Dental

Emergency dental services are dental procedures administered in a dentist’s office, dental clinic, or other comparable facility, to evaluate and stabilize dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a reasonably prudent lay person possessing average knowledge of dentistry to believe that immediate care is needed.

If you require emergency dental services, you may go to any dental provider, go to the closest emergency room, or call 911 for assistance, as necessary. Prior Authorization for emergency dental services is not required.

Your reimbursement from SafeGuard for emergency dental services, if any, is limited to the extent the treatment you received directly relates to emergency dental services — i.e. to evaluate and stabilize the dental condition. All reimbursements will be allocated in accordance with your plan benefits, subject to any exclusions and limitations. Hospital charges and/or other charges for care received at any hospital or outpatient care facility that are not related to treatment of the actual dental condition are not covered benefits.

If you receive emergency dental services, you will be required to pay the charges to the dentist and submit a claim to SafeGuard for a benefits determination. If you seek emergency dental services from a provider located more than 25 miles away from your Selected General Dentist, you will receive emergency benefits coverage up to a maximum of $50, less any applicable co-payments.

To be reimbursed for emergency dental services, you must notify Customer Service within forty-eight (48) hours after receiving such services. If your physical condition does not permit such notification, you must make the notification as soon as it is reasonably possible to do so. Please include your name, family ID number, address and telephone number on all requests for reimbursement.

If you do not require emergency dental services and a delay in receiving treatment would not be detrimental to your health, please contact your Selected General Dental Office or SafeGuard’s Customer Service Department at (800) 880-1800 to make reasonable arrangements for your care.

Emergency dental services are procedures administered in a dentist’s office, dental clinic, or other comparable facility, to evaluate and stabilize dental conditions of a recent onset accompanied by excessive bleeding, severe pain, or acute infection that would lead a prudent layperson, possessing an average knowledge of dentistry, to believe that immediate care is needed. If you cannot reach your dentist or SafeGuard’s Customer Service, you may obtain Emergency Dental Services from any licensed dentist.

SafeGuard will provide coverage for the following Emergency Dental Services without regard to whether the dentist or provider furnishing the services has a contractual or other arrangement to provide services to covered individuals:

• Dental screening examinations or other evaluations required by state or federal law, which are necessary to determine whether an emergency dental condition exists.

• Necessary emergency dental care services, including the treatment and stabilization of an emergency dental condition.

• Services originating in a dental office following treatment or stabilization of an emergency dental condition, provided the treating dentist has made inquiry to and received authorization from SafeGuard for the post stabilization services.

SafeGuard shall respond to the treating dentist within the time appropriate to the circumstances relating to the delivery of the services and the condition of the member, but in no case to exceed one (1) hour.

SafeGuard’s Customer Service will request that you send a copy of the bill incurred as a result of such dental emergency to SafeGuard, along with a brief explanation as to the unavailability of your dentist. No claim forms are required. Please include your name, Family Identification Number, address and telephone number on all pages.

After verifying the circumstances, SafeGuard will reimburse you for the expenses for covered services, less any applicable co-payment, if an emergency existed. Examples of a dental emergency are defined as procedures administered in a dentist’s office, dental clinic, or other comparable facility, to evaluate and stabilize dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a prudent layperson possessing an average knowledge of dentistry to believe that immediate care is needed.