Proposed Care Plan

Member Information

Name:

Relationship:

Plan Description:

Product ID:

Provider

Name:
Status: Out of Network

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Exception Code	Procedure Code	Alternate Benefit Applied	Description	Frequency Limitations	Unit	Tooth #	Age Limit	Amount Allowed	Insurance to Pay Amount	Co-Insurance Percentage	Utilization Rule	Documentation Required

Totals

Allowed Amount:

Insurance Amount:

Deductible Amount Applied:

Total out-of-pocket:

Please Note:

Treatment plans will be deleted after 30 days of inactivity.
Prices displayed are estimates calculated based on members eligibility and planned benefit as of today's date. These are subject to change.

By deleting this Plan, it will be deleted permanently. Do you want to proceed.

Disclaimer 1: This is the most current information that we have; however, it is the patient’s responsibility to check with the dental provider to verify they are participating and accept the patient’s plan. This is neither an authorization nor a guarantee of eligibility, benefits or payment.
Disclaimer 2: Some ADA codes require dental review. Please be sure to include narrative or xrays. Predeterminations are highly recommended for procedures over $500.
Disclaimer 3: The information contained is a summary of the patient’s history. Not all plan information is listed. Absence of information indicates no history exists for the patient for that category/procedure but does not indicate that there are no limits on the plan.
Disclaimer 4: This document including attachments, may include confidential and/or proprietary information as designated by state or federal law, and may be used only by the person or entity to which it is addressed. If the reader of this document is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution, or copying of this fax is prohibited. If you have received this document in error, please notify the sender by calling customer service at 1-800-445-9090 and delete this document and its attachments immediately.
Disclaimer 5: Treatment plan and guarantee are valid for 30 days. Member must remain eligible for benefits at the time services are rendered. Guarantee is only applicable to services included in the original treatment plan as submitted to the Treatment Plan Calculator. Providers should: a) Include same-day services (e.g., evaluations, prophys, diagnostic, etc.) in the Treatment Plan Calculator to ensure accumulations reflect appropriately, and b) Consult with the member and the extended care team, to account for any additional services during the 30-day guarantee period, up to and including all services provided during the initial evaluation.
Disclaimer 6: The guarantee will not apply if: a) Member has utilized additional services from this or any other provider during the 30-day guarantee period, or b) Provider is on the Provider Outlier Program (POP).
Disclaimer 7: If your Treatment Plan Calculator amount does not match your reimbursement, please contact Customer Service at 800-822-5353 to discuss whether you qualify for a reimbursement adjustment.