[PDF] [PDF] CERTIFICATE OF COVERAGE The Guardian Life - HealthSource RI

[PDF] Understanding Your Health Insurance: Certificate of Coverage and

What is a health insurance certificate of coverage? When you enroll in a health insurance plan, you are given a certificate of coverage It may also be called a

[PDF] Certificate of Coverage - Blue Cross Complete of Michigan

2 06 CERTIFICATE OF COVERAGE (or Certificate) is the statement of covered benefits, including the terms of enrollment and covered services Certificate of Coverage may also be referred to as the Certificate

[PDF] Online certificate of coverage available through Cigna Envoy

A Certificate of Coverage will auto-generate based on the customer's reported work location and will include their coverage details and any dependents covered 

[PDF] Certificate of Coverage - Molina Healthcare

This Certificate of Coverage represents that in consideration of the Member's enrollment, Molina Healthcare shall provide and/or arrange for covered health care 

[PDF] CERTIFICATE OF COVERAGE The Guardian Life - HealthSource RI

covered charges for covered services Plan: This term means the group dental expense coverage described in the Policy and this Certificate

[PDF] Certificate of Coverage Under Group Health Plans Notice HIPAA

Certificates of coverage are written documents provided by a group health plan ( or another source that offers health care coverage) to show the type of health 

[PDF] Certificate of Coverage - Wisconsin Department of Employee Trust

For PARTICIPANTS enrolled in IYC MEDICARE PLUS coverage, the following benefits apply PARTICIPANTS covered under this section must be covered by 

[PDF] CERTIFICATE OF GROUP HEALTH PLAN COVERAGE - NJgov

Date coverage ended: (or check if coverage is continuing as of the date of this certificate _____ ) NOTE: Separate certificates will be furnished if information is not 

[PDF] a1 débutant tv5 monde apprendre le français

[PDF] a1 débutant tv5 monde apprendre le français

[PDF] a1 driving lecture

[PDF] a1 english grammar test pdf

[PDF] a1 english placement test pdf

[PDF] a1 english practice test pdf

[PDF] a1 english test (sample papers)

[PDF] a1 english test pdf with answers

[PDF] a1 english test practice

[PDF] a1 english test sample papers pdf

[PDF] a1 form belgium

[PDF] a1 form download

[PDF] a1 form online application

[PDF] a1 form working in belgium

[PDF] a1 lecture in benin

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001

CERTIFICATEOFCOVERAGE

TheGuardianLifeInsuranceCompanyofAmerica

7HanoverSquare

NewYork,NewYork10004

providingsimilaror

GROUPDENTALEXPENSECOVERAGE

GuardiancertifiesthattheEmployeenamed

belowisentitledtothebenefits

Planfor

Policyholder:GroupPolicyNumber:

IssuedTo:

GroupPolicyNumber:00494953

TheGuardianLifeInsuranceCompanyofAmerica

VicePresident,GroupProduct

B951.0055

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001

TABLEOFCONTENTS

ELIGIBILITYFORDENTALCOVERAGE

DEPENDENTCOVERAGE

DENTALEXPENSEBENEFITS

ADULTDENTALSERVICES

LISTOFADULTCOVEREDDENTALSERVICES

LISTOFCOVEREDPEDIATRICDENTALSERVICES

TABLEOFCONTENTS(CONT.)

CONTINUATIONRIGHTS

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.1

DEFINITIONS

Prosthesis.

andendsonDecember31. pedodontics. arecoveredbythisPlan. andanyofYourcovereddependents. dentalpracticeparameters. implants;and(d)postsandcores.

YouareeligibleforcoverageunderthisPlan.

aW-2form.

Employer:ThistermmeansRI-SUPPLEMENTPLAN.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.2

chewingorbitingfoodorothersubstances. requiredpayments.

Provider.

B951.0056

coveredchargesforcoveredservices.

PolicyandthisCertificate.

thenecessityoftheproposedtreatment. consideredaCoveredPersonunderthisPlan. accruedRollover. receiveaRollover.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.3

InsuranceCompanyofAmerica.

B951.0057

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.4

GENERALPROVISIONS

LimitationofAuthority

isnotinasignedapplication.

Incontestability

non-paymentofpremiums. herlifetime. thePlan. addressonfilewithYourEmployerorUS.

B951.0058

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.5

DENTALCLAIMSPROVISIONS

governedasshownbelow.

Notice

alsobeshown.

ClaimForms

thelossforwhichtheclaimisbeingmade.

ProofofLoss

loss.

LateNoticeofProof

andproofassoonasreasonablypossible.

PaymentofBenefits

children;or(5)Yourbrothersandsisters.

LegalActions

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.6

lossisrequiredtobegiven.

Workers'Compensation

B951.0059

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.7

UTILIZATIONREVIEWPROCESS

provider. theclaimant. theendoftheinitial15-dayperiod. totherequestforadditionalinformation. provider. beingreviewed. approval. anappeal.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.8

applicable. providermayinitiateanappeal. eachappeallevelareshownbelow.

B951.2712

InternalAppeals

hastherighttorequestafirstlevelappeal. thenoticeoftheadversedetermination. shouldbemadeto:

TheGuardianLifeInsuranceCompanyofAmerica

GroupQualityAssurance-WROP.O.Box2457

Spokane,WA99210-2457

Telephone:(800)541-7846

determination.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.9

determination. adversedetermination. businessdaysfollowingtheverbalnotice. made. toaddinformationtothisfileinwriting. determination. determination. adversedetermination. businessdaysfollowingtheverbalnotice. externalappeal. writtenrequestforaexpeditedappeal. thedecision.

ExternalAppeals

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.10

noadverseeffectonanybenefit.

Personwith:

abilitytoreachmaintainmaximumfunction;or expeditedexternalreview.

IndependentReviewOrganizations

Wewill:

anexternalappeal. a.Us; proposingtheservice; or neithertheCoveredPersonnorWeobject.

AllcostswillbepaidbyUs.

B951.2713

RightsandDuties

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.11

toanexternalappealunderthisCertificate; reviewprocess; servicethroughoutthereviewprocess;and organization. considersnecessaryandappropriate. apply: and

2.ThetermsofthisCertificate.

conditionforwhichcoveragehasbeenwaived. ofitsdetermination: businessdaysaftermakingthedetermination. bindingonUs.

ComplaintProcess

GuardianCompliance

TheGuardianLifeInsuranceCompanyofAmerica

7HanoverSquareMailStationH23N

NewYork,NY10004-2616

TelephoneNumber(212)598-1384

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.12

inwriting. tohowitwillbesettled. thecomplaint. sharingarrangements. assistanceat1-855-747-3224(855-RIREACH).

B951.2714

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.13

ELIGIBILITYFORDENTALCOVERAGE

EligibleEmployee

YoupurchasethiscoverageontheExchange.

ConditionsofEligibility

dentalcoverageunderthisPlan.

WhenEmployeeCoverageStarts

WhenEmployeeCoverageEnds

Employer.

thisPlan.

B951.0063

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.14

DEPENDENTCOVERAGE

AdoptedChildrenandStep-Children

theageoftheDependentChildren.

DependentsNotEligible

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.15

HandicappedChildren

orshereachedtheagelimit. andmaintenance. onceayear.

WaiverofDentalLateEntrantPenalty

duetooneoftheeventslistedbelow:

TerminationofYourspouse'semployment.

Divorce.

DeathofYourspouse.

Terminationoftheotherdentalplan.

withYourEmployer'srules. order.

B951.0064

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.16

WhenDependentCoverageStarts

oflikeageandsex. coveredasoftheenrollmentdate.

WhenDependentCoverageEnds

when:

YourEmployeecoverageends.

monthwhen:

YourEmployeecoverageends.

Heorshestopsbeinganeligibledependent.

Heorsheattainstheagelimit.

B951.0109

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.17

DENTALEXPENSEBENEFITS

Plan'sScheduleofBenefits.

ProviderOrganization

whichiscalledDentalGuardPreferred.

PreferredProviderisused.

PaymentLimits.

CoveredCharges

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.18

benefitsfortheosseoussurgery. bythisPlan. chamberisopened. furnished.

B951.2715

AlternateTreatment

fillingbenefit.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.19

ProofofClaim

newproof.

Pre-TreatmentReview

besenttoUs. dentalpractice. Plan. pre-treatmentreviewismade.

Claim.

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.20

BenefitsfromOtherSources

works.

B951.0111

WaitingPeriodsforCertainServices

coverchargesforthefollowingservices:

GroupIIIServices.

Plan. priorgroupcoveragewithnolapseincoverage.

B951.0065

PenaltyforLateEntrants

GroupIIServices.

GroupIIIServices.

bythisPlan. portionofthisPlan.

B951.0067

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.21

HowWePayBenefitsforServices

ScheduleofBenefits.

person'scoverageends.

B951.0069

RolloverofBenefitYearPaymentLimit

unusedBenefitYearPaymentLimit,asfollows: below.

Non-PreferredProvider.

chargesduringaBenefitYear.

AccountMaximumare:

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.22

rolloverprovisionfirstapplies.

B951.0070

ADULTDENTALSERVICES

Limitations

heorshebecamecoveredbythisPlan.

Exclusions

Wewillnotpayfor:

GC-SUPP-SHOP-15-RI

00494953/00000.0/A/K60070/9999/0001P.23

similarlaws. experimentalinnature. procedurewhichisnotcoveredbythisPlan. madeserviceable.quotesdbs_dbs4.pdfusesText_8