Benefit Details

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Member Information

Subscriber ID:

Employee ID:

Product ID:

Eligibility Status:

Plan Year Begins:

Plan Type:

Plan Description:

Assigned Dentist:

Phone Number:

Address:

Patient Last Name:

Patient First Name:

Group ID:

Group Policy Number:

Group Name:

Member Product Effective Date:

Member Product Term Date:

Group Plan Effective Date:

Product Description:

Plan Information - Coverage and Deductible

Procedure Category	Procedure Category Description	Coverage	Deductible Applies	Waiting Period Met Date	Coverage	Deductible Applies	Waiting Period Met Date
		IN			OUT

Plan Information - Deductible

Description	Member Amount	Family Amount	Member Amount	Family Amount
	IN		OUT

Plan Information - Limit

Description	Member Limit Amount	Family Limit Amount	Member Limit Amount	Family Limit Amount
	IN		OUT

Amount of Limit Met

Limit Description	Member Limit Amount	Family Limit Amount	Member Limit Amount	Family Limit Amount
	IN		OUT

Rollover Benefit

Benefit Year Maximum:

Benefit Year Award Received:

Benefit Year Bonus Received:

Benefit Year Maximum Paid Toward Award:

Benefit Year Award Used:

Benefit Year Bonus Used:

Benefit Year Award Balance:

Benefit Year Bonus Balance:

Utilization

ADA Code	ADA Description	Procedure Category	Service Dates				Service Date Procedure Code Frequency* (i-ii-iii)	Age Limit	Alternate Benefit	Related Codes
* Frequency Definition: i = Number of Procedure (999 = unlimited); ii = ProcedureFrequency Type (C=Calendar Year, F=Floating, P=Plan Year); iii = Period and Timeframe(D=Day, M=Month, Y=Year) Example: 1 F 36M read as 1 Procedure per 36 Floating Months

Claims Address Payor Id:

521337971

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: 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 4: 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.