Plan 3000 - Dental Alternatives Insurance Services Inc

TABLE OF CONTENTS
Section
Page
NOTICE FOR RESIDENTS OF CALIFORNIA..............................................................................................4
Confidentiality of Dental Records ..............................................................................................................4
Organ Donation .........................................................................................................................................4
Language Assistance ................................................................................................................................4
Notice Regarding Your Rights and Responsibilities..................................................................................5
Rights:....................................................................................................................................................5
Responsibilities:.....................................................................................................................................5
DENTAL BENEFITS.....................................................................................................................................6
Dentist-Patient Relationship ......................................................................................................................6
Who May Enroll .........................................................................................................................................7
SERVICE AREA............................................................................................................................................7
DEPENDENT COVERAGE...........................................................................................................................7
WHEN COVERAGE BEGINS.......................................................................................................................7
Choice of Dentists .....................................................................................................................................8
Facilities.....................................................................................................................................................8
Changing Your Selected General Dental Office........................................................................................8
Provider Reimbursement...........................................................................................................................8
Liability of Subscriber or Enrollee for Payment .........................................................................................8
Prepayment Fee ....................................................................................................................................8
Co-Payments .........................................................................................................................................9
Orthodontic Covered Services...............................................................................................................9
Yearly Maximums ..................................................................................................................................9
Covered Services After Dental Coverage Ends ....................................................................................9
Non-Covered Services...........................................................................................................................9
Other Charges .....................................................................................................................................10
Reimbursement Provisions......................................................................................................................10
Specialty Care Referrals..........................................................................................................................10
Second Opinion .......................................................................................................................................10
Emergency Dental Care ..........................................................................................................................11
TERMINATION OF BENEFITS...................................................................................................................12
Cancellation of Benefits...........................................................................................................................12
Renewal Provisions.................................................................................................................................13
Reinstatement .........................................................................................................................................13
Disenrollment...........................................................................................................................................13
CONTINUITY OF CARE.............................................................................................................................13
Current Members.....................................................................................................................................13
New Members .........................................................................................................................................13
DENTAL BENEFITS: INQUIRIES AND GRIEVANCE PROCEDURES.....................................................14
Routine Questions About Dental Benefits...............................................................................................14
Grievance Procedures.............................................................................................................................14
Arbitration ................................................................................................................................................15
Coordination of Benefits ..........................................................................................................................15
Third Party Liability..................................................................................................................................15
Assignment of Benefits............................................................................................................................15
INDIVIDUAL CONTINUATION OF DENTAL BENEFITS WITH PAYMENT OF THE PREPAYMENT FEE
....................................................................................................................................................................16
For Mentally Or Physically Handicapped Children..................................................................................16
For Family And Medical Leave................................................................................................................16
GCERT2011-DHMO-EOC 2