11-104 0721 - Dental Benefit Handbook 8.14.25.pdf

Dental Benefit Handbook Delta Dental of New Mexico www.deltadentalnm.com

104 0721 Delta Dental of New Mexico

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104 0721 Delta Dental of New Mexico

Dental Benefit Handbook Delta Dental of New Mexico

Thank you for choosing Delta Dental of New Mexico for your fully insured dental Benefits. This Dental Benefit Handbook, along with the Summary of Dental Plan Benefits, describes important Plan provisions. We recommend reviewing this Handbook for general information about your Benefits, including topics such as eligibility, how to use your Benefits, and how we define Benefits and their accompanying limitations and exclusions. Please refer to your Summary of Dental Plan Benefits for specific information about your Plan and available Provider network(s).

To the extent that anything set forth in this Handbook conflicts with your Summary of Dental Plan Benefits, your Summary of Dental Plan Benefits will control. Any modification to this Plan will apply to all Enrollees covered by this Plan at the time of such changes.

Your Plan is underwritten by Delta Dental Plan of New Mexico, Inc., a not-for-profit health care plan providing dental and other ancillary services (“Delta Dental”).

Benefits are provided under a Group Dental Insurance Contract (“Contract”) entered into between an employer (“Group”) and Delta Dental.

To obtain copies of Plan documents, including the Dental Benefit Handbook and the Summary of Dental Plan Benefits, please contact Delta Dental Customer Service by calling (877) 395-9420 or sending an email to customerservice@deltadentalnm.com.

You can also request these documents from your organization’s Human Resources or Benefits Manager.

You can access lists of Delta Dental Participating Providers by using the Provider search feature on www.deltadentalnm.com.

Please take time now to become familiar with your dental coverage. For answers to questions about Benefits, please call:

Delta Dental Customer Service Department

(505) 855-7111 or toll-free (877) 395-9420

Oral health is an important part of your overall wellness. Delta Dental plans are designed to promote regular dental visits. Take advantage of your Benefits by calling a Delta Dental Participating Provider today for an appointment.

mailto:customerservice@deltadentalnm.com http://www.deltadentalnm.com/

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Table of Contents I. Eligibility and Enrollment

II. Accessing Your Benefits

III. Benefits, Limitations, and Exclusions

IV. Coordination of Benefits

V. Claims Appeal

VI. Termination of Coverage

VII. Continuation of Coverage

VIII. ERISA

IX. Notice of Privacy Practices

X. General Conditions

XI. Definitions

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I. Eligibility and Enrollment

A. Determining Eligibility Subject to the eligibility rules set forth in your Summary of Dental Plan Benefits, the following eligibility rules apply. To the extent that these rules conflict with those stated in your Summary of Dental Plan Benefits, the rules in your Summary of Dental Plan Benefits control.

No person will be refused enrollment based on health status, health care needs, genetic information, previous medical information, disability, age, race, color, national origin, gender, gender identity, sex, sexual orientation or religion.

1. Individuals who meet one of the following qualifications and enroll in this Plan are eligible:

a. An Employee who satisfies the following: the eligibility definition(s) specified by the Group and accepted by Delta Dental; and the Eligibility Waiting Period specified by the Group and agreed to by Delta Dental.

The Eligibility Waiting Period shall not exceed twelve (12) months.

b. A dependent of the Eligible Employee defined as:

i. Spouse as defined by New Mexico State Law;

ii. Domestic Partner as defined by the Group or as otherwise required by law, unless stated otherwise in the Summary of Dental Plan Benefits;

iii. children from birth through the end of the month of their twenty-sixth (26th) birthday;

iv. children age twenty-six (26) or older who cannot support themselves because of intellectual or development disability or physical disability that began before age twenty-six (26) and are dependent on the Enrolled Employee for support and maintenance. Proof of these facts must be given to Delta Dental within thirty-one (31) days if requested.

2. The definition of “children” for the purposes of coverage under this Plan is:

a. natural child(ren);

b. newly born child(ren);

c. stepchild(ren);

d. child(ren) of a non-custodial parent;

e. child(ren) for whom the Enrolled Employee is the legal guardian;

f. legally adopted child(ren), including children placed with an Enrolled Employee, Spouse, or Domestic Partner for adoption. Coverage shall apply without any pre-existing Benefit restrictions;

g. dependent child(ren) required by a Qualified Medical Child Support Order (QMCSO) or a court or administrative order are also eligible for coverage without regard to Open Enrollment restrictions.

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3. Any individuals not defined above as eligible are not eligible.

B. Enrollment Requirements

1. Employees and their Eligible Dependents must enroll to be covered under this Plan. Unless required by law, Eligible Dependents may enroll only if the Eligible Employee enrolls. Enrollments must be completed and received within thirty-one (31) days of the eligibility date.

2. Newly Eligible Employees and dependents may enroll in accordance with their dates of eligibility.

3. An Enrolled Employee may elect to enroll Eligible Dependents under the following conditions:

a. Eligible Dependents must be enrolled at the time the Eligible Employee becomes enrolled, or within thirty-one (31) days from the date they become dependents, or within thirty-one (31) days of loss of other dental coverage, or during an Open Enrollment period;

b. An Enrolled Employee may not also enroll as a dependent under the same employer’s Plan;

c. A dependent may enroll as the Enrollee of only one Enrolled Employee;

d. Newly born dependents become eligible on the date of birth and may be enrolled on the Group’s Effective Date, within thirty-one (31) days of birth, or at Open Enrollment.

4. Delta Dental will allow an annual Open Enrollment period for all Eligible Employees of the Group. Open Enrollment is a period of time specified by the Group and approved by Delta Dental to allow Eligible Employees and/or their dependents to enroll in this Plan or to cancel coverage under this Plan for the renewed Contract period. Open Enrollment changes are effective the first day of the Group’s renewed Contract period.

5. While an Enrollee is covered by Delta Dental, that person agrees to provide Delta Dental with any information it needs to process claims and administer Benefits. This includes allowing Delta Dental to have access to his or her dental records.

6. If an Eligible Employee does not elect coverage when first eligible, he/she may only enroll during the next Open Enrollment period. If an Eligible Employee elects not to enroll himself/herself or his/her dependents, a waiver must be signed on the Group Plan Enrollment/Change Form at the time of initial eligibility. For individuals waiving due to other dental coverage, this waiver does not affect eligibility for enrollment within thirty-one (31) days if a loss of coverage occurs in the future. Proof of loss of other dental coverage must be provided to Delta Dental within thirty-one (31) days.

7. Delta Dental will not pay Benefits for persons who are not enrolled, nor will Delta Dental pay Benefits for an Enrolled Person if the Group Premium has not been paid for that person for the month in which dental services are performed.

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8. The Group is responsible for submitting monthly Premium to Delta Dental on behalf of all Enrollees. Premium may include contributions by Enrollees as determined by the Group.

C. Effective Dates of Coverage

1. Unless otherwise approved by Delta Dental and indicated in the Summary of

Dental Plan Benefits, coverage for an Enrolled Employee becomes effective on the first day of the month following that Employee’s date of eligibility.

2. Coverage for newly born child(ren) will become effective on the date of birth, if enrolled within thirty-one (31) days, but not before the coverage date applicable to the Enrolled Employee.

3. Coverage for Enrolled Dependents, except as noted in paragraph two (2) above, becomes effective on the same date as the Enrolled Employee or on the first of the month following the dependent’s date of eligibility.

4. You must notify Delta Dental in a timely manner through your employer or organization of any event that changes the eligibility status of an Enrollee or Eligible Dependent. Events that can affect the eligibility status of an Enrollee or Eligible Dependent include, but are not limited to, marriage, birth, death, and divorce. With respect to Qualifying Events that require the enrollment of an individual into this Plan, including but not limited to marriage, birth, or adoption, Delta Dental must receive notification of such Qualifying Event within thirty-one (31) days of such Qualifying Event. Delta Dental may require proof of the Qualifying Event.

D. Re-Enrollment After Voluntary Cancellation of Coverage

1. An Enrolled Employee may cancel Employee or dependent coverage during an annual Open Enrollment period. Re-enrollment is not available until the next annual Open Enrollment period or upon subsequent loss of coverage.

2. Re-enrollment in this Plan between Open Enrollment periods after voluntary cancellation of coverage is not allowed for any reason other than the loss of other dental coverage or another Qualifying Event. Re-enrollment and proof of loss of other dental coverage must be provided to Delta Dental within thirty-one (31) days.

II. Accessing Your Benefits This section describes basic information about selecting a Provider and how to access your Benefits. Please refer to your Summary of Dental Plan Benefits for specific information about the network(s) available under your Plan and the effect of your Provider selection. If you have additional questions regarding how your Plan works, please call Delta Dental Customer Service at (505) 855-7111 or toll-free (877) 395-9420.

A. General Information About Selecting a Provider

1. Your Summary of Dental Plan Benefits contains specific information about your Plan’s network(s). You will have the lowest out-of-pocket costs when

4 – Dental Benefit Handbook 104 0721 you select a Provider who participates in the network specified at the top of your Summary of Dental Plan Benefits.

2. You can search for Participating Providers on www.deltadentalnm.com.

3. Delta Dental does not require that you pre-select a Provider and does not guarantee that a particular Provider will be available.

4. Each Enrolled Person in your family may choose a different Provider.

5. You are responsible for the full payment for any non-covered services.

B. Accessing Benefits To use this Plan, follow these steps:

1. Read this Handbook and the Summary of Dental Plan Benefits carefully to become familiar with your Benefits, network(s), Delta Dental’s method of payment, and the provisions of this Plan.

2. Make an appointment with your Provider and tell him or her that you have dental coverage under this Plan. If the dental office is not familiar with the coverage applicable to this Plan or has questions regarding this Plan, the office may contact the Delta Dental Customer Service Department at (505) 855-7111 or toll-free (877) 395-9420.

3. Following dental treatment, a claim needs to be filed with Delta Dental. All Delta Dental Participating Providers will file the claim directly with Delta Dental. Non-Participating Providers may require patients to file their own claims.

Enrollees may obtain a claim form from www.deltadentalnm.com or request one by calling the Delta Dental Customer Service Department at (505) 855- 7111 or toll-free (877) 395-9420. Upon receiving a request for a claim form, Delta Dental will provide one to the Enrollee within fifteen (15) days. If Delta Dental does not provide a claim form within that time frame, the Enrollee may still submit to Delta Dental written proof, as outlined in Section II(B)4 of this Handbook, of the dental services he or she received. The Enrollee must submit this written proof within the standard time frame for submitting a claim. Upon doing so, the Enrollee shall be deemed to have complied with the requirements of this Plan for submitting a claim for Benefits.

Claims for Benefits must be submitted to Delta Dental in writing within twelve (12) months from the date services were provided. Failure to submit a claim within the time limitation shall not void or reduce the claim if it is shown it was not reasonably possible to submit within the twelve (12) months. Upon review, Delta Dental will make a final determination.

4. Enrolled individuals are responsible for filing claims for services received from a Non-Participating Provider, including Providers outside of the United States. A claim form, including the “Patient Section,” must be completed.

Prior to submission to Delta Dental, the dental office providing services must complete an itemization of services that includes the name of the clinic and Provider, tooth number or area of the oral cavity (if applicable), a description of each individual service, a date of service, a fee for each individual service, and a signature by the Provider. Upon review of any out-of-country claim, 104 0721 Dental Benefit Handbook – 5

Delta Dental may respond to you with a letter requiring your signature acknowledging you received the specified services.

For out-of-country claims, Delta Dental requires an itemized receipt indicating the country’s currency. Please contact the Delta Dental Customer Service Department at (505) 855-7111 or toll-free (877) 395-9420 for assistance with filing an out-of-country claim.

Delta Dental will calculate foreign currency Benefit payments based on published currency conversion tables that correspond to the date of service.

If the services performed outside of the United States are for extractions, crowns, bridges, dentures, or partial dentures, a radiographic image of the area must be obtained prior to the service being considered for Benefits.

Enrolled Persons are responsible for obtaining the necessary documentation for services provided, filing a claim with Delta Dental, and paying the Provider at the time services are performed.

5. Completed claim forms should be submitted to Delta Dental, 100 Sun Avenue NE STE 400, Albuquerque, New Mexico, 87109. The Delta Dental Customer Service Department is available Monday through Friday, 8:00 A.M. – 4:30 P.M. Mountain Time, at (505) 855-7111 or toll-free (877) 395-9420.

6. Within thirty (30) days of receiving a valid claim, Delta Dental will make available an Explanation of Benefits which records Delta Dental’s Benefit determination, any payment made by Delta Dental, and any amount still owed to the Provider. The Explanation of Benefits will be made available to the Enrolled Employee, or other appropriate beneficiary, and to the treating Provider if a Delta Dental Participating Provider. The thirty (30) day period for claim determination may be extended by an additional fifteen (15) days if matters beyond the control of Delta Dental delay Benefit determination.

Notification of any necessary extension will be sent prior to the expiration of the initial thirty (30) day period.

In the event a Group does not pay its monthly Premium, all claims for that Group will be placed on hold. If a claim is on hold for more than thirty (30) days, it may be denied, in which case the Enrollee becomes responsible for any outstanding fees owed to his or her Provider.

7. If a claim for Benefits is reduced or denied, the Explanation of Benefits will state the reason for the Adverse Benefit Determination. Should an Enrolled Person believe Delta Dental incorrectly denied all or part of a claim, a review may be requested by following the steps described in Section V, “Claims Appeal.”

8. You may appoint an Authorized Representative to make contact with Delta Dental on your behalf with respect to any Benefit claim you file or any review of a denied claim you wish to pursue. To download the form to designate your Representative, visit www.deltadentalnm.com, or request a form by calling the Customer Service Department at (505) 855-7111 or toll-free (877) 395-9420 or mailing a letter to 100 Sun Avenue NE STE 400, Albuquerque, New Mexico, 87109. Once you have appointed an Authorized Representative, Delta Dental will communicate directly with your Representative.

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9. For questions and assistance regarding your coverage, you may contact your Human Resources Department or call Delta Dental’s Customer Service Department at (505) 855-7111 or toll-free (877) 395-9420. You may also write to Delta Dental’s Customer Service Department at 100 Sun Avenue NE STE 400, Albuquerque, New Mexico, 87109. When writing to Delta Dental, please include your name, the Group’s name, your member ID number, and your daytime telephone number. If you need the assistance of the government agency that regulates insurance, or have a complaint you have been unable to resolve, you may contact the Office of Superintendent of Insurance.

10. Pre-Treatment Estimates – A Pre-Treatment Estimate of Benefits provides both the patient and the Provider with an estimate of the Benefit levels, maximums, and limitations that may apply to a proposed treatment plan.

Most importantly, the Enrolled Person’s share of the cost will be estimated, allowing you to know what services may be covered before your Provider provides them. A Pre-Treatment Estimate is not required to receive payment, unless stated otherwise in the Summary of Dental Plan Benefits. Your Provider submits the proposed dental treatment to Delta Dental in advance of providing the treatment. You and your Provider should review your Pre- Treatment Estimate before treatment. Once treatment is complete, the dental office will submit a claim to Delta Dental for payment.

a. A Pre-Treatment Estimate is for informational purposes only and is not required before you receive dental care, unless stated otherwise in the Summary of Dental Plan Benefits. It is not a prerequisite or condition for approval of future dental Benefits payment. You will receive the same Benefits under this Plan whether or not a Pre-Treatment Estimate is requested. The Benefits estimate provided on a Pre-Treatment Estimate notice is based on Benefits available on the date the notice is received. It is not a guarantee of future dental Benefits or payment.

b. A Pre-Treatment Estimate is not a guarantee of coverage. Availability of dental Benefits at the time your treatment is completed depends on several factors. These factors include, but are not limited to, your continued eligibility for Benefits, your available annual or lifetime Maximum Benefit Amount, Coordination of Benefits, the status of your Provider, this Plan’s limitations and any other provisions, together with any additional information or changes to your dental treatment. A request for a Pre-Treatment Estimate is not a claim for Benefits or a preauthorization, precertification, or other reservation of future Benefits.

11. If an Enrollee receives emergency care for services specified in this Plan and cannot reasonably reach a Participating Provider (as outlined in the Summary of Dental Plan Benefits), the emergency care rendered during the course of the emergency will be reimbursed as though the Enrollee had been treated by a Participating Provider.

C. Out-of-Pocket Expenses The following out-of-pocket expenses may apply to your Plan:

1. Deductible

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This Plan may require Enrolled Persons to pay a portion of the initial expense toward some Covered Services in each Benefit Period. When applicable, the amount of this Deductible is stated in the Summary of Dental Plan Benefits.

2. Patient Coinsurance The patient Coinsurance is the percentage of Covered Services that the Enrolled Person is responsible for paying to the Provider. The amount of patient Coinsurance will vary depending on the level of Benefits for the particular dental treatment and the selection of a Participating or Non- Participating Provider as described in the accompanying Summary of Dental Plan Benefits.

3. Maximum Benefit Amount Delta Dental will pay for Covered Services up to a maximum amount for each Enrolled Person for each Benefit Period. Enrolled Persons are responsible for payment of amounts due for any dental services that exceed the Maximum Benefit Amount applicable in the Benefit Period. The Maximum Benefit Amount is stated in the Summary of Dental Plan Benefits.

D. Clinical Review

1. All claims are subject to review by a Dental Consultant. A Dental Consultant is a licensed New Mexico Dentist who has no affiliation or connection with Delta Dental other than as an independent consultant.

2. Payment of Benefits may require that an Enrolled Person be examined by a licensed Dental Consultant or an Independent Licensed Dentist.

3. Delta Dental may require additional information prior to approving a claim.

All information and records acquired by Delta Dental will be kept confidential.

E. To Whom Benefits Are Paid

1. Delta Dental will pay a Participating Provider directly for Covered Services rendered. The Enrolled Person is responsible for paying the Provider directly for any Deductible, Coinsurance, and non-covered services.

2. Delta Dental will pay a New Mexico Non-Participating Provider when an assignment of Benefits is received on the individual claim.

3. Delta Dental will pay a Non-Participating Provider practicing outside the state of New Mexico when required by law or when required by the Delta Dental Member Company in that state, and when an assignment of Benefits is received on the individual claim.

4. All available Benefits not paid to the Provider shall be payable to the Enrolled Person or to the estate of the Enrolled Person.

5. Delta Dental must pay directly to the Human Services Department or Indian Health Services any eligible dental Benefits under this Contract which have already been paid or are being paid by the Human Services Department or Indian Health Services on behalf of the Enrolled Person under the state’s Medicaid Program or Indian Health Program.

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6. In cases of a Qualified Medical Child Support Order (QMCSO), Delta Dental will send Benefit payments directly to Participating Providers. Payment of Benefits for services obtained from Non-Participating Providers will be directed in compliance with the valid order of judgment provided in the

QMCSO.

F. Right to Recover Benefits Paid by Mistake If Delta Dental makes a Benefit payment to an Enrolled Person or to a Provider and the patient is subsequently determined as not eligible for all or part of that Benefit, Delta Dental has the right to recover payment. If Benefit payment is made under fraudulent, false, or misleading pretenses or circumstances, Delta Dental has the right to recover that payment. The right to recover a payment includes the right to deduct the amount paid from future dental Benefits for any covered family member. An explanation of the payment being recovered will be provided at the time a deduction is made.

III. Benefits, Limitations, and Exclusions Your Benefits are outlined in your Summary of Dental Plan Benefits. Unless stated otherwise in the Summary of Dental Plan Benefits, the following Benefits, limitations, and exclusions described in this section apply to this Plan. A dental service will be considered for Benefits based on the date the service is completed. Benefits are subject to the Processing Policies of Delta Dental and the terms and conditions of the entire Contract. Refer to the accompanying Summary of Dental Plan Benefits for patient Coinsurance amounts. In addition to the limitations applicable to each type of service, refer to “General Limitations and Exclusions” for a detailed list of other applicable Plan exclusions. To the extent that anything set forth herein conflicts with your Summary of Dental Plan Benefits, your Summary of Dental Plan Benefits will control.

A. Diagnostic and Preventive Services Diagnostic: Procedures to aid the Provider in choosing required dental treatment (patient screenings, oral examinations, diagnostic consultations, diagnostic casts, clinical oral evaluations, and radiographic images).

Palliative: Minor, non-definitive emergency treatment to temporarily relieve pain.

Preventive: Brush biopsy and related lab tests, cleanings, application of topical fluoride, space maintainers, and sealants. Periodontal maintenance is considered to be a cleaning for Benefit frequency determination.

B. Limitations on Diagnostic and Preventive Services

1. Benefit for patient prediagnostic screenings is limited to once in a calendar year. A separate fee for patient assessment is not billable to the patient.

2. A caries risk assessment and documentation, with a finding of low, moderate, or high risk, is a Benefit once every thirty-six (36) months.

a. A separate fee for a caries risk assessment is not billable to the patient when submitted for children under the age of three (3).

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b. A separate fee for a caries risk assessment is not billable to the patient within twelve (12) months of the date of service.

c. A caries risk assessment is not a Benefit at twelve (12) to thirty-six (36) months from the date of service.

d. A separate fee for a caries risk assessment is not billable to the patient when the procedure is performed in addition to any other risk assessment procedure on the same date of service by the same Provider or dental office.

3. Blood glucose level tests and HbA1c tests are not Covered Services.

4. Assessment of salivary flow by measurement is a Benefit once every thirty-six (36) months. Subsequent submissions are not billable to the patient within twelve (12) months and not a Benefit at twelve (12) to thirty-six (36) months.

5. Brush biopsies are limited to once in a twelve (12) month period. A separate fee for interpretation is not billable to the patient.

6. Benefits for oral examinations, including diagnostic consultations, emergency or re-evaluation exams, clinical oral evaluations, routine cleanings, and topical fluoride treatment are limited as shown in the Summary of Dental Plan Benefits.

7. Enrollees under the age of fourteen (14) are limited to routine child cleanings.

Enrollees age fourteen (14) and over will be considered adults for the purpose of determining Benefits for cleanings.

8. Delta Dental will Benefit a complete series of radiographic images as stated in the Summary of Dental Plan Benefits. A panoramic radiographic image with or without bitewing images is considered a complete series of radiographic images. Images exceeding the diagnostic equivalent of a complete series of radiographic images are not billable to the patient when taken on the same date of service. Bitewing radiographic images exceeding the diagnostic equivalent of a complete series of radiographic images are not billable to the patient when taken on the same date of service.

9. Emergency palliative treatment does not include Services and Supplies that exceed the minor treatment of pain. Benefit is limited to radiographic images and tests necessary to diagnose the emergency condition.

10. Services for diagnostic casts, oral/facial photographic images, laboratory and diagnostic tests, non-routine diagnostic imaging, non-surgical collection of specimens, oral hygiene instruction, home fluoride, mounted case analysis, and nutrition or tobacco counseling are not covered. A separate fee for image interpretation is not billable to the patient.

11. Pulp tests are a Benefit per visit, not per tooth, and only for the diagnosis of emergency conditions. Fees for pulp tests are not billable to the patient as part of any other definitive procedure on the same day by the same Provider or dental office except for limited oral evaluation (problem focused), palliative treatment, radiographic images, and protective restorations.

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12. Benefits for sealants are limited to permanent molars. Sealants are a Covered Service for Enrollees as stated in the Summary of Dental Plan Benefits.

13. A separate fee for the replacement or repair of a sealant by the same Provider or dental office is not billable to the patient within two (2) years of the initial placement.

14. An age limitation may apply to services related to space maintainers. Please refer to the Summary of Dental Plan Benefits for applicable age limitations.

15. Fixed bilateral space maintainers are payable once per arch per lifetime for people up to age fourteen (14).

16. Fixed unilateral, removable unilateral, and removable bilateral space maintainers are payable once per quadrant per lifetime for people up to age fourteen (14).

17. A separate fee for the removal of a space maintainer by the same Provider or dental office who placed the initial appliance is not billable to the patient.

Removal of a space maintainer by a different Provider or dental office is a Benefit once per appliance per lifetime.

18. Benefits for distal shoe space maintainers are payable once per area per lifetime for people up to age nine (9).

19. A separate fee for the repair or adjustment of a distal shoe space maintainer by the same Provider or dental office who placed the initial appliance is not billable to the patient.

20. A separate fee for the recementation, re-bond, or repair to a space maintainer by the same Provider or dental office is not billable to the patient within six (6) months of the original treatment. Six (6) months after the original treatment date, recementation, re-bond, or repair is a Benefit once per appliance.

21. Interim caries arresting medicament application is limited to twice per tooth per Benefit Period.

22. Preventive restorations are not a Benefit.

23. Refer to “General Limitations and Exclusions” for additional provisions that may apply.

C. Additional Benefits for Patients with Specified Medical Conditions Delta Dental may pay for additional Benefits for people with specified medical conditions.

1. Patients with the following medical conditions may be eligible for additional cleanings, up to four (4) total cleanings per Benefit Period:

a. Diabetes with periodontal disease

b. Pregnancy with periodontal disease

c. Renal failure/dialysis

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d. Suppressed immune system—chemotherapy/radiation treatment, HIV positive, organ transplants, and stem cell (bone marrow) transplants

e. Head and neck radiation patients

f. Individuals at risk for infective endocarditis

2. Qualifying heart conditions are:

a. History of infective endocarditis

b. Certain congenital heart defects (ex. one ventricle instead of the normal two)

c. Individuals with artificial heart valves

d. Heart valve defects caused by acquired conditions like rheumatic heart disease

e. Hypertrophic cardiomyopathy (causes abnormal thickening of the heart muscle)

f. Individuals with pulmonary shunts or conduits

g. Mitral valve prolapse (MVP) (blood leakage)

3. In addition, head and neck radiation patients may also be eligible for additional topical fluoride treatments, up to two (2) total topical fluoride treatments per Benefit Period.

4. It is important to notify your Provider of these or any other serious medical conditions and to discuss what treatment options may be right for you.

5. You must be able to submit to Delta Dental a documented diagnosis of any of the above conditions to qualify for additional procedures.

D. Restorative Services Restorative services are amalgam, resin-based composite restorations (fillings), or stainless steel and prefabricated stainless steel restorations. These Covered Services are a Benefit for the treatment of visible destruction of the hard tooth structure resulting from the process of decay or injury.

E. Limitations on Restorative Services

1. A separate fee for the replacement of a restoration or any component of a restoration on a tooth for the same surface by the same Provider or dental office is not billable to the patient if done within twenty-four (24) months of the initial service.

2. When multiple restorations involving multiple surfaces of the same tooth are performed, Benefits will be limited to that of a multi-surface restoration. A separate Benefit may be allowed for a non-contiguous restoration on the buccal or lingual surface(s) of the same tooth subject to clinical review.

3. Unless stated otherwise in the Summary of Dental Plan Benefits, resin restorations in posterior teeth are limited to premolars and maxillary first molars. On all other teeth, they are considered optional services and are limited to the equivalent amalgam restoration Benefit.

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4. Prefabricated resin crowns are a Benefit for primary anterior teeth only.

5. Services for metallic, porcelain/ceramic, or composite/resin inlays are limited to the Benefit for the equivalent amalgam/resin filling procedure.

6. Services for metallic, porcelain/ceramic, or composite/resin onlays are subject to clinical review, and limitations on optional services may apply.

7. Replacement of existing restorations (fillings) for any purpose other than treating active tooth decay or fracture is not covered.

8. Separate fees for more than one (1) pin per tooth or a pin performed on the same date of service as a build-up are not billable to the patient. A separate fee for the replacement of pin retention on the same tooth, by the same Provider or dental office, within twenty-four (24) months is not billable to the patient.

9. Refer to “General Limitations and Exclusions” for additional provisions that may apply.

F. Basic Services Anesthesia: Intravenous sedation and general anesthesia.

Endodontics: The treatment of teeth with diseased or damaged nerves (for example, root canals).

Extractions: Surgical extractions. Extraction of coronal remnants of a primary tooth and extraction of an erupted tooth or exposed root are considered non-surgical extractions for Benefit determination purposes.

Oral Surgery: Oral surgery including oral maxillofacial surgical procedures of all hard and soft tissue of the oral cavity.

Periodontics: The treatment of diseases of the gums and supporting structures of the teeth.

G. Limitations on Basic Services

1. Evaluation for deep sedation or general anesthesia is not billable to the patient when billed in conjunction with an evaluation by the same Provider or dental office.

2. Intravenous (IV) sedation and general anesthesia are not Benefits for non-surgical extractions and/or patient apprehension.

3. Intravenous (IV) sedation and general anesthesia are Benefits only when administered by a licensed Provider in conjunction with specified surgical procedures, subject to clinical review and when Medically Necessary.

4. Nitrous oxide and non-intravenous conscious sedation are not covered Benefits.

5. Benefits for pulpal therapy procedures are limited to once in a twenty-four

(24) month period.

104 0721 Dental Benefit Handbook – 13

6. A separate fee is not billable to the patient for pulp therapy procedures when performed on the same day, by the same Provider or dental office, as other surgical procedures involving the root.

7. A separate fee is not billable to the patient for a pulp cap placed on the same day as a restoration or within twenty-four (24) months of a pulp cap placed on the same tooth by the same Provider or dental office.

8. A pulpotomy or pulpal debridement is a Benefit once per tooth per lifetime.

9. Placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization, per site, is considered part of the extraction and/or post-operative procedure. A separate fee is not billable to the patient.

10. Benefits for certain oral surgery procedures are subject to the receipt of an operative report and clinical review, and may be reduced by benefits provided under the patient’s medical benefits coverage, if applicable.

11. Root canal therapy in conjunction with overdentures is not a Benefit.

12. Re-treatment of root canal therapy or re-treatment of surgical procedures involving the root, by the same Provider or dental office, within twenty-four

(24) months, is considered part of the original procedure and a separate fee is not billable to the patient.

13. Apexification Benefits are limited to permanent teeth, once per tooth per lifetime. This procedure is not billable to the patient if performed by the same Provider or dental office within twenty-four (24) months of root canal therapy.

14. Endodontic endosseous implants are not a Benefit.

15. Tooth transplantation, including re-implantation, is not a Benefit.

16. Scaling in the presence of generalized moderate or severe gingival inflammation is considered to be a cleaning for Benefit frequency determination.

17. Periodontal maintenance is considered to be a cleaning for Benefit frequency determination. Benefits for periodontal maintenance are limited as shown in the Summary of Dental Plan Benefits.

18. A separate fee for periodontal maintenance may be not billable to the patient within three (3) months of other periodontal therapy provided by the same Provider or dental office, as determined by clinical review.

19. Full mouth debridement is only a Benefit when necessary to enable comprehensive evaluation and diagnosis on a subsequent visit and is limited to once per lifetime.

20. Periodontal scaling and root planing are a Benefit once per quadrant or site in a two (2) year period.

21. Localized delivery of antimicrobial agents may be performed at six (6) weeks to six (6) months after initial therapy (scaling and root planing or surgery) on no more than two (2) sites per quadrant, with pocket depth at least five (5) millimeters and less than ten (10) millimeters.

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a. If different teeth are treated in the quadrant within twelve (12) months, the treatment is not a Benefit.

b. If the same teeth are re-treated within twenty-four (24) months, the treatment is not a Benefit.

22. Periodontal surgeries, such as gingivectomy, gingival flap, osseous surgery, bone grafts, and tissue graft procedures are limited to once per site in a three

(3) year period.

23. Gingivectomy or gingivoplasty to allow access for a restorative procedure is considered part of the restorative procedure.

24. A bone replacement graft, biologic materials, or guided tissue regeneration in conjunction with an apicoectomy, gingivectomy, crown lengthening, retrograde filling, root amputation, periradicular surgery, soft tissue grafts, subepithelial tissue grafts, extraction, implant site, ridge augmentation, anatomical crown exposure, wedge procedure, or an apically positioned flap is a Specialized Procedure and not a Benefit.

25. Extra-oral soft tissue grafts (grafting of tissues from outside the mouth to oral tissues) or bone graft accession from a donor site is not a Benefit.

26. Separate fees for crown lengthening in the same site are not billable to the patient when charged by the same Provider or dental office within three (3) years.

27. Additional fees for more than two (2) quadrants of osseous surgery on the same day of service are not billable to the patient.

28. Separate fees for postoperative visits and/or dressing changes by the same Provider or dental office performing the treatment are not billable to the patient.

29. Refer to “General Limitations and Exclusions” for additional provisions that may apply.

H. Major Services Crown Build-Ups and Substructures: Benefits when necessary to retain a cast restoration due to extensive loss of tooth structure from caries, fracture, or endodontic treatment.

Crowns and Cast Restorations, Including Repairs to Covered Procedures:

Benefits when a tooth is damaged by decay or fractured to the point that it cannot be restored by an amalgam or resin filling.

Implants: Specified services, including repairs, and related prosthodontics. A crown Benefit is considered the same whether it is placed on a natural tooth or an implant.

Prosthodontics: Procedures for construction, modification, or repair of bridges and partial or complete dentures.

TMD Treatment: Medically Necessary treatment of Temporomandibular Joint Dysfunction, including related diagnostic imaging.

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I. Limitations on Major Services

1. Replacement of cast restorations (including veneers, crowns, pontics, inlays, and onlays) and associated procedures (such as cores and substructures) on the same tooth are not a Benefit if the previous placement is less than five

(5) years old.

2. Inlays are not a Covered Service and will be optioned to an amalgam or resin restoration.

3. Veneers are not a Covered Service.

4. Replacement of a bridge or denture is not a Benefit if the previous placement is less than five (5) years old.

5. Services which are beyond the standard of care customarily provided, or not necessary to restore function, are limited to the Benefit applicable to a standard partial or complete denture. A standard denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

6. Cantilever bridges are beyond the standard of care customarily provided and are subject to clinical review.

7. Overdentures are not a Covered Service.

8. Substructures are only a Benefit when necessary to retain a cast restoration due to the extensive loss of tooth structure from caries or fracture.

Substructures are not billable to the patient when enough tooth structure is present to retain a cast restoration.

9. The fee for a core build-up and/or substructures is not billable to the patient when performed in conjunction with inlays, onlays, ¾ crowns, and veneers.

10. Posts and cores in addition to a crown are a Benefit only on endodontically treated teeth. In addition to the requirement for endodontic treatment, anterior teeth must have insufficient tooth structure to support a cast restoration. Fees are not billable to the patient when these requirements are not satisfied.

11. A separate fee for the recementation or re-bond to crowns, implants, inlays, onlays, posts and cores, veneers, or bridges within six (6) months of the original treatment by the same Provider or dental office is not billable to the patient.

12. A separate fee for the repair to crowns, inlays, onlays, or veneers within twenty-four (24) months of the original treatment by the same Provider or dental office is not billable to the patient.

13. A separate fee for the repair to crowns, inlays, onlays, or veneers within twenty-four (24) months of the original treatment by a different Provider or dental office is not a Benefit.

14. Services for the recementation, re-bond, or repair to crowns, implants, inlays, onlays, posts and cores, veneers, or bridges are a Benefit once per twelve

(12) months. Procedures to modify existing partials and dentures are considered construction of prosthesis, not the repair of prosthesis.

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15. A pontic required due to spaces in excess of those resulting from the extraction of the normal complement of natural teeth is a special condition of that patient’s mouth and is not a Benefit.

16. Surgical placement of an implant body is a Benefit once per tooth per five (5) year period.

17. Implant supported prosthetics and/or abutment supported crowns are not a Benefit if the previous placement is less than five (5) years old. This limitation applies to the placement of crowns on natural teeth, abutment supported crowns on implants, and fixed partial denture pontics.

18. Implant maintenance procedures are limited to twice in a Benefit Period.

19. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure are subject to these limitations and/or exclusions:

a. A separate fee is not billable to the patient when the procedure is performed in conjunction with routine cleanings, periodontal maintenance, root planing and scaling, gingival flap procedures, periodontal osseous surgery, or debridement of a peri-implant defect.

b. This Benefit is limited to once per tooth per twenty-four (24) months.

c. A separate fee for this procedure by the same Provider or dental office within twenty-four (24) months of initial therapy is not billable to the patient.

d. A separate fee is not billable to the patient when this procedure is performed within twelve (12) months of implant-supported crown or bridge procedures by the same Provider or dental office.

20. Stress breaker, semi-precision, or precision attachments or the replacement of an implant/abutment supported prosthesis is considered an optional service and is not a Benefit.

21. A separate fee for the removal of an implant within twenty-four (24) months of the original placement, by the same Provider or dental office, is not billable to the patient. After twenty-four (24) months, this service is a Benefit once per tooth per lifetime.

22. A separate fee is not billable to the patient for a radiologic surgical implant index.

23. A posterior fixed bridge and a partial denture are not Benefits in the same arch. Benefit is limited to the allowance for a partial denture.

24. Temporary restorations, temporary implants, and temporary prosthodontics are considered part of the final restoration. A separate fee by the same Provider or dental office is not billable to the patient.

25. Benefits for porcelain crowns or porcelain supported prosthetics on posterior teeth are limited to premolars and maxillary first molars. On all other teeth, they are considered optional services and Benefits are limited to the equivalent metal crown or metal supported prosthetic Benefit.

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26. Maxillofacial prosthetics and related services are not a Benefit.

27. Crowns, implants, prosthodontics, and all related services are not Benefits for Enrollees under the age of sixteen (16).

28. Fees for full or partial dentures include any reline/rebase, adjustment, or repair required within six (6) months of delivery except in the case of immediate dentures. After six (6) months, adjustments to dentures are a Benefit twice in a twelve (12) month period and relines or rebases are a Benefit once in a three (3) year period.

29. Tissue conditioning is not a Benefit more than twice per denture unit in a three (3) year period.

30. Treatment of Temporomandibular Joint Dysfunction (TMD) is covered within the scope of dental practice and does not include coverage for orthodontic appliances and treatment, crowns, bridges, and dentures unless the dysfunction is trauma related.

31. Non-invasive TMD physical therapies are not Covered Services.

32. Refer to “General Limitations and Exclusions” for additional provisions that may apply.

J. Orthodontic Services No payment will be made by Delta Dental for Orthodontic Services unless stated otherwise in the Summary of Dental Plan Benefits.

Orthodontic Services are procedures performed by a Provider using appliances to treat poor alignment of teeth and their surrounding structure. The Benefit determination for the Orthodontic Lifetime Maximum may include specific non-orthodontic procedure codes that are directly related, as determined by Delta Dental, to be part of an orthodontic treatment plan. Procedures directly related to Orthodontic Services will only be considered eligible expenses if Benefits for Orthodontic Services apply.

Payment for charges that exceed the maximum Benefit applicable to Orthodontic Services is the patient’s responsibility. Refer to the Summary of Dental Plan Benefits to verify if this Plan includes coverage for Orthodontic Services along with specific and lifetime Benefit provisions.

Diagnostic casts will be considered for payment at the Diagnostic and Preventive Services Coinsurance level when performed in conjunction with covered Orthodontic Services. Payments for diagnostic casts are part of the Orthodontic Lifetime Maximum.

K. Limitations on Orthodontic Services

1. If the Enrolled Person is already in orthodontic treatment, Benefits shall commence with the first treatment rendered following the patient’s Effective Date or any applicable Benefit waiting period. Charges for treatment incurred prior to the patient’s Effective Date are not covered.

2. Benefits are determined based on the total cost and total months of treatment.

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3. Benefits will end immediately if orthodontic treatment is stopped.

4. Charges to repair or replace any orthodontic appliance (including, but not limited to, retainers and replacement retainers) are not covered, even when the appliance was a covered Benefit under this or any other Plan.

5. Charges for radiographic images (except for cephalometric radiographic images) and extractions are not covered under Orthodontic Services.

6. Oral/facial photographic images and diagnostic casts are a Benefit once per orthodontic treatment case. Additional fees for these procedures are not billable to the patient when performed by the same Provider or dental office.

7. Self-directed or “at-home” orthodontic treatment is not a Benefit.

8. Refer to “General Limitations and Exclusions” for additional provisions that may apply.

L. General Limitations and Exclusions

1. A Benefit waiting period prior to obtaining some services applies if stated in the Summary of Dental Plan Benefits. This means an Enrolled Person is not eligible for Benefits for those services until he/she has been continually enrolled under this Contract for the time frame stated in the Summary of Dental Plan Benefits.

2. Services for any covered procedures which exceed the frequency or age limitation shown in the Summary of Dental Plan Benefits are not eligible for Benefits.