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Second Opinion <br />You or Your dependent may request a second opinion if there are unanswered questions about diagnosis, <br />treatment plans, and/or the results achieved by such dental treatment. In addition, We or You or Your <br />dependent's Selected General Dentist may also request a second opinion. There is no second opinion <br />consultation charge. You or Your dependent will be responsible for the office visit Co -Payment as listed in the <br />Schedule of Benefits. <br />Reasons for a second opinion to be provided or authorized shall include, but are not limited to, the following: <br />(1) If You or Your dependent question the reasonableness or necessity of recommended surgical <br />procedures. <br />(2) If You or Your dependent question a diagnosis or plan of care for a condition that threatens loss of <br />life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a <br />serious chronic condition. <br />(3) If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to <br />conflicting test results, or the treating Selected General Dentist is unable to diagnose the condition, <br />and the enrollee requests an additional diagnosis. <br />(4) If the treatment plan in progress is not improving Your or Your dependent's dental condition within an <br />appropriate period of time given the diagnosis and plan of care, and You or Your dependent request <br />a second opinion regarding the diagnosis or continuance of the treatment. <br />Requests for second opinions are processed within five (5) business days of Our receipt of such request, <br />except when an expedited second opinion is warranted; in which case a decision will be made and conveyed <br />to You within twenty-four (24) hours. Upon approval, We will contact the consulting Selected General Dentist <br />and make arrangements to enable You or Your dependent to schedule an appointment. <br />All second opinion consultations will be completed by a Selected General Dentist with qualifications in the <br />same area of expertise as the referring Selected General Dentist or Selected General Dentist who provided <br />the initial examination or dental care services. <br />You or Your dependent may request a second opinion or obtain a copy of the second dental opinion policy by <br />contacting Us either by calling (800) 880-1800 or sending a written request to the following address: <br />SafeGuard <br />Go Customer Service <br />PO Box 3594 <br />Laguna Hills, CA 92654-3594 <br />Emergency Dental Care <br />Emergency Dental Care means dental screening, examination, and evaluation by a Dentist, or, to the extent <br />permitted by applicable law, by appropriate personnel under the supervision of a Dentist to determine if an <br />Emergency Dental Condition exists, and, if it does, the care and treatment necessary to relieve or eliminate <br />the Emergency Dental Condition. <br />All Selected General Dental Offices provide treatment for Emergency Dental Conditions twenty-four (24) <br />hours a day, seven (7) days a week and We encourage You or Your dependent to seek care from Your <br />Selected General Dental Office. If treatment for an Emergency Dental Condition is required, You or Your <br />dependent may go to any dental provider, go to the closest emergency room, or call 911 for assistance, as <br />necessary. Prior authorization is not required. <br />Your reimbursement from Us for treatment for an Emergency Dental Condition, if any, is limited to the extent <br />the treatment You or Your dependent received directly relates to the evaluation and stabilization of the <br />Emergency Dental Condition. All reimbursements will be allocated in accordance with the group contract, <br />subject to any exclusions and limitations. Hospital charges and/or other charges for care received at any <br />hospital or outpatient care facility are not Covered Services. <br />If You or Your dependent receive treatment for an Emergency Dental Condition, You will be required to pay <br />the charges to the Dentist and submit a claim to Us for a benefits determination. If You or Your dependent <br />seek treatment for an Emergency Dental Condition from a provider located more than fifty (50) miles away <br />GCERT2011-DHMO-EOC 2 <br />5^-2 <br />4 <br />10 <br />