Proposed Care Plan
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Member Information

Name:


Relationship:
Plan Description:
Product ID:

Provider

Name:

Status: Out of Network
Exception Code Procedure Code Alternate Benefit Applied Description Frequency Limitations Unit Tooth # Age Limit Amount Allowed Insurance to Pay Amount Co-Insurance Percentage Utilization Rule Documentation Required

Totals

Allowed Amount:
Insurance Amount:
Deductible Amount Applied:
Total out-of-pocket:

Please Note:

  1. Treatment plans will be deleted after 30 days of inactivity.
  2. Prices displayed are estimates calculated based on members eligibility and planned benefit as of today's date. These are subject to change.

By deleting this Plan, it will be deleted permanently. Do you want to proceed.