Dental Questionairre 2011 by xiaopangnv

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									Brownsville ISD
Dental Program Questionnaire

                                                   Company
                                                       X
                                               Agent Information
                                          x
                                          x
                                          x
                                                  Claims Office
                                          x
                                          x
                                          x
                                          x
Rates:                                               Rates
Employee Only                             x
Employee + Dependent                      x
Employee + Spouse
Employee + Family                         x
Benefits/Covered Services:                          Benefits
Deductible                                x
Is Deduct waived for
Diagnostic/Preventive?                    x
Annual Max.                               x
Waiting Period                            x
Services:                                           Services
Diagnostic/Preventive                         Diagnostic/Preventive
Exams, Cleaning, x-rays, etc.             x
Basic                                                 Basic
Fillings, sealants, etc.                  x
Major/Waiting Period (              )                Major
Crowns, bridges, dentures                 x
Endodontic - root canals                  x
Periodontics - gum treatment              x
Oral Surgery                              x
Orthodontic                               x
Orthodontic Maximum                       x

Special Questions:
Coverage for anesthesia for extractions
How pay nonparticipating providers
Turnaround time claims pmt
Claims in Mexico
Exclusions:

Required: Granfather of Waiting Period

								
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