attachment-1-rfp-490-27.pdf

Form #: NHDPD-010125 (2CDPDI) Plan Year 2026

Dental Plan Description State of New Hampshire

Active Employees

Group #1776

Effective January 1, 2026

Notice to Buyer: This certificate provides dental benefits only.

Northeast Delta Dental Delta Dental Plan of New Hampshire, Inc.

Delta Dental National Coverage

ACA-1557 (v.2023)

Discrimination is Against the Law

Northeast Delta Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Northeast Delta Dental does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Northeast Delta Dental:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact Neiko Lavery, Associate General Counsel.

If you believe that Northeast Delta Dental has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Neiko Lavery, Associate General Counsel One Delta Drive Concord, NH 03301 603-223-1127

TTY: 711

Fax: 603-223-1035 nlavery@nedelta.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Neiko Lavery, Associate General Counsel, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:nlavery@nedelta.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

ACA-1557 (v.2023)

Language Assistance Services

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-832-5700 (ATS : 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-800-832-5700 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-832-5700

(TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.

Gọi số 1-800-832-5700 (TTY: 711).

यान दनु होस:◌◌्तपाइ ले नेपाल बो नह छ भन तपाइ को ि◌न त भाषा सहायता सवाह नःश क पमा उपल ध छ । फोन गनु होसर् ◌◌्1- 800-332-5700 (ट टवाइ: 711) ।

008-238-0075-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).117 (رقم ھاتف الصم والبكم

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-832-5700 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-832-5700 (телетайп: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para

1-800-832-5700 (TTY: 711).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 1-800-832-5700 (TTY: Telefon za osobe sa oštećenim govorom ili sluhom:

711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-832-5700

(TTY: 711) 번으로 전화해 주십시오.

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-832-5700 (TTY: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-832-5700 (TTY: 711).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-832-5700 (TTY: 711).

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(TTY: 711)។

TABLE OF CONTENTS

I. Definitions

II. How to File a Claim

III. Benefits

Diagnostic & Preventive Benefits (Coverage A)

Coverage A Exclusions and Limitations

Basic Benefits (Coverage B)

Coverage B Exclusions and Limitations

Major Benefits (Coverage C)

Coverage C Exclusions and Limitations

Orthodontic Benefits (Coverage D)

Coverage D Exclusions and Limitations

IV. General Exclusions and Limitations

V. Coordination of Benefits (Dual Coverage)

VI. General Claims Inquiry

VII. Disputed Claims Procedure

VIII. Disputed Claims Review Procedure

IX. Patients’ Bill of Rights

X. Termination

XI. Continuation of Benefits

XII. General Conditions

XIII. Assignment of Benefits

XIV. Exceptional Service Is Our Guarantee

Welcome

Northeast Delta Dental welcomes you to the growing number of people receiving benefits through our Dental Care programs.

This booklet, together with your Outline of Benefits, describes the benefits of your program and tells you how to use your plan. Please read it carefully to understand the benefits and provisions of your Northeast Delta Dental plan. But, before you turn the page, we’d like you to know something about us.

Northeast Delta Dental is a not-for-profit organization originally established and supported by Dentists to make Dental Care more available to the general public.

Northeast Delta Dental is affiliated with a national association known as the Delta Dental Plans Association (DDPA) which provides Dental Care programs in all states and U.S. territories.

A majority of Dentists in Maine, New Hampshire, and Vermont participate with Northeast Delta Dental through participating agreements. In addition, there is a nationwide network of Participating Dentists available to you.

You are encouraged to take advantage of your Northeast Delta Dental plan since good oral health is an important part of your overall general health. you are also encouraged to obtain your Dental Care from a Participating Dentist to get the best value from your program.

Your Coverage: The coverage selected for your dental benefits plan uses Delta Dental’s PPO and Premier networks of Participating Dentists. This Delta Dental network plan allows you to go to any Dentist of your choice and receive a level of benefits for covered services, but you will receive the best value from your plan if you visit a network Dentist. You pay no more than the Delta Dental contractual fee for covered services Northeast Delta Dental Participating Dentists provide, even if you exceed your annual benefit maximum.

Delta Dental PPO Dentists are part of a more limited network of Participating Dentists who offer lower fees to their Delta Dental PPO patients. Delta Dental PPO Dentists are reimbursed by Delta Dental based on the lesser of the submitted charge or Delta Dental’s allowance for PPO Dentists in the geographic area in which the services were provided. PPO Dentists agree to accept Delta Dental’s payment as payment in full, and further agree not to charge any difference between their fees and the amount paid by Delta Dental back to their Delta Dental patients. Like all Dentists, PPO Dentists are allowed to charge for any applicable Co-payments, Deductible, or non-covered services.

You will also receive benefits under your dental benefits plan if you choose to visit a Delta Dental Premier Dentist. Delta Dental Premier Dentists are reimbursed by Delta Dental based on the lesser of the submitted charge or Delta Dental’s allowance for Premier Dentists in the geographic area in which the services were provided. Like all Dentists, Premier Dentists are allowed to charge for any applicable Co-payments, Deductibles or non-covered services.

You may also choose to visit Dentists who are not Delta Dental Participating Dentists (Non- Participating Dentists) or Other Dental Providers (ODPs). You will receive benefits based on the lesser of the submitted charge or Delta Dental’s allowance for Non-Participating Dentists or ODPs in the geographic area in which the services were provided. The Non-Participating Dentist or ODP may balance bill up to their submitted charge. When there is not sufficient fee information available for a specific dental procedure, Delta Dental will determine an appropriate payment amount. You may be requested to bring a claim form to your visit. Claim forms can be downloaded from www.nedelta.com or you may call 800-832-5700.

Remember: All Delta Dental Participating Dentists agree to:

• File your claim forms for you.

• Charge you no more than the amount allowed for payment by Delta Dental.

• Accept payment directly from Delta Dental.

http://www.nedelta.com/

I. Definitions

1. Agreement: the contractual relationship between your group and Delta Dental to provide dental benefits to Eligible Persons, including this document, the contract application, the group contract, and the Outline of Benefits.

2. Co-insurance: the amount of the Dental Care cost which you are required to pay after application of Co-insurance Percentages.

3. Co-insurance Percentage: the percentage specified in your Outline of Benefits as the amount covered by this dental benefits plan for Coverages A, B, C and D respectively.

4. Co-payment: the amount of the Dental Care cost which you are required to pay and the Co-insurance Percentage.

5. Contract Holder: the group named in the contract application.

6. Coverage: the Dental Care referred to in the Agreement.

7. Coverage Period: Benefit Period as defined in the Outline of Benefits.

8. Deductible: the portion of the charge for covered Dental Care which the Subscriber or Eligible Dependent must pay before Northeast Delta Dental’s payment responsibility begins.

The Deductible for your Coverage is listed in your Outline of Benefits.

9. Delta Dental Plans Association (DDPA): the association which comprises all of the Delta Dental Plans and affiliated organizations operating in the United States and its territories.

10. Denied: if the fee for a procedure or service is Denied and chargeable to the Eligible Person, the procedure or service is not a benefit of the Eligible Person’s plan. The approved amount is not payable by Northeast Delta Dental, but is collectable from the Eligible Person.

11. Dental Care: dental services ordinarily provided by licensed Dentists or ODPs for diagnosis or treatment of dental disease, injury, or abnormality based on valid dental need in accordance with generally accepted standards of dental practice at the time the service is rendered.

12. Dental Plan Description (DPD): this document. The Dental Plan Description and the Agreement form the terms and conditions under which Northeast Delta Dental shall administer your dental benefits plan.

13. Dentist: a person duly licensed to practice dentistry in the state in which the Dental Care is provided.

14. Denturist: a person licensed to practice denturism by the state in which the services are rendered. The practice of denturism includes:

a) The taking of denture impressions and bite registration for the purpose of or with a view to the making, producing, reproducing, construction, finishing, supplying, altering or repairing of a complete maxillary (upper) or complete mandibular (lower) prosthetic denture, or both, to be fitted to an edentulous arch or arches.

b) The fitting of a complete maxillary (upper) or mandibular (lower) prosthetic denture, or both, to an edentulous arch or arches, including the making, producing, reproducing, constructing, finishing, supplying, altering and repairing of dentures.

c) The procedures incidental to the procedures specified in paragraphs (a) and (b), as defined by the applicable state licensing board.

For the purpose of paying claims, licensed Denturists will be treated as an Other Dental Provider (ODP). Claims submitted by a licensed Denturist must be accompanied by a copy of a certificate of good oral health that has been issued for the Eligible Person by a licensed Dentist. A copy of the Denturist’s license must be filed with Northeast Delta Dental before claims can be processed.

15. Dependent:

a) Legal Spouse of the Subscriber; and/or

b) Qualified Dependent Children: Subscriber’s child by blood or by law who is under the age of twenty-six (26). Dependent children are your natural children, legally adopted children, stepchildren from a current marriage, and children for whom you are the proposed adoptive parent and who have been placed in your care and custody during the waiting period before the adoption becoming final. Qualified children are eligible regardless of student status and coverage will terminate at the end of the month that they reach age of twenty-six (26).

c) Qualified Dependent Due to Legal Guardianship: Children for whom you are the legal guardian may be covered up to the age of 18, or when the court order expires, whichever occurs first.

Incapacitated Children: Incapacitated children are the Subscriber’s dependent children already enrolled in the State of New Hampshire Health Benefit Plan who are mentally or physically incapable of earning their own living on the date that eligibility under this Benefit Booklet would otherwise end due to age. The impairment must have occurred before the child reached age 26. Incapacitated dependents may remain covered as long as their impairment continues and as long as they are financially dependent on the Subscriber and are incapable of self-support and are claimed as a tax dependent on the subscriber’s or alternative parent’s taxes, as outlined through custody or other parental agreement. The State New Hampshire’s medical carrier must receive an application for this incapacitated status, and medical confirmation by a physician of the extent and nature of the impairment, within 31 days of the date coverage would otherwise end.

The State of New Hampshire’s medical carrier’s Medical Director must certify that your child is incapacitated. The State of New Hampshire’s medical carrier may periodically request that the incapacitated status of your child be recertified. If the child’s impairment ends, he or she may elect to continue group coverage as stated in subsection XI “Continuation of Benefits” section of this DPD.

d) Newborn: Newborn children are automatically covered for the first thirty-one (31) days following birth. Coverage will continue if the child is formally enrolled within the first ninety (90) days following birth or the child may be enrolled thereafter at any open enrollment.

e) Turning Age Two: A child may be enrolled within 30 days of their second birthday with appropriate election forms submitted within that time frame. Coverage begins first of the month following receipt of the enrollment form and birth certificate.

f) Foster children and Grandchildren are not eligible for coverage unless they meet the definition of a dependent child stated in this subsection.

16. Eligible Dependent(s): those Dependents who meet the eligibility requirements of the Agreement and are enrolled by Subscribers in the group’s benefit program.

17. Eligible Person(s): the Subscriber and Dependent(s) (as defined herein) to the extent eligible in accordance with the eligibility requirements established by the Group (or the employer).

18. Explanation of Benefits (EOB): the notice which explains the benefits that were paid on your behalf, lets you know if any services are Denied or Not Billable to the Eligible Person, and gives you the reason(s) for the denial or why this service is not billable to you.

19. Maximum: the dollar amount Northeast Delta Dental will pay per Eligible Person within any Coverage Period (or in a lifetime for orthodontic benefits) for covered benefits. All benefits paid, including benefits for Diagnostic and Preventive services, are counted toward an Eligible Person’s Coverage Period Maximum. However, orthodontic payments count only toward the orthodontic Maximum.

20. Non-Participating Dentist: a Dentist who has not signed a participating agreement with Northeast Delta Dental or another Delta Dental company.

21. Northeast Delta Dental: the Delta Dental Plans in Maine, New Hampshire, and Vermont, collectively known as Northeast Delta Dental.

22. Not Billable to the Eligible Person: if the fee for a procedure or service is Not Billable to the Eligible Person, it is not payable by Northeast Delta Dental, nor collectable from the Eligible Person by a Participating Dentist. The Exclusions and Limitations provisions in Section III. and Section IV. identify services which are Not Billable to the Eligible Person. In each instance, a Delta Dental Participating Dentist agrees not to charge a separate fee.

23. Other Dental Providers (ODP): a person, other than a Dentist, who provides dental services and is authorized and licensed to provide such services by the state in which the services are rendered.

24. Outline of Benefits (OOB): the insert to this booklet that describes some of the particular provisions of your dental benefits.

25. Participating Dentist: a Dentist who has signed a participating agreement with Northeast Delta Dental or another Delta Dental company. A Participating Dentist agrees to abide by such uniform rules and regulations as are from time to time prescribed by Northeast Delta Dental. A Participating Dentist is required to submit appropriate clinical documentation for procedures. All clinical procedures are subject to review of clinical notes, radiographs, etc. to determine coverage.

26. Predetermination: an administrative procedure by which the Dentist submits the treatment plan to Northeast Delta Dental in advance of performing dental services. Northeast Delta Dental recommends that you ask your Dentist to request a Predetermination of proposed services that are considered to be other than brief or routine. A Predetermination provides an estimate of what Northeast Delta Dental will pay for the services which helps avoid confusion and misunderstanding between you and your Dentist.

27. Processing Policies: policies approved by Northeast Delta Dental, as may be amended from time to time, to be used in processing claims for payment or review, and processing treatment plans for Predetermination. Processing Policies are approved by the Contract Holder by signing the Group Contract. Most frequently used Processing Policies are contained in the terms, conditions and limitations described in this DPD.

28. Subscriber: any person who:

(a) Renders service to the Contract Holder as a paid employee.

(b) Is certified by the Contract Holder as a member of the group specified in the application.

(c) Enrolls in the group’s dental benefits plan.

II. How to File a Claim To Use Your Plan, Follow These Steps:

Please read this Dental Plan Description carefully to familiarize yourself with the benefits and provisions of your dental benefits plan.

Ask your Dentist if he/she participates with Delta Dental, visit Northeast Delta Dental’s website at www.nedelta.com refer to your Northeast Delta Dental Participating Dentist Directory, or call Northeast Delta Dental for information.

When you visit your dental office, inform them that you are covered under a Northeast Delta Dental program and provide your identification card or other means of verifying Northeast Delta Dental coverage. Your Dentist will perform an evaluation and plan the course of treatment. When the treatment has been completed, the claim form will be sent to Northeast Delta Dental for payment for covered services. Clean written claims must be paid in thirty (30) days; clean electronic claims must be paid within fifteen (15) days.

Participating Dentists: Participating Dentists will have claim forms available in their offices. A Participating Dentist will not charge at the time of treatment for covered services, but may request payment for non-covered services, Deductibles, or Co-payments. Northeast Delta Dental will pay the Participating Dentists directly based on the lesser of the submitted charge or Delta Dental’s allowance for Participating Dentists in the geographic area in which the services were provided. An Explanation of Benefits form will be sent or accessible to you that will indicate the amount you should pay, if any, to your Dentist.

Non-Participating Dentists or Other Dental Providers (ODPs): Northeast Delta Dental provides coverage regardless of your choice of Dentist, participating or not. When visiting a Non- Participating Dentist or ODP (who is a person, other than a Dentist, who provides Dental Care and is authorized and licensed to provide such services by the state in which the services are rendered), you may be required to submit your own claim (available at www.nedelta.com) and pay for services at the time they are provided. All claims should be submitted to Northeast Delta Dental. Payment will be made directly to you. Some states may require that assignment of benefits (directing that payment be sent to the provider) be honored. In these instances, payment will be made directly to the Non-Participating Dentist or ODP when written notice of such an assignment is made on the claim. In either case, payment for treatment performed by a Non-Participating Dentist or ODP will be limited to the lesser of the submitted charge or Delta Dental’s allowance for Non-Participating Dentists or ODPs in the geographic area in which services were provided. It is your responsibility to make full payment to the Dentist or ODP. When there is not sufficient fee information available for a specific dental procedure, Northeast Delta Dental will determine an appropriate payment amount.

You or someone in the dental office must fill in the Eligible Person information portion of the claim form. Please be sure information is complete and accurate to ensure the prompt and correct payment of your claim.

Predetermination of Benefits: Northeast Delta Dental strongly encourages Predetermination of cases involving costly or extensive treatment plans. Although it is not required, Predetermination helps avoid any potential confusion regarding Northeast Delta Dental’s payment and your financial obligation to the Dentist.

Please note that Predetermination does NOT guarantee payment. Rather, Predetermination is an estimate of payment based on your current benefits. A new Coverage Period, additional paid benefits and/or a contract change may alter the final payment, because payment is based on information at the time treatment is provided (the date of service) which may be different than information available at the time the Predetermination estimate was given. Any changes in a Dentist’s participating status or Northeast Delta Dental’s allowance may also affect Northeast Delta Dental’s final payment.

The Predetermination voucher reflects your benefits based on the procedures and costs submitted by your dental office. Questions concerning Predetermination should be directed to Northeast Delta Dental’s Customer Service Department at 800-832-5700 or 603-223-1234.

III. Benefits PLEASE NOTE: Eligible Persons will only be entitled to those benefit coverages selected by the Contract

Holder. See your Outline of Benefits for the coverages selected. Section III. describes the benefit coverages which may be selected.

Diagnostic & Preventive Benefits (Coverage A)

Diagnostic: Oral evaluations - two (2) times in a calendar year.

Radiographic images – a comprehensive series or a panoramic image once in a period of three (3) years; bitewings two (2) times in a calendar year; images of individual teeth as necessary.

Brush biopsy – once in a twelve (12) month period.

Preventive: Prophylaxis (cleaning) – three (3) times in a calendar year (child cleaning through age thirteen (13), adult cleaning thereafter). This can be a routine cleaning or a full mouth debridement under Diagnostic and Preventive Benefits (Coverage A), or periodontal maintenance under Basic Benefits (Coverage B).

A full mouth debridement under Diagnostic and Preventive Benefits (Coverage A) is covered once in a lifetime and, when performed, is counted towards your cleaning benefit.

Fluoride treatments – two (2) times in a calendar year to age nineteen (19).

Space Maintainers.

Sealants.

NOTE: Time limitations are measured from the date the services were most recently performed.

Only those coverage classifications selected by the Contract Holder shall apply as shown on the OOB.

Coverage A Exclusions and Limitations:

• If the fee for a procedure or service is “Not Billable to the Eligible Person,” it is not payable by the plan, nor collectable from the Eligible Person by a Participating Dentist. Participating Dentists agree not to charge a separate fee.

• If the fee for a procedure or service is “Denied,” it is not payable by the plan, but is chargeable to the Eligible Person as the procedure or service is not a covered benefit under the plan.

1. Oral evaluations of any kind are Not Billable to the Eligible Person if performed within ninety

(90) days after periodontal surgery by the same Dentist/dental office.

2. Comprehensive oral evaluations and comprehensive periodontal evaluations are a covered benefit once in a lifetime per provider. Subsequent oral evaluations are covered as a periodic oral evaluation and are subject to frequency limitations.

3. Detailed and extensive oral evaluations are a covered benefit once per Dentist/dental office and is counted toward your oral evaluation benefit. Comprehensive, detailed and extensive oral evaluations performed on children under the age of three (3) will be payable as an oral evaluation. The difference in fees is Not Billable to the Eligible Person.

4. Oral evaluations for Eligible Persons under age three (3), when performed on the same date of service by the same Dentist/dental office as a comprehensive evaluation, are Not Billable to the Eligible Person.

5. Pre-diagnostic services, such as a screening or an assessment of an Eligible Person, are covered benefits once in a period of twelve (12) months and crosscheck for time limitations.

Payment for a screening or assessment are Not Billable to the Eligible Person if billed on the same date of service or billed with an oral evaluation.

6. Pre-visit screening of an Eligible Person is not a covered benefit. The fee for a pre-visit screening is Not Billable to the Eligible Person.

7. A panoramic radiographic image is a covered benefit once in a three (3) year period for Eligible Persons.

8. Benefits are limited to either a panoramic radiographic image or an intraoral complete series radiographic images once in a period of three (3) years.

9. Payment for additional periapical, bitewing and/or occlusal radiographic images within a thirty (30) day period of a comprehensive series, unless there is evidence of trauma, is Not Billable to the Eligible Person.

10. Routine working and final treatment radiographic images taken for endodontic therapy by the same Dentist/dental office are considered a component of the complete treatment procedure and separate fees are Not Billable to the Eligible Person on the same date of service.

11. Bitewing images for children under the age of ten (10) are limited to two (2) bitewing images in a twelve (12) month period. Three (3) or more images will be covered as two (2) bitewing images and any difference in fees is Not Billable to the Eligible Person.

12. If the fee for bitewings, periapicals, intraoral occlusal and extraoral radiographic images is equal to or exceeds the fee for a comprehensive series, it is considered a comprehensive series for payment purposes and time limitations. Any fee in excess of the fee for the comprehensive series is Not Billable to the Eligible Person on the same date of service.

13. Intraoral tomosynthesis - comprehensive series, image capture only, received on the same day as an intraoral tomosynthesis comprehensive series by the same Dentist/dental office is Not Billable to the Eligible Person.

14. Intraoral tomosynthesis - periapical images, image capture only, received on the same day as an intraoral tomosynthesis periapical series by the same Dentist/dental office is Not Billable to the Eligible Person.

15. Intraoral periapicals are Not Billable to the Eligible Person if performed with surgical and non-surgical procedures, and all indirect restorations (crowns, onlays, bridges, inlays or implants).

16. Intraoral tomosynthesis - bitewing images, image capture only, received on the same day as an intraoral tomosynthesis bitewing radiographic image by the same Dentist/dental office is Not Billable to the Eligible Person.

17. Fees for additional bitewings (including vertical bitewings) done by the same Dentist/dental office within six (6) months of a comprehensive series is Not Billable to the Eligible Person. If performed by a different Dentist/dental office, the fee is Denied.

18. If an extra oral posterior dental radiographic image is performed within five (5) years of a prior extra oral posterior dental radiographic image by the same Dentist/dental office, the fee is Not Billable to the Eligible Person.

19. Fees for additional radiographic images taken by the same Dentist/dental office within sixty

(60) days of vertical bitewings are Not Billable to the Eligible Person.

20. The fee for a full mouth debridement is Not Billable to the Eligible Person when performed by the same Dentist/dental office on the same date of service as a comprehensive periodontal evaluation.

21. Cone beam imaging and interpretation are covered benefits once in a period of twelve (12) months. Cone beam image capture only, received on the same day as a cone beam image capture and interpretation, by the same Dentist/dental office is Not Billable to the Eligible Person.

22. Cephalometric images and oral/facial photographic images are not a covered benefit.

23. Oral cancer screening, including brush biopsy, is a covered benefit.

24. Oral Pathology laboratory services are a covered benefit when accompanied by a pathology report. If more than one of these procedures is billed for the same tooth site on the same day, by the same Dentist/dental office, payment is allowed for the most inclusive procedure and the less inclusive procedure is Not Billable to the Eligible Person.

25. A cleaning done on the same date by the same Dentist/dental office as a periodontal maintenance, or scaling and root planing is considered to be part of and included in those procedures, and the fee is Not Billable to the Eligible Person.

26. Laboratory tests for caries susceptibility are not a covered benefit and are Not Billable to the Eligible Person when billed with an oral evaluation for children under the age of three (3).

27. Caries risk assessment is a covered benefit once in a period of one (1) year for Eligible Persons age three (3) and older. Benefits for caries risk assessment are Not Billable to the Eligible Person if billed for children under the age of three (3), if billed within twelve (12) months by the same Dentist/dental office, or if performed with other risk assessments by the same Dentist/dental office.

28. Sealant benefit limitation:

(a) The sealant benefit includes the application of sealants only to caries-free (no decay) and restoration-free permanent molars.

(b) The sealant benefit is provided no more than once in a three (3) year period per tooth.

(c) Sealants are Not Billable to the Eligible Person within two (2) years of initial placement on the same tooth by the same Dentist/dental office. A sealant is Not Billable to the Eligible Person if performed by the same Dentist/dental office, on the same date of service as a restoration which includes the occlusal surface.

29. Pulp vitality tests are a covered benefit only when done in conjunction with a radiographic image, a limited oral evaluation, a palliative treatment, or placement of interim direct restoration. The fee is otherwise Not Billable to the Eligible Person.

30. Space maintainers are a covered benefit once in a lifetime per tooth when a space is being maintained for an erupting permanent tooth.

31. The replacement or repair of space maintainers is not a covered benefit, unless performed by a Dentist who did not do the original placement.

32. Removal of a space maintainer is included as part of the total treatment. Charges for removal of a space maintainer are Not Billable to the Eligible Person if performed by the same Dentist/dental office as the initial placement or if performed with the recementation of a space maintainer.

33. Distal shoe space maintainers are a covered benefit for Eligible Persons age eight (8) and younger. Fees for distal shoe space maintainers performed on Eligible Persons nine (9) and older are Denied.

34. Nutritional counseling, tobacco counseling and oral hygiene instruction are not covered benefits.

35. Genetic test for susceptibility to diseases is not a covered benefit.

36. Application of caries arresting medicament is a covered benefit twice per tooth in a twelve (12) month period. If the application of caries arresting medicament is placed by the same Dentist/dental office on the same day as a restoration, it is not a covered benefit and is Not Billable to the Eligible Person.

37. Fees for restorations on the same tooth by the same Dentist/dental office performed within sixty (60) days of the application of caries arresting medicament are Denied. The Eligible Person is responsible for the fee.

38. HbA1c and blood glucose testing are not covered benefits and fees are Denied. If blood glucose level testing is performed on the same day as an HbA1c test, fees for the blood glucose testing are Not Billable to the Eligible Person.

39. Assessment of salivary flow is a covered benefit once in a three (3) year period. Additional assessments are Not Billable to the Eligible Person within twelve (12) months of initial assessment. Assessments performed between twelve (12) months and three (3) years are Denied and the Eligible Person is responsible for the fee.

40. 3D intraoral surface scans, whether direct or indirect, are included as part of the definitive procedure and the fees are Not Billable to the Eligible Person.

Basic Benefits (Coverage B)

Restorative: Amalgam (silver) fillings.

Resin (white) fillings are a covered benefit.

Oral Surgery: Extractions and covered surgical procedures.

Periodontics: Prophylaxis (cleaning) – three (3) times in a calendar year (child cleaning through age thirteen (13), adult cleaning thereafter).

This can be a routine cleaning or a full mouth debridement under Diagnostic and Preventive Benefits (Coverage A), or periodontal maintenance under Basic Benefits (Coverage B).

A full mouth debridement under Diagnostic and Preventive Benefits (Coverage A) is covered once in a lifetime and when performed is counted towards your cleaning benefit.

Injection Drugs.

Endodontics: Pulpal therapy, apicoectomies, retrograde fillings, and root canal therapy.

Denture Repair: Repair of a removable complete or partial denture to its original condition.

Clinical Crown Lengthening: Once per tooth per lifetime.

Denture Rebase and Reline: Rebase and reline of complete and partial dentures.

Palliative Treatment: Minor emergency treatment for the relief of pain.

Athletic Mouthguards: Once in a twenty-four (24) month period.

Anesthesia: General anesthesia or intravenous sedation when administered in a dental office and in conjunction with: an extraction, tooth reimplantation, surgical exposure of a tooth, surgical placement of implant body, biopsy, transseptal fiberotomy, alveoloplasty, vestibuloplasty, incision and drainage of an abscess, frenulectomy, and/or frenuloplasty.

General anesthesia or intravenous sedation will also be covered when administered in conjunction with procedures performed in the dental office for the following covered Eligible Persons:

(a) A child under the age of thirteen (13) who is determined by a licensed Dentist in conjunction with a licensed primary care physician to have a dental condition of significant complexity which requires the child to receive general anesthesia for the treatment of such condition; or

(b) A person who has exceptional medical circumstances or a developmental disability, as determined by a licensed physician, which place the person at serious risk.

NOTE: Time limitations are measured from the date the services were most recently performed.

Only those coverage classifications selected by the Contract Holder shall apply as shown on the OOB.

Coverage B Exclusions and Limitations:

• If the fee for a procedure or service is “Not Billable to the Eligible Person,” it is not payable by the plan, nor collectable from the Eligible Person by a Participating Dentist. Participating Dentists agree not to charge a separate fee.

• If the fee for a procedure or service is “Denied,” it is not payable by the plan, but is chargeable to the Eligible Person as the procedure or service is not a benefit under the plan.

1. Restorations are a covered benefit only once per surface in a period of twenty-four (24) months, irrespective of the number or combination of procedures performed. The replacement of amalgam (silver) or resin (white) restorations within twenty-four (24) months by the same Dentist/dental office is Not Billable to the Eligible Person.

2. A cleaning done on the same date by the same Dentist/dental office as a periodontal maintenance, or scaling and root planing is considered to be part of and included in those procedures and the fee is Not Billable to the Eligible Person.

3. Tooth preparation; bases; copings; placement of interim direct restorations; impressions;

image capture only and local anesthesia; or other services that are part of the complete dental procedure, are considered components of, and included in the fee for, a complete procedure and are Not Billable to the Eligible Person.

4. Placement of interim direct restorations are Not Billable to the Eligible Person if performed on the same date of service as a definitive restoration or palliative treatment by the same Dentist/dental office.

5. The placement of interim direct restoration is a covered benefit once in a lifetime. The fee for the placement of interim direct restorations are Not Billable to the Eligible Person when performed in conjunction with definitive dental treatment on the same date of service, by the same Dentist/dental office.

6. Prefabricated stainless steel crowns are a covered benefit once in a period of two (2) years.

The fee for replacement of a stainless steel crown by the same Dentist/dental office within twenty-four (24) months is included in the initial crown placement and is Not Billable to the Eligible Person.

7. Payment is made for one (1) restoration in each tooth surface irrespective of the number of combinations of restorations placed. A Northeast Delta Dental Participating Dentist agrees not to charge a separate fee.

8. Removal of an indirect restoration on a natural tooth is included in the fee for definitive treatment and the fees are Not Billable to the Eligible Person.

9. Removal of coronal remnants of a primary tooth is considered part of any other (more comprehensive) surgical procedure in the same surgical area, same date by the same Dentist/dental office and the fees are Not Billable to the Eligible Person.

10. Routine post-operative visits are considered part of, and included in the fee for, the total procedure. A Northeast Delta Dental Participating Dentist agrees not to charge a separate fee.

11. Exploratory surgical services are not a covered benefit. The Eligible Person is financially responsible.

12. Periodontal scaling and root planing is a covered benefit per quadrant (maximum of two (2) quadrants per office visit) once in a period of twenty-four (24) months.

13. Fees for periodontal scaling and root planing per quadrant are Not Billable to the Eligible Person within twenty-four (24) months when performed by the same Dentist/dental office. If treatment is done by a different Dentist/dental office within twenty-four (24) months, benefits are Denied.

14. The fee for periodontal scaling and root planing is Not Billable to the Eligible Person if performed within ninety (90) days of periodontal surgery by the same Dentist/dental office, or if more than two (2) quadrants are treated in one office visit.

15. Fees are Not Billable to the Eligible Person if more than two quadrants of periodontal scaling and root planing are performed by the same Dentist/dental office on the same date of service.

16. If periodontal surgery is performed less than four (4) weeks after periodontal scaling and root planing by the same Dentist/dental office, the fee for the surgical procedure is Not Billable to the Eligible Person.

17. Fees are Not Billable to the Eligible Person for periodontal scaling and root planning done on the same day by the same Dentist/dental office as a gingival flap procedure, surgical repair of root resorption or surgical exposure of root surface.

18. The fee for cleanings, scaling in the presence of generalized, moderate or severe inflammation, full mouth debridement and/or periodontal maintenance is Not Billable to the Eligible Person if the services are provided by the same Dentist/dental office within thirty

(30) days after the most recent scaling and root planing or other periodontal therapy. The fee for cleanings, scaling in the presence of generalized, moderate or severe inflammation, full mouth debridement and/or periodontal maintenance is Denied if the services are provided by a different Dentist/dental office within thirty (30) days of periodontal therapy.

19. Periodontal surgical procedures include all necessary postoperative care, finishing procedures, and evaluations for three (3) months, as well as any surgical re-entry, except soft tissue grafts, for three (3) years. The fee for surgical re-entry by the same Dentist/dental office within three

(3) years is Not Billable to the Eligible Person.

20. Recementation or re-bond of a space maintainer is a covered benefit once per space maintainer.

21. An adjustment will be made for two (2) or more restoration surfaces which are normally joined together. A Northeast Delta Dental Participating Dentist agrees not to charge a separate fee.

22. Clinical crown lengthening is a covered benefit once per tooth per lifetime and only when performed in a healthy periodontal environment, on natural teeth only, in which bone must be removed for placement of the restoration or crown, or prosthetic device. The fee for clinical crown lengthening is Not Billable to the Eligible Person if performed on the same date of service by the same Dentist/dental office as the crown placement.

23. Clinical crown lengthening, when done in conjunction with osseous surgery, crown preparations, or restorations is considered a component of, and included in the fee for, the complete procedure and is Not Billable to the Eligible Person.

24. Clinical crown lengthening, when performed in conjunction with other periodontal procedures, will be subject to a dental consultant’s review. Payment will be based on the most comprehensive procedure.

25. Direct or indirect pulp caps are a covered benefit once in a period of three (3) years. A pulp cap performed on the same date of service as the final restoration by the same Dentist/dental office is considered part of a single complete restorative procedure and the fee for the pulp cap is Not Billable to the Eligible Person.

26. Recementation of a crown, onlay, veneer or partial coverage restoration is a covered benefit once per tooth per lifetime. The fee is Not Billable to the Eligible Person if performed within six (6) months of the initial placement by the same Dentist/dental office.

27. Recementation of a cast or prefabricated post and core is a covered benefit once per tooth per lifetime. The fee is Not Billable to the Eligible Person if performed within six (6) months of the initial placement by the same Dentist/dental office, or if performed on the same date of service of a crown recementation by the same Dentist/dental office.

28. The relining of a denture is a covered benefit once in a period of three (3) years for Eligible Persons age twelve (12) and older. The fee for reline of a denture cannot exceed one-half of the fee for a new appliance, and any excess fee by the same Dentist/dental office is Not Billable to the Eligible Person on the same date of service.

29. The rebase of a denture is a covered benefit once in a period of five (5) years for Eligible Persons age twelve (12) and older. The fee for rebase of a denture cannot exceed one-half of the fee for a new appliance, and any excess fee by the same Dentist/dental office is Not Billable to the Eligible Person on the same date of service.

30. The reline or rebase of a denture is Not Billable to the Eligible Person if performed within six

(6) months of initial placement by the same Dentist/dental office.

31. Recementation of a fixed partial denture is a covered benefit once in a twelve (12) month period. Fees for recementation of fixed partial dentures are Not Billable to the Eligible Person if done within six (6) months of the initial placement by the same Dentist/dental office.

32. Anterior deciduous root canal therapy is not a covered benefit.

33. A partial pulpotomy is a covered benefit once per tooth per lifetime on permanent teeth only.

The fee for a partial pulpotomy is Not Billable to the Eligible Person if performed within thirty

(30) days on the same tooth by the same Dentist/dental office as root canal therapy.

34. Pulpal therapy is a covered benefit once in a three (3) year period on primary first and second molars only. If pulpal therapy is performed on primary anterior or permanent teeth, the procedure will be covered as a palliative treatment.

35. Therapeutic pulpotomy is a covered benefit once in a three (3) year period per tooth on primary teeth only. If the service is provided on permanent teeth, the procedure will be covered as a palliative treatment.

36. Fees for therapeutic pulpotomy or palliative treatment are Not Billable to the Eligible Person when performed on the same date of service as root canal procedure or root canal therapy.

37. Root canal therapy is a covered benefit once in a period of three (3) years. Retreatment of root canal therapy by the same Dentist/dental office within twenty-four (24) months is considered part of the original procedure. Fees for the retreatment by the same Dentist/dental office are Not Billable to the Eligible Person.

38. Root canal therapy is not a benefit in conjunction with overdentures and benefits are Denied.

The Eligible Person is responsible for the additional fee.

39. Endodontic treatments and retreatments are Not Billable to the Eligible Person if performed by the same Dentist/dental office within twenty-four (24) months of an initial endodontic treatment or within twenty-four (24) months of a previous endodontic retreatment.

40. Incomplete endodontic procedure due to inoperable or fractured tooth may be covered at 50% of the fee for a completed endodontic therapy, subject to a consultant’s review of radiographic images and clinical notes.

41. Root amputation performed in conjunction with an apicoectomy by the same Dentist/dental office is Not Billable to the Eligible Person.

42. An upper or lower frenulectomy or frenuloplasty is a covered benefit once per site per lifetime and is Not Billable to the Eligible Person when billed on the same date as any other surgical procedure in the same surgical area by the same Dentist/dental office.

43. Alveoloplasty is included in the fee for extractions. Separate fees for these procedures are Not Billable to the Eligible Person if performed by the same Dentist/dental office, in the same area on the same date.

44. The fee for repairs of complete or partial dentures cannot exceed half the fees for a new appliance. Any excess fee billed by the same Dentist/dental office is Not Billable to the Eligible Person on the same date of service.

45. The fee for palliative treatment is Not Billable to the Eligible Person when submitted with all procedures except radiographic images and diagnostic codes and is performed by the same Dentist/dental office on the same date.

46. Palliative treatment is part of the initiation of endodontic therapy and therefore is included in the fee when performed on the same date by the same Dentist/dental office and a separate fee is Not Billable to the Eligible Person.

47. General anesthesia is a covered benefit only when administered by a properly licensed Dentist in a dental office in conjunction with covered oral surgical procedures or when necessary due to concurrent medical conditions. Otherwise, the fee for general anesthesia is Denied.

48. Local anesthesia in conjunction with any procedure by the same Dentist/dental office is considered part of the overall procedure and fees are Not Billable to the Eligible Person.

49. Nitrous oxide is not a covered benefit and the fee is Denied. The Eligible Person is responsible for the fee. The fee for nitrous oxide is Not Billable to the Eligible Person in conjunction with Intravenous sedation and/or general anesthesia.

50. Non-intravenous conscious sedation is not a covered benefit and the fee is Denied. The Eligible Person is responsible for the fee. The fee for non-intravenous conscious sedation is Not Billable to the Eligible Person in conjunction with intravenous sedation and/or general anesthesia.

51. Fees for repairs of complete or partial dentures, if performed within six (6) months of initial placement by the same Dentist/dental office are Not Billable to the Eligible Person. Benefits are Denied if done by a different Dentist/dental office within six (6) months of initial placement.

52. Pin retention is a covered benefit once per tooth in a period of twenty-four (24) months in conjunction with all restorations. Additional pins in the same tooth are Not Billable to the Eligible Person. Pin retention is Not Billable to the Eligible Person when billed in conjunction with a core buildup.

53.