TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 TABLE OF CONTENTS Section I. Definitions 7 Section II. How Your Coverage Works 11 Participating Providers 11 The Role of Primary Care Dentists 11 Services Subject to Preauthorization 11 Medical Necessity 12 Important Telephone Numbers and Addresses 13 Section III. Cost-Sharing Expenses and Allowed Amount 14 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 19 Section VI. Adult Dental Care 21 Section VII. Exclusions and Limitations 23 Section VIII. Claim Determinations 25 Section IX. Grievance Procedures 27 Section X. Utilization Review 29 Section XI. External Appeal 32 Section XII. Termination of Coverage 35 Section XIII. Extension of Benefits 36 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 37 Section XV. General Provisions 38 Section XVI. Schedule of Benefits 42 Riders, Contract Amendments. End of Contract This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueShield of Northeastern New York 00 Xxxxxxx Xxxx Xxxxx Latham, New York 12110 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueShield of Northeastern New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 President & CEO BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Cost-Sharing Expenses and Allowed Amount 11 Section IV. Who is Covered 13 Section V. Pediatric Dental Care 16 Section VI. Adult Dental Care 18 Section VII. Exclusions and Limitations 20 Section VIII. Claim Determinations 22 Section IX. Grievance Procedures 24 Section X. Utilization Review 26 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 Section XIII. Extension of Benefits 34 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 Section XV. General Provisions 36
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000. TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 9 Participating Providers 9 The Role of Primary Care Dentists 9 Services Subject to Preauthorization 10 Medical Necessity 11 Important Telephone Numbers and Addresses 12 Section III. Cost-Sharing Expenses and Allowed Amount 13 Section IV. Who is Covered 16 Section V. Pediatric Dental Care 20 Section VI. Adult Dental Care… 23 Section VII. Exclusions and Limitations 26 Section VIII. Claim Determinations 29 Section IX. Grievance Procedures 32 Section X. Utilization Review 35 Section XI. External Appeal 40 Section XII. Termination of Coverage 44 Section XIII. Extension of Benefits 46
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. Xxxxxxx X. Xxxxx, Executive Vice President/Chief Operating Officer TABLE OF CONTENTS SECTION I. Definitions 1 SECTION II. How Your Coverage Works 5 C. Participating Providers 5 D. The Role of Primary Care Dentists 6
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand- alone dental plan offered outside the New York State of Health. MVP Health Services Corp. Schenectady, New York By: President TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 8 Participating Providers 8 The Role of Primary Care Dentists 8 Services Subject to Preauthorization 9 Medical Necessity 9 Important Telephone Numbers and Addresses 10 Section III. Access to Care and Transitional Care 11 Section IV. Cost-Sharing Expenses and Allowed Amount 13 Section V. Who is Covered 15 Section VI. Pediatric Dental Care 18 Section VII. Exclusions and Limitations 20 Section VIII. Claim Determinations 22 Section IX. Grievance Procedures 24 Section X. Utilization Review 26 Section XI. External Appeal 30 Section XII. Termination of Coverage 33 Section XIII. Extension of Benefits 34 Section XIV. Temporary Suspension Rights for Armed Forces’ Members 35 Section XV. General Provisions 36 Schedule of Benefits Attached SECTION I
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueShield of Northeastern New York 00 Xxxxxxx Xxxx Xxxxx Latham, New York 12110 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueShield of Northeastern New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.
TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 SECTION I Definitions Defined terms will appear capitalized throughout the Contract Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this Contract for a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by BlueShield of Northeastern New York, including the Schedule of Benefits and any attached riders. Child, Children: The Subscriber’s Children, including any natural, adopted or stepchildren, unmarried disabled Children, newborn Children, or any other Children as described in the Who is Covered section of this Contract. Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the service that You are required to pay to a Provider. The amount can vary by the type of Covered Service.
