SCOPE OF WORK AND RESPONSIBILITIES 1. Interconnection Customer’s Scope of Work and Responsibilities
Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services. This plan covers dental care for members until the last day of the month in which they turn nineteen (19). This plan covers services only if they meet all of the following requirements: • listed as a covered dental care service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered dental care service under this plan. • dentally necessary, consistent with our dental policies and related guidelines at the time the services are provided. • not listed in Exclusions section. • received while a member is enrolled in the plan. • consistent with applicable state or federal law. • services are provided by a network provider.
Service Specification The Parties have agreed upon the scope and specification of the Services provided under this Service Agreement in the Service Specification.
Attachment A, Scope of Services The scope of services is amended as follows:
Statement of Work The Statement of Work to which Grantee is bound is incorporated into and made a part of this Grant Agreement for all purposes and included as Attachment A.