covered. SCHEDULE OF BENEFITS D0120 Periodic oral evaluation - established patient D0140 Limited (problem focused) oral evaluation D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation - new or established patient D0180 Comprehensive periodontal evaluation - new or established patient SmileSaver 400 North Principal Benefits and Coverages: The following services are the principal benefits to which Members are entitled. Only these procedures are provided for, either partially or totally by the Plan. The Member may be responsible for a co-payment for these procedures. Please reference your Evidence of Coverage to fully understand what is meant by Coverage for a given procedure. If a service is requested and provided to a Member and the procedure is not listed in this Schedule of Benefits, the Member shall pay the dentist his or her usual and customary fee for the treatment received. There may be some procedures that are listed in this document that may not be available at all locations due to individual dentist's scope of practice. Other Charges: The Member is responsible for the Co-payments for services listed in the following Schedule of Benefits. Services not listed will be billed to the Member at the dentist's usual and customary fee (U&C). Specialty Care Information: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dental specialist. *Your SafeGuard selected general dentist is responsible for coordinating your dental care, and if necessary, referring you to a SafeGuard contracted specialist, and will submit all required documentation for any necessary referral. Pedodontics: Pedodontic services are available at a Specialist at 75% of that provider’s usual fee for this service for children under the age of six (6) when referred by a SafeGuard selected general dentist. •If you choose to receive this service from a SafeGuard contracted specialty care provider (periodontics, oral surgery, endodontics, orthodontics), your co-payment will be 75% of that provider’s usual fee for this service. Code Benefit Summary for Specialty Care Calendar Year Limit $1,000/Person Limit per Lifetime $2,000/Person Service Benefits provided by SafeGuard Health Plans, Inc. Co-payment When Services Performed by Contracted General Dentist SM-400N-IDP-SOB Customer Service (800) 880-1800 1/09 $5 $5 $5 $5 $5 Co-payment When Services Performed by Contracted Specialist • $50 $50 $50 $5
Page 1 and 2: Dental HMO SmileSaver Individual 40
Page 3: SmileSaver dental and vision plans
Page 7 and 8: Code Crowns • Cost of Noble or Hi
Page 9 and 10: Code D5211 D5212 D5213 D5214 D5225
Page 11 and 12: Code D7250 D7510 D7530 D7550 D7910
Page 13 and 14: Dental Terminology Definitions Thes
Page 15 and 16: Principle Exclusions and Limitation
Page 17 and 18: Principle Exclusions and Limitation
Page 19 and 20: Evidence of Coverage and Disclosure
Page 21 and 22: Who May Enroll You may enroll yours
Page 23 and 24: SmileSaver Individual & Family Enro
Page 25 and 26: Uniform Health Plan Benefits and Co
Page 27 and 28: No co-payment is required for a sec
Page 29 and 30: prescribed time, the member must ma
Page 31 and 32: • Failure to establish a satisfac
Page 33 and 34: TDD number for the hearing impaired
Page 35 and 36: The following definitions are used
Page 37 and 38: SAFEGUARD DENTAL & VISION HIPAA NOT
Page 39 and 40: Information to a coroner or medical
Page 41 and 42: electronically). The first list you
Page 44 and 45: 000685723/3297-CA-DAIS-CDT9KIT-1
Page 46: SM-DHMO-C

400N Enrollment Form - Dental Alternatives Insurance Services Inc

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