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
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Samples: Preferred Provider Organization Insurance Contract, Preferred Provider Organization Insurance Contract, Preferred Provider Organization Insurance Contract
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-stand- alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this ContractMVP Health Services Corp. Schenectady, You may call Us at 0-000-000-0000. New York [ ] By: CEO & Director TABLE OF CONTENTS Section I. Definitions 4 Section II. How Your Coverage Works 9 8 Participating Providers 9 8 The Role of Primary Care Dentists 9 8 Services Subject to Preauthorization 10 9 Medical Necessity 11 9 Important Telephone Numbers and Addresses 10 Section III. Access to Care and Transitional Care 12 Section IIIIV. Cost-Sharing Expenses and Allowed Amount 13 14 Section IV. V. Who is Covered 16 Section V. VI. Pediatric Dental Care 20 Section VI. Adult Dental Care… 23 19 Section VII. Exclusions and Limitations 26 21 Section VIII. Claim Determinations 29 23 Section IX. Grievance Procedures 32 25 Section X. Utilization Review 35 27 Section XI. External Appeal 40 31 Section XII. Termination of Coverage 44 33 Section XIII. Extension of Benefits 4634
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