HomeMy WebLinkAboutAGMT - Private Medical-Care Inc. (PMI) RIVATE MEDICAL-CARE, INC.
? 12898 1 u ne Center Drive, Cerritos, California 9 03
(562) 924 - 8311
• AMENDMENT
TO
GROUP DENTAL SERVICE CONTRACT
(Prepaid)
As of the date stated below„ the Group Dental Service Contract ("Contract") issued to
you by Private Medical-Care, Inc. (PMI) is amended as follows to comply with changes in
state and federal law which apply to this Contract.
1. The following Definitions are added to the list of Definitions in Article 1.
DEFINITIONS:
"Acute Condition" means a condition requiring Emergency Services while a New
Enrollee is within thirty-five (35) miles from the office of the assigned Panel
Dentist.
"New Enrollee" means an Enrollee who is enrolled less than thirty (30) days from
the date he or she is eligible for Benefits.
2. Article 4. BENEFITS, LIMITATIONS AND EXCLUSIONS is modified as follows:
•
• necessary to avoid placing his or health in serious
jeopardy; and
b. that treatment for an Acute Condition does not include any
services other than Emergency Services; and
• c. that PMI will reimburse the Enrollee for the cost of such
treatment up to a maximum of $100.00 during any 12-
month period; and
d. that the Enrollee must submit a claim within ninety (90)
days after receiving the treatment; and
e. that the Enrollee must visit his or her Panel Dentist.for
further treatment.
PMI may require a non-Panel Dentist providing treatment to an
Enrollee of an Acute Condition to agree in writing to meet the
same contractual terms and conditions which are imposed upon
Dentists who have signed a contract with PMI. PMI is not liable for
actions resulting solely from the negligence, malpractice or other
tortious or wrongful acts arising out of the treatment provided by a
non-Panel Dentist.
C. The following provision is added as Section 4.10:
4.10 A Panel Dentist is compensated by PMI through monthly
capitation (an amount based on the number of Enrollees assigned
to the Dentist), and by Enrollees through required Copayments for
• treatment received. A Specialist is compensated by PMI through
an agreed-upon amount for each covered procedure, and by
Enrollees through applicable Copayments. In no event does PMI
pay a Dentist or a Specialist any incentive as an inducement
to deny, reduce, limit or delay any appropriate treatment.
D. The following provision is added as Section 4.11:
4.11 PMI does not authorize or deny services provided by a Panel
Dentist. All Benefits provided by a Panel Dentist are in
accordance with Dental Care Guidelines which establish the
standard of care to be followed by Panel Dentists. PMI's
"processing policies" and the Dental Care Guidelines are reviewed
by PMI's Dental Advisory Committee, and updated as needed. An
Enrollee may contact PMI's Customer Relations Department at
1-800-422-4234 for information regarding PMI's "processing
policies".
E. The following provision is added as Section 4.12:
4.12 PMI may request that an Enrollee obtain a second
opinion to verify the necessity and appropriateness of dental
treatment or application of Benefits. When PMI requests a second
• opinion, it will pay for all second opinion charges. An Enrollee
may also request a second opinion if he or she disagrees with the
2
dialpsis and/or treatment plan determinatifade by his ;,r her
Pan Dentist. In such cases, the Enrollee s uld contact PMI's
Customer Relations Department for assistance in requesting
authorization for a second opinion. Second opinions will only be
authorized at a Panel Dentist's office, unless otherwise authorized
• by PMI's Dental Consultant. Charges for second opinions that are
not authorized by PMI are excluded from coverage.
3. Article 5. COORDINATION OF BENEFITS is modified as follows:
A. Section 5.01 is replaced by the following:
5.01 This Contract provides Benefits without regard to coverage by any
other group insurance policy or any other group benefits program
if the other policy or program covers services in addition to dental
care. Otherwise, Benefits under this Contract are coordinated with
such other group insurance or any group health benefits program.
B. The first paragraph of Section 5.02 is replaced by the following:
5.02 When Benefits are coordinated with another group insurance
policy or group health benefits program, the determination of
which policy or program is primary shall be governed by the
following rules:
4. Article 6. COMPLAINT PROCEDURE, CLAIMS APPEAL AND ARBITRATION is
modified as follows:
A. All references to PMI's Quality Assurance Coordinator, are changed to
• PMI's Quality Management Coordinator.
B. The following provisions are added. If your Contract already includes
provisions concerning this matter, the following provisions replace the
provisions already in your Contract.
Within 30 days after PMI receives an Enrollee's written complaint
and the above information, PMI will send the Enrollee a report which
describes the complaint and PMI's resolution, or explains why additional
time is required to report on the complaint. In the event the Enrollee
disagrees with the resolution of the complaint, he or she may submit a
written request for reconsideration within 15 days after he or she receives
that response. The Enrollee should provide the reason for the appeal and
any additional information which he or she feels may affect his or her
case. PMI may require additional documents as it deems necessary or
desirable in making a review. Within 30 days after PMI receives the
appeal and supporting documentation, PMI will forward to the Enrollee a
written response or an explanation of why additional time is required.
If an Enrollee is dissatisfied with PMI's response and he or
she has been involved in PMI's grievance and appeals process for
60 days, the Enrollee may contact the Department of Corporations
for assistance. The Enrollee may file a complaint with the
•
Department immediately in an emergency situation, which is one
involving imminent and serious danger to his or her health.
3
The California Department of Corporations is responsible for regulating
health service plans. The Department has a toll-free telephone number
(1-800-400-0815) to receive complaints against health plans. If an
Enrollee has a grievance against the health plan, he or she should contact
• the plan and use the plan's grievance procedure. If the Enrollee needs
the Department's help with a complaint involving an emergency procedure
or with a grievance that has not been satisfactorily resolved by the plan,
he or she may call the Department's toll-free telephone number.
C. The following paragraph is added, and shall be the last paragraph
in this Article:
In the event of extreme hardship on the part of an enrollee or
subscriber, and upon application for relief presented to the American
Arbitration Association ("AAA"), PMI shall assume all or a portion of the
arbitration fees and expenses as determined by the AAA in accordance
with procedures established and administered by the AAA.
5. The third paragraph of the COBRA CONTINUATION OPTION in SCHEDULE E is
replaced by the following two paragraphs:
A Primary Enrollee who is entitled to continue coverage as a result of Qualifying
Event (a) or (b) above may continue that coverage, for himself or herself and any
Dependent Enrollees, for 29 months if the Primary Enrollee is determined under
Title II or Title XVI of the Social Security Act to have been disabled at the time the
Qualifying Event occurred or to have become so disabled within 60 days after
such event occurred. The Primary Enrollee must notify the Applicant during the
initial 18 months and within 60 days after the date of determination, and extended
• coverage for disability will terminate on the first day of the month that begins
more than 30 days after the date of final determination that the Primary Enrollee
is no longer disabled.
A Dependent Enrollee who has elected to continue coverage because (i)
Qualifying Event (a) or (b) occurred to the Primary Enrollee, and (ii) the Primary
Enrollee did not elect continued coverage for that Dependent Enrollee, and who
is or becomes disabled within 60 days after that event, may also continue
coverage, for himself or herself and any other Dependent Enrollees, for 29
months, subject to the notice and termination requirements described above with
respect to the Primary Enrollee.
IN WITNESS WHEREOF, PRIVATE MEDICAL-CARE, INC. has executed this
Amendment on the 16th day of August, 1999
0 I ,1 em/`tee,
Marilyn T. Masters
Vice President, Underwriting
•
4
Ca DELTA DRTAL®
DENTAL HEALTH PLAN
Affiliate of Delta Dental Plon
Delta Dental Plan of California s ac.rromi,
January 19,2000
City of Seal Beach
P.O.Boa 3370 211 81h Street
Cerritos Seal Beach,CA 90740
•
California 90703 RE: City of Seal Beach
2s9s Towne Center Drive DeltaPreferred Option Program; Delta Group#7809
(Second rate revision Delta only)
Cerritos DeltaCare Dental HMO Program; PMI Group#0140
California 90703
(562)403-4040
We are pleased to present your upcoming contract renewal, and to thank you for this opportunity to
Headquarters Office: continue our successful partnership with the City of Seal Beach.
P.O.Box 7736
Your employees are among the more than twelve million enrollees—representing more than 6,000
San Francisco client groups—who rely on Delta for quality, affordable dental coverage.
California 94120
Under your DeltaPreferred Option Program, Delta is offering you a two-year renewal contract
100 First Street with a 12%rates increase.
San Francisco
California 94105 Current Rates 2 yr-Renewal Rates Renewal Change
(415)972-8300
2/1/99-1/31/00 2/1/00-1/31/02 12%
One Party $43.45 $48.66
Offices in: Two Party $72.80 $81.54
Sacramento Three Party+ $117.42 $131.51
San Diego
Fresno
A crucial assumption made by Delta in the calculation of your renewal rate is that all applicable
guidelines are being met. Please be aware that if enrollment guidelines have been changed without
Delta's approval, Delta may adjust your rates.
Delta is adopting new standard policies that will affect your group contract effective January
1, 2000.The two changes outlined below are a continuation of Delta's cost management.We
project your benefit costs to be one percent lower as a result of these changes.
• Delta's standard examination policy will now cover no more than two examinations,
consultations and office visits per year. Previously,two examinations and unlimited
consultations and office visits were covered each year.
• Delta's standard contract will now make an allowance toward the cost of posterior
composite(resin) restorations based on the dentist's fee for the corresponding amalgam
restoration.The patient will be responsible for the remainder of the cost. Use of
composites on the facial surface of bicuspids will continue to be covered in full.
•
Upon renewal,you will also receive a revision to your Evidence of Coverage.
' •
0
• •
• Under your DeltaCare Dental HMO Program,administered through affiliate PMI, the renewal
date of your contract is February 1,2000. In order to maintain the same high standards and level
of care currently provided, it is necessary to increase the dues to fulfill capitation, specialty care and
administrative trend requirements. The new monthly dues for a one year contract renewal period
are:
Current Renewal
Dues Dues
Enrollee only $ 15.49 $15.80
Enrollee plus one dependent 27.12 27.66
Enrollee plus two or more dependents 39.98 40.78
To renew coverage for one year,simply begin paying the rates as outlined above for the new
contract term. Should you choose however not to renew,written notification must be received
by Certified Mail on or before January 1,2000.
This renewal letter serves as an amendment to your Delta and PMI contracts. Also attached is an
amendment to your PMI contract reflecting changes as required by state and federal law. The
attached amendment and this renewal letter should be kept with your contract documents.
If you have any questions regarding this renewal,or any other matter regarding your account,please
feel free to contact Dick Cook at:
Delta Dental Plan of Califomia
• 12898 Towne Center Drive
Cerritos,CA 90703
562-403-4040
Your continued confidence in Delta Dental is appreciated. It has been our pleasure to serve you and
we look forward to a long and mutually successful relationship in the future.
Sincerely,
DELTA DENTAL PLAN OF CALIFORNIA
&A_
Dick Cook John W. Crooms,Jr.
Account Executive Vice President, Sales
PRIVATE MEDICAL-CARE, INC. (PM()
Marilyn T. Masters
Vice President, Underwriting
cc: Emile J. Bayle
411
• PRIVATE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 - 8311 (800) 801 - 7105
APPLICATION FOR DeltaCare GROUP DENTAL SERVICE CONTRACT
The undersigned group ( "Applicant ") hereby applies for a DeltaCare GROUP DENTAL SERVICE
CONTRACT with PRIVATE MEDICAL -CARE, INC. ( "PMI ") on the following terms:
I. Applicant hereby authorizes PMI to furnish the dental Benefits described in the attached
Contract, subject to all of the terms and conditions of the Contract.
II. Applicant or Enrollees agree to pay to PMI, in advance, the Premiums specified in
Schedule D to the Contract.
III. Upon acceptance of this Application by PMI, and payment of the initial Premiums, the
Contract shall be effective at 12:01 a.m. on the Effective Date shown on Schedule D and the
Contract shall continue until terminated as provided.
IV. Applicant agrees to make available to Eligible Employees or Enrollees any notices
concerning Benefits required to be furnished by PMI.
V. "PMI WILL PROVIDE DIRECTLY TO EACH ELIGIBLE PERSON OR ENROLLEE A
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM (EOC). THE
EOC WILL DISCLOSE THE TERMS AND CONDITIONS OF COVERAGE, BUT WILL
CONSTITUTE ONLY A SUMMARY OF THE PROGRAM. AS REQUIRED BY THE
CALIFORNIA HEALTH & SAFETY CODE, THE CONTRACT MUST BE CONSULTED
TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE COVERAGE
• PROVIDED. A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST.
ENROLLEES SHOULD READ THE EOC CAREFULLY. PERSONS WITH SPECIAL
HEALTHCARE NEEDS SHOULD READ THE SECTION ENTITLED "SPECIAL
NEEDS ". ENROLLEES MAY ALSO OBTAIN INFORMATION ABOUT BENEFITS BY
CALLING PMI'S CUSTOMER RELATIONS DEPARTMENT AT (800) 422 -4234.
VI. Applicant agrees to receive, on behalf of Enrollees, all applicable notices concerning Benefits
under this Contract.
VII. THE PREMIUMS PAYABLE UNDER THIS CONTRACT ARE SUBJECT TO INCREASE
UPON RENEWAL AFTER THE END OF THE INITIAL CONTRACT TERM OR ANY
SUBSEQUENT CONTRACT TERM.
VIII. THIS CONTRACT IS SUBJECT TO ARBITRATION IN ACCORDANCE WITH
ARTICLE 6.
e / .1 /
(Date)
3T12
(Group Number)
HCM /City of Seal Beach
(Applicant)
City Hall 211 Eighth St., Seal Beach, CA 90740
.plicant Address)
• By: M. A. - h By: Walk A
(Authorized Signa. e) ( icense Registered Agent)
CP
PMI -CA 1 3T12.AT.doc
PRIVATE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 - 8311 (800) 801 - 7105
DeltaCare GROUP DENTAL SERVICE CONTRACT
IN CONSIDERATION of the Application, a copy of which is attached hereto and made a part of this
DeltaCare GROUP DENTAL SERVICE CONTRACT ( "Contract ") and IN CONSIDERATION of
payment of the required Premiums, PRIVATE MEDICAL -CARE, INC. ( "PMI") agrees to provide
• the Benefits described for the Contract Term shown on Schedule D and from year to year thereafter,
unless this Contract is terminated as provided. Premiums are payable in advance of the Effective
Date and thereafter as provided. This Contract is issued and delivered in the State of California, is
governed by the laws thereof, and is subject to the terms and conditions recited on the following
pages.
IN WITNESS WHEREOF, PMI has caused this Contract to be executed on:
Date: n O •
• PRIVATE MEDICAL -CARE, INC.
• By: mm . `yt zv
•
cP
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•
• ARTICLE 1. DEFINITIONS
For the purpose of this Contract, the following definitions shall apply:
1.01 "Acute Condition" means a condition requiring Emergency Services while a New Enrollee
is within thirty -five (35) miles from the office of the assigned Panel Dentist.
1.02 "Applicant" means the employer, union or other organization or group contracting to obtain
dental Benefits.
1.03 `Benefits" mean those dental services which are provided under the terms of this Contract
as specified in Article 4 and Schedule A.
1.04 "Contract" means this agreement between PMI and Applicant including the Application for
this Contract, the attached schedules, and any appendices, endorsements or riders. This
Contract constitutes the entire agreement between the parties.
1.05 "Contract Term" means the period commencing and terminating on the dates shown on
Schedule D, and each yearly period thereafter during which this Contract remains in effect.
• 1.06 "Copayment" means the fee charged to an Enrollee by a Dentist for the Benefits provided
under this Contract.
1.07 "Dentist" means a duly licensed Dentist legally entitled to practice Dentistry at the time and
in the state or jurisdiction in which services are performed.
1.08 "Effective Date" means the date this Contract becomes effective as provided in Schedule D.
1.09 "Eligibility Date" means the date upon which an Eligible Person's eligibility for Benefits
becomes effective under this Contract.
1.10 "Eligible Employee" means any employee or member of Applicant who meets the conditions
of eligibility outlined in Article 2.
1.11 "Eligible Dependent" means any of the dependents of an Eligible Employee who are eligible
to enroll for Benefits in accordance with the conditions of eligibility outlined in Article 2.
1.12 "Eligible Person" means an Eligible Employee or Eligible Dependent.
. I
1.13 "Emergency Services" mean only those dental services immediately required for alleviation
of severe pain, swelling or bleeding, or immediately required to avoid placing the patient's
• health in serious jeopardy.
1.14 "Enrollee" means an Eligible Employee ( "Primary Enrollee ") or an Eligible Dependent
( "Dependent Enrollee ") enrolled to receive Benefits.
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• 1.15 "New Enrollee" means an Enrollee who is enrolled less than thirty (30) days from the date
he or she is eligible for Benefits.
1.16 "Open Enrollment Period" means the period preceding the date of commencement of the
Contract Term or the 30 -day period immediately preceding the annual anniversary of the
commencement of the Contract Term or a period as otherwise requested by the Applicant
and agreed to by PMI.
1.17 "Panel Dentist" means a Dentist who has contracted with PMI to provide Benefits to
Enrollees.
1.18 "Premiums" mean amounts payable by Applicant or an Enrollee as provided in Article 3 and
Schedule D.
1.19 "Special Health Care Need," means a physical or mental impairment, limitation or condition
that substantially interferes with an Enrollee's ability to obtain Benefits. Examples of such
a Special Health Care Need are (i) the Enrollee's inability to obtain access to the assigned
Panel Dentist's office because of a physical handicap and (ii) the Enrollee's inability to
comply with the Panel Dentist's instructions during examination or treatment because of
physical handicap or mental incapacity.
• 1.20 "Specialist Services" mean services performed by a Dentist who specializes in a particular
type of dental care (i.e., oral surgery, endodontics, periodontics or pedodontia) and which
must be preauthorized in writing by PMI.
. I
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•
• ARTICLE 2. ELIGIBILITY, ENROLLMENT AND CANCELLATION OF ENROLLMENT
2.01 Eligible Employees are those employees or group members described in Schedule D. New
employees shall become eligible for coverage as specified in Schedule D.
Eligible Dependents of an Eligible Employee are spouse (unless legally separated or
divorced) and unmarried dependent children from birth to age 19, or to age 23 while enrolled
as full -time students in an accredited school, college or university, provided that the student
is chiefly dependent upon the Eligible Employee for maintenance and support. Children
include step - children, adopted children and foster children, provided such children are
dependent upon the employee for support and maintenance. Dependents become eligible
coincident with the Eligible Employee or upon attainment of dependent status. Newborn
• infants are eligible from and after the moment of birth. Adopted children are eligible from
and after the moment the child is placed in the physical custody of the Eligible Employee for
adoption.
An unmarried dependent 19 years or over may continue to be eligible as a dependent if
incapable of self - support because of physical or mental disability that commenced prior to
reaching age 19, or prior to reaching age 23 while enrolled as a full -time student in an
accredited school, college or university, and if chiefly dependent on the Eligible Employee
for support and maintenance, provided proof of such disability and dependency is submitted
• not less than 31 days prior to the dependent's attainment of the limiting age, and
subsequently as may be required by either PMI or Applicant, but not more frequently than
annually after the disabled and dependent child has attained the limiting age.
Dependents in military service are not eligible. No one may be an Eligible Dependent if
eligible as an Eligible Employee and no one may be an Eligible Dependent of more than one
Eligible Employee.
Medicare eligibility shall not affect eligibility of an Eligible Employee or Eligible
Dependent.
2.02 Eligible Employees must complete and sign enrollment forms provided by PMI during the
Open Enrollment Period in order to receive Benefits and for their Eligible Dependents to
receive Benefits. Persons not originally eligible during the Open Enrollment Period may be
enrolled immediately upon attainment of dependent status. Subject to cancellation as
provided under this Contract, enrollment of Eligible Employees and any Eligible Dependents
is for a minimum period of one year.
Applicant shall compile and furnish to PMI on or prior to the first day of every month, a list
of all Primary Enrollees showing their Social Security numbers and, if applicable, location
codes and all Dependent Enrollees. PMI shall be obligated to provide Benefits only to
Primary Enrollees and their Dependent Enrollees who are enrolled and are reported on the
• list of Primary Enrollees submitted by Applicant and for whom the appropriate Premiums
are paid pursuant to Article 3 and Schedule D of this Contract for the period in which
covered dental services are provided. Newborn infants are covered from the moment of birth
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• up to 31 days, and thereafter if notification of birth and the appropriate Premiums are
received by PMI within 31 days after the date of birth.
2.03 Subject to any rights provided under Article 6, enrollment under this Contract may be
cancelled, or renewal of enrollment refused, in the following events:
a) Upon 30 days' notice if the Contract is terminated or not renewed.
b) Immediately upon loss of eligibility.
c) Upon 15 days' written notice if the Premiums are not paid by or on behalf of the
Enrollee on the date due. However, the Enrollee may continue to receive Benefits
during the 15 -day period and may be reinstated during the term of this Contract upon
payment of any unpaid Premiums.
d) Immediately if the Enrollee is guilty of misconduct detrimental to the delivery of
services while in the office of a Panel Dentist.
e) Upon 15 days' written notice if the Enrollee knowingly perpetrates or permits another
person to perpetrate fraud or deception in obtaining Benefits under this Contract.
f) Upon 30 days' written notice if the Enrollee fails to pay Copayments; provided,
• however, that the Enrollee may be reinstated during the term of this Contract upon
payment of all delinquent charges.
g) Upon 30 days' written notice, if (i) the Enrollee and a Panel Dentist fail to establish
a satisfactory patient- Dentist relationship, (ii) it is shown that PMI has, in good faith,
provided the Enrollee with the opportunity to select an alternative Panel Dentist, (iii)
the Enrollee has been notified in writing at least 30 days in advance that PMI
considers the patient- Dentist relationship to be unsatisfactory and PMI specifies the
changes that are necessary in order to avoid cancellation, and (iv) the Enrollee has
failed to make such changes.
Cancellation of a Primary Enrollee's enrollment shall automatically cancel the enrollment
of any of his or her Dependent Enrollees.
2.04 An Enrollee who believes that enrollment has been cancelled or not renewed because of the
Enrollee's health status or requirements for health care services, may request a review by the
Director of the California Department of Managed Health Care in accordance with Section
1365(b) of the California Health and Safety Code.
•
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ID
• ARTICLE 3. PREMIUMS AND COPAYMENTS
3.01 In accordance with Schedule D, Applicant agrees to pay Premiums on behalf of Primary
Enrollees and to collect Premiums by means of payroll deductions for Dependent Enrollees
voluntarily enrolled for Benefits under this Contract. Applicant shall remit one check each
period as required by Schedule D. Should an Enrollee voluntarily cancel enrollment and
subsequently desire to re- enroll dependent(s), all Premiums retroactive to the date of
cancellation (but not to exceed 12 months) must be paid before the Dependent(s) shall be re-
enrolled.
3.02 This Contract shall not be in effect until initial Premiums are received. Subsequent Premiums
shall be payable in accordance with Schedule D.
3.03 PMI may change the amount of Premiums whenever the terms of this Contract are changed
by amendment or PMI's liability is changed by law or regulation. However, in the absence
of an amendment mutually agreed upon between Applicant and PMI or such a change in
liability, no change in the Premiums shall become effective within a Contract Term except
as provided in Section 3.04.
3.04 If during a Contract Term, any new tax is imposed on PMI by any government agency on the
amount of Premiums payable under this Contract or the number of the persons covered, or
• if the rate of an existing tax on the amount of Premiums or the number of persons covered
is increased, the Premiums stated in Schedule D shall be increased by the amount of any such
new tax or increased taxes upon 30 days' written notice.
3.05 Upon discovery of clerical errors made by PMI with respect to enrollment data for a Primary
Enrollee, Premiums may be adjusted back to the Primary Enrollee's Enrollment Date. The
amount of credit which may be taken with respect to a Primary Enrollee shall not exceed the
Premiums for the current month in which Premiums are due, plus two (2) months of
retroactive Premiums. In addition, the total amount of credit which may be taken on any due
date shall not exceed 10% of the billed amount for that due date.
3.06 Enrollees are required to pay any Copayments listed in the Description of Benefits and
Copayments (attached as Schedule A) directly to the Dentist. Charges for broken
appointments (unless notice is received by the Dentist at least 24 hours in advance or an
emergency prevented such notice) and charges for emergency visits after normal visiting it
hours are shown on Schedule A.
3.07 In the event of cancellation of enrollment by PMI (except in the case of fraud or deception
in obtaining Benefits from PMI or knowingly permitting such fraud or deception by another),
PMI shall return to Applicant the pro rata portion of the Premiums paid to PMI which
• corresponds to any unexpired period for which payment had been received, together with any
amounts due on claims, if any, less any amounts owed to PMI.
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• ARTICLE 4. BENEFITS, LIMITATIONS AND EXCLUSIONS
4.01 PMI shall provide the Benefits in Schedule A, subject to the Limitations and Exclusions in
Schedule B, and in accordance with the Governing Administrative Policies in Schedule C.
Benefits are available to each Enrollee on the Eligibility Date.
4.02 PMI shall provide Panel Dentists at convenient locations during the term of this Contract.
A list of Panel Dentists shall be furnished to all Primary Enrollees. A Primary Enrollee may
select any Panel Dentist whose name is on said list at the time of enrollment, to render
services to the Primary Enrollee and any Dependent Enrollees. If a Primary Enrollee fails
to select a Panel Dentist or the Panel Dentist selected becomes unavailable, PMI shall request
the selection of another Panel Dentist or shall assign that Enrollee to another Panel Dentist.
A Primary Enrollee may make a change to any other Panel Dentist during the open
enrollment period. Upon the approval of PMI, an Enrollee may select another Panel. Dentist
if the Enrollee has a change in family status or residence or fails to establish a satisfactory
patient/doctor relationship with the Panel Dentist. The change must be requested prior to the
21st of the month to become effective on the first day of the following month.
4.03 The services which are Benefits shall be rendered by Panel Dentists, and PMI shall have no
obligation or liability with respect to services rendered by non -Panel Dentists, with the
exception of Emergency Services as provided in Section 4.04, or Specialist Services
recommended by a Panel Dentist, and approved in writing by PMI. All services other than
Emergency Services or Specialist Services shall be rendered at the office of the Panel
Dentist. Referral of Specialist Services must be by a Panel Dentist and must be authorized
in writing by PMI. All approved Specialist Services claims will be paid by PMI less any
applicable Copayments. A Panel Dentist may provide services either personally, or through
associated Dentists, or the other technicians or hygienists who may lawfully perform the
services. If an Enrollee is assigned to a dental school clinic for Specialist Services, those
services may be provided by a Dentist, a dental student, a clinician or a dental instructor.
4.04 If an Enrollee is more than 35 miles from the office of the assigned Panel Dentist, and
requires Emergency Services, PMI shall reimburse the Enrollee for the cost of such
treatment, less any applicable Copayments, up to a maximum of $1 00.00 during any 12-
month period upon submission to PMI of a verifiable claim within 90 days after such
treatment is received.
If an Enrollee has been enrolled less than 30 days, and if the Enrollee is currently
experiencing an Acute Condition, he or she should contact PMI's Customer Relations
Department at 1- 800 - 422 -4234 for authorization for treatment of the condition.
If PMI determines that the circumstances of the Acute Condition require that the Enrollee
obtain treatment from a Dentist who is not one of PMI's Panel Dentists, the Enrollee will be
instructed:
a) to seek treatment immediately necessary to alleviate severe pain, swelling or
bleeding, or immediately necessary to avoid placing his or her health in serious
jeopardy;
• b) that treatment for an Acute Condition does not include any services other than
Emergency Services;
BEN
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•
• c) that PMI will reimburse the Enrollee for the cost of such treatment up to a maximum
of $100.00 during any 12 -month period;
d) that the Enrollee must submit a claim within 90 days after receiving the treatment;
and
e) that the Enrollee must visit his or her Panel Dentist for further treatment.
PMI may require a non -Panel Dentist providing treatment to an Enrollee of an Acute
Condition to agree in writing to meet the same contractual terms and conditions which are
imposed upon Dentists who have signed a contract with PMI. PMI is not liable for actions
resulting solely from the negligence, malpractice or other tortious or wrongful acts arising
out of the treatment provided by a non -Panel Dentist.
4.05 In the event that PMI fails to pay a Panel Dentist, the Enrollee shall not be liable to that
Dentist for any sums owed by PMI. In the event that PMI fails to pay a Dentist who is not
a Panel Dentist, the Enrollee may be liable to that Dentist for the cost of services.
4.06 Claims for Specialist Services or Emergency Services which are Benefits must be submitted
within 90 days after termination of treatment. Failure to submit a claim within such time
shall not invalidate nor reduce any claim for reimbursement if it shall be shown not to have
been reasonably possible to submit the claim within such time and that such claim was
submitted as soon as reasonably possible, but in no event later than one year from the time
otherwise required.
• PMI shall acknowledge receipt of a claim within 20 working days unless payment of the
claim is made within that time. Within 30 working days after receipt of a claim, PMI shall
accept or deny the claim, in whole or in part, unless more time is required to determine
whether the claim should be accepted or denied. If more time is required, PMI shall notify
the Dentist within 30 working days of receipt of the claim of the reasons more time is
required. PMI shall notify the Dentist again 45 days thereafter of the reasons any additional
time is required to determine whether the claim should be accepted or denied.
4.07 Upon termination of a contract with a Panel Dentist, PMI shall be liable for Benefits rendered
by such Panel Dentist to an Enrollee who is under the care of such Dentist at the time of such
termination until any single procedure commenced prior to termination by such Dentist is
completed, unless PMI makes reasonable and medically appropriate provisions for the
completion of such procedure by another Panel Dentist. PMI shall give written notice to
Applicant within a reasonable time of any termination or breach of contract by, or inability
to perform of, any Panel Dentist if Applicant will be materially and adversely affected.
If an Enrollee's assigned Network Dentist's contract with PMI terminates, that Network
Dentist will complete (a) a partial or full denture for which final impressions have been
taken, and (b) all work on every tooth upon which work has started (such as completion of
root canals in progress and delivery of browns when teeth have been prepared.)
4.08 In the absence of an amendment mutually agreed upon between Applicant and PMI, no
change in Benefits shall be made during a Contract Term.
110 4.09 All Benefits shall terminate for any Enrollee as of the date that this Contract
such person ceases to be eligible under the terns of this Contract, or such person's enrollment
is cancelled under this Contract. PMI shall not be obligated to continue to provide Benefits
PMI -CA BEN
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to any such person in such event, except for completion of single procedures commenced
while this Contract was in effect.
4.10 A Panel Dentist is compensated by PMI through monthly capitation (an amount based on the
number of Enrollees assigned to the Dentist), and by Enrollees through required Copayments
for treatment received. A Specialist is compensated by PMI through an agreed -upon amount
for each covered procedure, and by Enrollees through applicable Copayments. In no event
does PMI pay a Dentist or a Specialist any incentive as an inducement to deny, reduce,
limit or delay any appropriate treatment. An Enrollee may obtain further information
concerning compensation of providers by calling PMI at 1- 800 - 422 -4234.
4.11 PMI does not authorize or deny services provided by a Panel Dentist. All Benefits provided
by a Panel Dentist are in accordance with dental care guidelines which establish the standard
of care to be followed by Panel Dentists. PMI's dental care guidelines are reviewed by
PMI's Dental Advisory Committee, and updated as an needed. An Enrollee may contact
PMI's Customer Relations Department at 1- 800 - 422 -4234 for information regarding PMI's
dental care guidelines.
4.12 PMI may request that an Enrollee obtain a second opinion to verify the necessity and
appropriateness of dental treatment or application of Benefits. When PMI requests a second
opinion, it will pay for all second opinion charges. An Enrollee may also request a second
opinion if he or she disagrees with the diagnosis and/or treatment plan determination made
by his or her Panel Dentist. In such cases, the Enrollee should contact PMI's Customer
Relations Department for assistance in requesting authorization for a second opinion.
• Second opinions will only be authorized at a Panel Dentist's office, unless otherwise
authorized by PMI's Dental Consultant. Charges for second opinions that are not authorized
by PMI are excluded from coverage.
4.13 If an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact
PMI's Customer Relations Department at 1 (800) 422 -4234. PMI will confirm whether such
a Special Health Care Need exists, and what arrangements can be made to assist the Enrollee
in obtaining such Benefits. PMI shall not be responsible for the failure of any Panel Dentist
to comply with any law or regulation concerning treatment of persons with Special Health
Care Needs which is applicable to the Dentist.
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PMI -CA BEN
10 3T12.AT.doc
ID 411/
• ARTICLE 5. COORDINATION OF BENEFITS
5.01 This Contract provides Benefits without regard to coverage by any other group insurance
policy or any other group health benefits program if the other policy or program covers
services or expenses in addition to dental care. Otherwise, Benefits under this Contract are
coordinated with such other group insurance policy or any group health benefits program.
5.02 When Benefits are coordinated with another group insurance policy or group health benefits
program, the determination of which policy or program is primary shall be governed by the
following rules:
a) The policy or program covering the patient as other than a dependent shall be primary
over the policy or program covering the patient as a dependent.
b) The policy or program covering a child as a dependent of a parent whose birthday
occurs earlier in a calendar year shall be primary over the policy or program covering
a child as a dependent of a parent whose birthday occurs later in a calendar year
(except for a dependent child whose parents are separated or divorced as described
in c) below).
c) In the case of a dependent child whose parents are legally separated or divorced:
• 1) If the parent with custody has not remarried, the policy or program covering
the child as a dependent of the parent with custody shall be primary over the
policy or program covering the child as a dependent of the parent without
custody.
2) If the parent with custody has remarried, the policy or program covering the
child as a dependent of the parent with custody shall be primary over the
policy or program covering the child as a dependent of the step - parent, and
the policy or program covering the child as a dependent of the step-parent
shall be primary over the policy or program covering the child as a dependent
of the parent without custody.
3) If there is a court decree that establishes financial responsibility for dental
services which are Benefits under this program, notwithstanding c) 1) and 2),
the policy or program covering the child as a dependent of the parent with
such financial responsibility shall be primary over any other policy or
program covering the child.
d) If the primary policy or program cannot be determined by the rules described in a),
b) or c), the policy or program which has covered the Enrollee for a longer period of
time shall be primary, with the following exception: A policy or program covering
the Enrollee as a laid -off or retired employee or the dependent of a laid -off or retired
• employee shall not be primary under this rule d) over a policy or program covering
the Enrollee as an employee or the dependent of an employee. However, if the
provisions of the other policy or program do not include this exception, which results
in benefits under neither being primary, then this exception shall not apply.
pp Y•
PMI -CA COB
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• 5.03 An Enrollee shall provide to PMI, and PMI may release to insurance
company or other organization, any information about the Enrollee that a s y needed to
administer coordination of benefits. PMI shall, in its sole discretion, determine whether any
reimbursement to an insurance company or other organization is warranted under these
coordination of benefits provisions, and any such reimbursement paid shall be deemed to be
Benefits under this Contract. PMI shall have the right to recover from a Dentist, Enrollee,
insurance company or other organization, as PMI chooses, the amount of any Benefits paid
by PMI which exceed its obligations under these coordination of benefit provisions.
•
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•
COB
PMI -CA
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411 ARTICLE 6. COMPLAINT PROCEDURE, CLAIMS APPEAL AND ARBITRATION
PMI shall provide notification if any dental services or claims are denied, in whole or in part, stating
the specific reason or reasons for the denial. If an Enrollee has any complaint regarding eligibility,
the denial of dental services or claims, the policies, procedures or operations of PMI, or the quality
. of dental services performed by a Panel Dentist, he or she may call PMI's Customer Relations
Department at 1 -800- 422 -4234, or the complaint may be addressed in writing to:
PMI Quality Management Coordinator
12898 Towne Center Drive
Cerritos, California 90703
and must include 1) the name of the patient, 2) the name, address, telephone number and social
security number of the Primary Enrollee, 3) the name of the Applicant and 4) the Dentist's name and
address.
Within 5 calendar days of the receipt of a complaint and the above information, the PMI Quality
Management Coordinator will forward to the complainant an acknowledgment of receipt of the
complaint. Those complaints requiring professional expertise shall be referred to the PMI Executive
Dental Director for response. Certain complaints may also require that the complainant be referred
to a Dentist for a clinical evaluation of the dental services provided. PMI will respond, within 3 days
• of receipt, to complaints involving severe pain and /or imminent and serious threat to a patient's
health.
Within 30 days of the receipt of the complaint, PMI shall send to the complainant a written report
which describes the complaint and PMI's resolution. The report shall advise that a review of PMI's
decision shall be undertaken if a written request for an appeal of the determination is made within
30 days of the date of receipt of the report. The complainant should provide the reason for the appeal
and any additional information which may affect the case. PMI shall undertake a full and fair review
upon any request for review. PMI may require additional documents as it deems necessary or
desirable in making such a review. PMI shall provide a written response to the complainant within
30 days after PMI receives the appeal and supporting documentation. !`
An Enrollee may file a complaint with the Department of Managed Health Care after he or she
has completed PMI's grievance procedure or after he or she has been involved in PMI's
grievance procedure for 30 days. An Enrollee may file a complaint with the Department
immediately in an emergency situation, which is one involving severe pain and /or imminent
and serious threat to the Enrollee's health.
The California Department of Managed Health Care is responsible for regulating health care services
plans. The Department has a toll -free number (1- 888 - HMO -2219) to receive complaints regarding
health plans. The hearing and speech impaired may use the California Relay Service's toll -free
numbers [1- 800 - 735 -2929 TT
( Y)] or [1- 888 - 877 -5378 (TTY)] to contact the Department. The
Department's website (http: / /www,hmohelp.ca.gov) has complaint forms and instructions online.
If you have a grievance against your health plan you should first telephone your plan at
(1 - 800 - 422 - 4234) and use the plan's grievance process before contacting the Department. If you
PMI -CA COMPL
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• need help with a grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your plan, or a grievance that has been unresolved for more than 30 days, you may call
the Department for assistance. The plan's grievance process and the Department's complaint review
process are in addition to any other dispute resolution procedures that may be available to you, and
your failure to use these processes does not preclude your use of any other remedy provided by law.
Any dispute arising out of or relating to this Contract or this dental health care program, including
any disagreement with a claim determination made by PMI after exhaustion of the procedures
outlined above, or any complaint regarding the quality of dental services performed by a Panel
Dentist, is subject to arbitration in accordance with the Consumer Rules of the American Arbitration
Association ( "AAA "). Any party to a dispute may initiate arbitration by written notice to each other
party to the dispute by filing two copies of such notice with the AAA Regional Office in San
•
Francisco or Los Angeles, together with the fee required by the AAA.
In the event of extreme hardship on the part of an enrollee or subscriber, and upon an application for
relief presented to the AAA, PMI shall assume all or a portion of the Enrollee's share of arbitration
fees and expenses as determined by the AAA in accordance with procedures established and
administered by the AAA.
•
COMPL
PMI -CA
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ARTICLE 7. GENERAL PROVISIONS
7.01 The Contract, the Contract application, and any attached schedules, appendices,
endorsements and riders, constitute the entire agreement between PMI and Applicant. No
agent has authority to amend this Contract or waive any of its provisions. No amendment
to this Contract shall be valid unless approved by an executive officer of PMI and evidenced
by endorsements.
7.02 If any portion of this Contract or any amendment thereof shall be determined by any
arbitrator, court or other competent authority to be illegal, void or unenforceable, such
determination shall not abrogate this Contract or any portion thereof other than such portion
determined to be illegal, void or unenforceable, and all other portions of this Contract shall
remain in full force and effect.
7.03 The parties agree that all questions regarding interpretation or enforcement of this Contract
shall be governed by the laws of the State of California, where the Contract is entered into
and is to be performed. PMI is subject to the requirements of Chapter 2.2 of Division 2 of
the California Health and Safety Code and of Subchapter 5.5 of Chapter 3, of Title 10 of the
California Code of Regulations. Any provisions required to be in the Contract by either of
the above shall bind PMI whether or not provided in this Contract.
• 7.04 PMI will issue to the Applicant for delivery to each Primary Enrollee an evidence of
coverage summarizing the Benefits to which each Enrollee is entitled. If any amendment to
this Contract shall materially affect any provisions described in such evidence of coverage,
new evidences of coverage or riders showing the change shall be issued. Any direct conflict
between the evidence of coverage and this Contract shall be resolved according to the terms
most favorable to the Enrollee.
7.05 Both parties to this Contract agree to consult to the extent reasonably practical concerning
all material published or distributed relating to this Contract. No such material shall be
published or distributed which is contrary to the terms of this Contract.
7.06 Applicant shall designate in writing a representative for purposes of receiving notices from
PMI under this Contract. Applicant may change its representative at any time on 30 days'
notice to PMI. Any notice under this Contract shall be sufficient if given by either Applicant
or PMI to the other addressed as stated on the Application of this Contract, and shall be
effective 48 hours after deposit in the United States mail with postage fully prepaid. Any
notice required from PMI to any Enrollee may be given to Applicant's representative, who
shall disseminate such notice to Enrollees by next regular communication but in no event
later than 30 days after receipt thereof.
7.07 PMI shall be excused from performance under this Contract for any period and to the extent
• that it is prevented from performing any services in whole or in part as a result of an act of
God, war, civil disturbance, strike, court order, or other cause beyond its reasonable control
and which it could not have prevented by reasonable precautions.
PMI -CA GENPROV
15 3T12.AT.doc
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•
• ARTICLE 8. TERMINATION AND RENEWAL
8.01 This Contract may be terminated by PMI upon Applicant's failure (i) to furnish PMI with the
eligibility list as required by Article 2, or (ii) to pay Premiums in the amount and manner
required by Article 3, provided Applicant has been notified of such failure and at least 15
days have elapsed since such notification.
8.02 Termination at the end of a Contract Term shall be by at least 30 days' advance written notice
of termination by certified mail given by the party desiring to terminate to the other party.
In the event that PMI shall desire to change Premiums or Benefits effective at the end of any
Contract Term, advice of such changes will be given to Applicant upon at least 30 days'
written notice, and such notice shall renew the Contract for another Contract Term at the
rates and with the coverage as stated in the notice unless Applicant provides written
notification to PMI by certified mail on or before the date stated in the notice that Applicant
does not choose to renew.
8.03 Acceptance by PMI of the proper Premiums after termination of this Contract and without
requiring a new application, shall continue this Contract as though it had never terminated,
unless PMI shall, within 20 business days of receipt of such payment, either i) refuse the
payment so made, or ii) issue to Applicant a new Contract accompanied by written notice
stating clearly those respects in which the new Contract differs from this terminated Contract
in Benefits, coverage or otherwise.
•
PMI -CA TERM -REN
16 3T12.AT.doc
•
• ARTICLE 9. ATTACHMENTS
The following schedules are a part of this Contract:
Schedule A - Description of Benefits and Copayments
Schedule B - Limitations and Exclusions of Benefits
Schedule C - Governing Administrative Policies
Schedule D - Group Variables and Premiums
Schedule E - COBRA Continuation Option
Schedule F - Accident Injury Rider
•
•
PMI -CA ATT
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III SCHEDULE A
PLAN CA735
CODES ENROLLEE
I. DIAGNOSTIC PAYS
Office visit, per visit (in addition to other services) No Cost
0120 Periodic oral evaluation
0140 Limited oral evaluation -- problem focused No Cost
0150 Comprehensive oral evaluation No Cost
0160 Detailed and extensive oral evaluation -- problem focused No Cost
0210 Intraoral radiographs -- complete series No Cost
(including bitewings) No Cost
0220,0230 Intraoral periapical film
0240 Intraoral occlusal film No Cost
0270, No Cost
0272,0274 Bitewing radiograph(s)
0330 Panoramic film No Cost
No Cost
II. PREVENTIVE
1110,1120 Prophylaxis (cleaning)-- adultichild -
1 per 6 month period No Cost
• 1201 Topical application of fluoride,
including prophylaxis (to age 19) - 1 per 6 month period No Cost
1203 Topical application of fluoride,
excluding prophylaxis (to age 19) - 1 per 6 month period No Cost
1330 Oral hygiene instructions
1351 Sealant, per tooth $ 1 Cost
1510 Space maintainer -- fixed -- unilateral $ 10.00
1515 Space maintainer -- fixed -- bilateral $ 15.00
1520 Space maintainer -- removable -- unilateral $ 15.00
$ 15.00
1525 Space maintainer -- removable -- bilateral
1550 Recementation of space maintainers $ 15.00
No Cost
III. RESTORATIVE (Fillings)
(Includes indirect pulp capping, bases, liners
and acid etch procedures)
2110 Amalgam- -one surface, primary
2120 Amalgam- -two surfaces, primary No Cost
2130 Amalgam- -three surfaces, primary No Cost
2131 Amalgam- -four or more surfaces, primary No Cost
2140 No Cost
Amalgam- -one surface, permanent No Cost
2150 Amalgam- -two surfaces, permanent
2160 Amalgam- -three surfaces, permanent No Cost
2161 Amalgam- -four or more surfaces, permanent No Cost
2330 Resin - -one surface anterior No Cost
• 2331 Resin - -two surface anterior No Cost
2332 Resin - -three surface anterior No Cost
2335 Resin - -four or more surfaces or involving No Cost
incisal angle (anterior)
No Cost
SCH -A
PMI -CA 18
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' . 4
• CODES ENROLLEE
PAYS
2336 Composite resin crown, anterior -- primary
2940 Sedative filling No Cost
2951 Pin retention - -per tooth, in addition to restoration $ 1 Cost
$ 10.00
IV. ORAL SURGERY
(Includes preoperative and postoperative evaluations
and treatment under local anesthetic)
7110,7120 Single tooth extraction/each additional
7130 Root removal -- exposed roots No Cost
7210 Surgical removal of erupted tooth No Cost
7220 Removal of impacted tooth - -soft tissue No Cost
7230 Removal of impacted tooth -- partially bony $ No Cost
7240,7241 Removal of impacted tooth -- completely bony $ 45.00
7250 Surgical removal of residual tooth roots $ 65.00
(cutting procedure)
7286 Biopsy of oral tissue - -soft No Cost
7310 Alveoloplasty in conjunction with extractions, per quadrant $ No Cost
7320 Alveoloplasty not in conjunction with extractions, per quadrant $ 50.00
7470 Removal of exostosis -- maxilla or mandible
7510 Incision and drainage of abscess -- intraoral soft tissue No Cost
7960 Frenulectomy-- (frenectomy or frenotomy) No Cost
• separate procedure
No Cost
V. PERIODONTICS
(Includes preoperative and postoperative evaluations
and treatment under a local anesthetic)
4210 !
Gingivectomy or gingivoplasty, per quadrant
4211 Gingivectomy or gingivoplasty, per tooth $100.00
(fewer than six teeth)
$ 20.00
4220 Gingival curettage surgical, per quadrant
4240 Gingival flap procedures including $ 10.00 j
root planing (per quadrant)
4260 Osseous surgery, flap entry and closure, per quadrant $100.00
4341 Periodontal scaling and root planing, quadrant $20.00
4355 Full mouth debridement to enable comprehensive periodontal $ 10.00
evaluation and diagnosis i
4910 Periodontal maintenance (following active therapy) $ 8. $ 8. 00
00
VI. PROSTHETICS
(Crowns, bridges and dentures)
2510 Inlay- -one surface- -base metal noble
2520,6520 Inlay- -two surfaces- -base metal noble No Cost
2530,6530 Inlay- -three or more surfaces - -base metal noble No Cost
2543,6543 Onlay- -three surfaces- -base metal noble No Cost
0 2544,6544 Onlay- -four or more surfaces- -base metal noble No Cost
2710 Crown- -resin (laboratory) $ 4 Cost
2740 Crown-- porcelain/ceramic j. $ 45.00
2750 Crown -- porcelain fused to high noble metal *t $ 75.00
2751 Crown -- porcelain fused to predominantly base metalt $ 75.00
2752 Crown -- porcelain fused to noble metalt $ 75.00
$ 75.00
PMI -CA 19 SCH -A
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•
• •
• CODES ENROLLEE
PAYS
2790 Crown - -full cast high noble metal*
2791 Crown - -full cast predominantly base metal $ 75.00
$ 75.00
2792 Crown - -full cast noble metal
2810 Crown - -3/4 cast metal noble $ 75.00
2910 Recement inlay $ 75.00
2920 Recement crown No Cost
2930,2931 Crown -- prefabricated stainless steel -- primary/permanent No Cost
2950 Crown buildup (restorative material and pins) Cost
$
2952 Cast post and core* (in addition to crown) $ 10.00
$ 10.00
2954 Prefabricated post and core (in addition to crown) 10.00
5110,5120. Denture -- complete maxillary or mandibular (upper or lower) $ 95.00
5130,5140 Immediate denture -- maxillary or mandibular (upper or lower) $110.00
5213,5214 Denture -- maxillary or mandibular (upper or lower) partial with
metal lingual or palatal bar, clasps and acrylic saddles,
and acrylic base or cast metal framework and teeth $110.00
5410 Adjust complete denture -- maxillary
5411 Adjust complete denture -- mandibular $ 5.00
5421 Adjust partial denture -- maxillary $ 5.00
5422 Adjust partial denture -- mandibular $ 5.00
5510 Repair broken complete denture base $ 5. 0 00
5520 Replace missing or broken teeth -- complete denture (per tooth) $ 10.00
5610 Repair resin denture base
• 5620 Repair cast framework $ 15.00
5630 Repair or replace broken clasp $ 15.00
5640 Replace broken teeth (per tooth) $ 15.00
5650 Add tooth to existing partial denture $ 10.00
5660 Add clasp to existing partial denture $ 10.00
5730 Reline complete maxillary denture (chairside) $ 10.00
5731 Reline complete mandibular denture (chairside) $ 20.00
$ 20.00
5740 Reline maxillary partial denture (chairside)
5741 Reline mandibular partial denture (chairside) $ 20.00
$ 20.00
5710 Rebase complete maxillary denture
5711 Rebase complete mandibular denture $ 40.00
5720 Rebase maxillary partial denture $ 40.00
5721 Rebase mandibular partial denture $ 40.00
5750 Reline complete maxillary denture (lab) $ 40.00
5751 Reline complete mandibular denture (lab) $ 40.00
$ 40.00
5760 Reline maxillary partial denture (lab)
5761 Reline mandibular partial denture (lab) $ 40.00
5820 Interim partial denture (maxillary) $ 40.00
5821 No Cost
Interim partial denture (mandibular)
5850,5851 Tissue conditioning - -per denture No Cost
6210 No Cost
Pontic- -cast high noble metal*
6211 Pontic - -cast predominantly base metal $ 75.00
6212 Pontic- -cast noble metal $ 75.00
6240 Pontic -- porcelain fused to high noble metal *t $ 75.00
6241 Pontic -- porcelain fused to predominantly base metalt $ 75.00
111 $ 6242 Pontic -- porcelain fused to noble metal- 75.00
6750 Crown -- porcelain fused to high noble metal *f $ 75.00
6751 Crown -- porcelain fused to predominantly base metalt $ 75.00
6752 Crown -- porcelain fused to noble metalt $ 75.00
6790 Crown - -full cast high noble metal* $ 75.00
6791 Crown - -full cast predominantly base metal $ 75.00
$ 75.00
PMI -CA SCH -A
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0 •
II CODES ENROLLEE
PAYS
6792 Crown - -full cast noble metal
6930 Recement bridge (fixed partial denture) $ 75.00
6940 Stress breaker, per unit (in addition to mixed partial No Cost
denture, retainer)
6970 Cast post and core* (includes canal preparation) $ 1 Cost
6972 Prefabricated post and core buildup (including canal $ 10.00
preparation, restorative material and any pins)
$ 10.00
* Base or noble metal is the benefit. High noble metal (precious),
if used, will be charged to the enrollee at the additional
laboratory cost of the high noble metal. This applies to crowns,
bridges, cast and post cores, inlays and onlays.
t Porcelain on molars is considered optional treatment.
VII. ENDODONTICS
3110,3120 Pulp capping (direct/indirect)
3220 Therapeutic pulpotomy (excluding final restoration No Cost
3310 Root canal therapy--anterior $ No Cost
PY anterior (excludi
3320 ng final restoration) $ 40.00
3330 Root canal therapy -- bicuspid (excluding final restoration) $ 80.00
Root canal therapy - -molar (excluding final restoration) $120.00
3410 Apicoectomy /periradicular surge
• 3421 rY- -anterior $ 50.00
Apicoectomy /periradicular surgery-- bicuspid (first root)
3425 Apicoectomy /periradicular sure $ 50.00
3426 Apicoectomy /periradicular surgery (each additional root) No Cost
3430 Retrograde filling, per root
3450 Root amputation, per root $ 50.00
No Cost
VIII. ADJUNCTIVE GENERAL SERVICES
9110 Palliative (emergency) treatment of dental pain
9211 Regional block anesthesia $ 5.00
9212 Trigeminal division block anesthesia No Cost
9215 Local anesthesia No Cost
9310 Consultation (diagnostic services provided by a dentist or No Cost
physician other than practitioner providing treatment) No Cost
9440 Office visit after regularly scheduled hours
0125 Failed appointment without 24 hour notification, $ 20.00
per 15 minutes of appointment time
$ 10.00
IX. ORTHODONTICS
Start-up fees (excluding records) i
Dependent children to age 19 $ 350.00
Adults and covered full -time students $1600.00
$1800.00
411 Any procedure not listed is available on a UCR basis.
The above procedures are performed as needed and deemed necessary subject to the Limitations, Exclusions and Governing Administrative Policies of the Program.
Dentist
PMI -CA 21 SCH -A
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•
• SCHEDULE B
LIMITATIONS OF BENEFITS
1. Prophylaxis is limited to one treatment each six month period (includes periodontal
maintenance following active therapy);
2. Full maxillary and/or mandibular dentures including immediate dentures are not to exceed one
each in any five year period from initial placement;
3. Partial dentures are not to be replaced within any five year period from initial placement, unless
necessary due to natural tooth loss where the addition or replacement of teeth to the existing
partial is not feasible;
4. Crown(s) and bridges are not to be replaced within any five year period from initial placement;
5. Denture relines are limited to one per denture during any 12 consecutive months;
6. Periodontal treatments (root planing/subgingival curettage) are limited to four quadrants during
any 12 consecutive months;
7. Full mouth debridement (gross scale) is limited to one treatment in any 12 consecutive month
period;
8. Bitewing x -rays are limited to not more than one series of four films in any six month period;
9. Full mouth x -rays are limited to one set every 24 consecutive months;
10. Sealant benefits include the application of sealants only to permanent first and second molars
with no decay, with no restorations and with the occlusal surface intact, for first molars up to j
age nine and second molars up to age fourteen. Sealant benefits do not include the repair or
replacement of a sealant on any tooth within three years of its application.
11. Accidental injury except as noted in Accident Injury Rider, Schedule F. Accidental injury
is defined as damage to the hard and soft tissues of the oral cavity resulting from forces
external to the mouth. Damages to the hard and soft tissues of the oral cavity from normal
masticatory (chewing) function will be covered at the normal schedule of benefits.
j
EXCLUSIONS OF BENEFITS
1. General anesthesia and the services of a special anesthesiologist;
• 2. Cosmetic dental care;
3. Dental conditions arising out of and due to enrollee's employment or for which Worker's
Compensation is payable. Services which are provided to the enrollee by state government or
agency thereof, or are provided without cost to the enrollee by any municipality, county or
SCH -B
PMI -CA 22
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® •
• other subdivision, except as provided in Section 1373(a
Code; of the California Health and Safety
4. Treatment required by reason of war;
5. Dental services performed in a hospital and related hospital fees;
6. Treatment of fractures and dislocations;
7. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partial dentures);
8. Dental expenses incurred in connection with any dental procedures started after termination of
eligibility for coverage;
9. Any service that is not specifically listed as a covered expense;
10. Dental expenses incurred in connection with any dental procedure started prior to enrollee's
eligibility with the DeltaCare program. Example: teeth prepared for crowns, root canals in
progress;
11. Congenital malformations (e.g. congenitally missing teeth, supernumerary);
• 12. Cysts and malignancies;
13. Dispensing of drugs not normally supplied in a dental office;
14. Cases which in the professional judgment of the attending dentist a satisfactory result cannot
be obtained or where the prognosis is poor or guarded;
15. Dental services received from any dental office other than the assigned dental office, unless
expressly authorized in writing by DeltaCare or as cited under "Out of Area Emergency
Treatment ";
16. Prophylactic removal of impactions (asymptomatic nonpathological);
17. "Specialist consultations" for noncovered benefits;
18. Implant placement or removal, appliances placed on or services associated with implants,
including but not limited to prophylaxis and periodontal treatment;
19. Crown lengthening procedures.
11111
SCH -B
PMI -CA 23
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•
•
ORTHODONTIC LIMITATIONS
The program provides coverage for orthodontic treatment plans provided through DeltaCare panel
orthodontists. The start-up fees and the cost to the enrollee for the treatment plan are listed in the
Description of Benefits and Copayments (Schedule A) subject to the following:
1. Orthodontic treatment must be provided by a DeltaCare orthodontist;
2. Plan benefits cover 24 months of usual and customary orthodontic treatment;
3. Should an enrollee's coverage be cancelled or terminated for any reason, and at the time of
cancellation or termination be receiving any orthodontic treatment, the enrollee and not PMI
will be responsible for payment of balance due for treatment provided after cancellation or
termination. In such a case the enrollee's payment shall be based on a maximum of $2,300 for
dependent children to age 19 and $2,500 for covered full -time students and adults. The amount
will be pro -rated over the number of months to completion of the treatment and, will be
payable by the enrollee on such terms and conditions as are arranged between the enrollee and
the orthodontist. Start-up fees are included in these amounts;
4. Start-up fees cover the initial examination, diagnosis, consultation and the retention phase of
treatment of up to two years maximum. This includes initial construction, placement and
• adjustments to retainers and office visits for a maximum period of two years;
5. If treatment is not required or the enrollee chooses not to start treatment after the diagnosis and
consultation has been completed by the orthodontist, the enrollee will be charged a consultation
fee of $25 in addition to diagnostic record fees.
6. Three (3) recementations or replacements of a bracket/band on the same tooth or a total of five
(5) rebracketings /rebandings on different teeth during the covered course of treatment is a
benefit. If any additional recementations or replacements of brackets/bands are performed, the
patient is responsible for the cost;
7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of
the permanent teeth in an effort to make the patient's occlusion as ideal as possible. This
treatment usually requires complete fixed appliances; however, when the DeltaCare
orthodontist deems it suitable, a European or removable appliance therapy may be substituted
at the same copayment amount as for fixed appliances.
An orthodontic treatment in progress provision is available subject to the following:
• Treatment in progress is only through the dental HMO benefits plan previously sponsored
by the Applicant;
• The Enrollee is in active treatment (as defined under the previous dental HMO benefit plan)
at the time of the Applicant's original effective date with PMI;
• • Qualifying orthodontic cases are subject to all copayments, fees and contract provisions of
the prior dental HMO benefit plan;
•
PMI is financially responsible only for amounts owed and unpaid by the previous dental
HMO carrier after the Applicant's original effective date with PMI; and only while the
Enrollee remains eligible for coverage under the DeltaCare program.
PMI -CA SCH -B
24 3T12.AT.doc
•
• ORTHODONTIC EXCLUSIONS
1. Pre, mid and post treatment records which include cephalometric x -rays, tracings, photographs
and study models;
2. Lost, stolen or broken orthodontic appliances, functional appliances, headgear, retainers and
expansion appliances;
3. Retreatment of orthodontic cases;
4. Changes in treatment necessitated by accident of any kind, and/or lack of patient cooperation;
5. Surgical procedures incidental to orthodontic treatment;
6. Myofunctional therapy;
7. Surgical procedures related to cleft palate, micrognathia, or macrognathia;
8. Treatment related to temporomandibular joint disturbances and/or hormonal imbalance;
9. Supplemental appliances not routinely utilized in typical Phase II orthodontics;
• 10. Treatment that extends more than 24 months from the point of banding dentition will be subject
to an office visit charge at orthodontist's usual, customary and reasonable fee;
11. Restorative work caused by orthodontic treatment;
12. Phase I* orthodontics is an exclusion as well as activator appliances and minor treatment for
tooth guidance and/or arch expansion;
13. Extractions solely for the purpose of orthodontics;
14. Treatment in progress at inception of eligibility, unless qualified for the one -time orthodontic
treatment in progress provision;
15. Transfer after banding has been initiated.
* Phase I is defined as early treatment including interceptive orthodontia prior to the development
of late mixed dentition.
SCH -B
PMI -CA 25 3T12.AT.doc
•
• SCHEDULE C
GOVERNING ADMINISTRATIVE POLICIES
Unlike medical care where the diagnosis dictates more specifically the method of treatment to be
rendered, in dental care, the dentist and patient frequently consider various treatment plans.
The following guidelines are an integral part of the dental program and are consistent with the
principles of accepted dental practice and the continued maintenance of good dental health.
In all cases in which the patient selects a more expensive plan of treatment than is customarily
provided, the more expensive treatment is considered optional. The patient must pay the difference
in cost between the dentist's usual fees for the covered benefit and the optional treatment plus any
copayment for covered benefits.
Replacement of prosthetic appliances (crowns, bridges, partials and full dentures) shall be considered
only if the existing appliance is no longer functional or cannot be made functional by repair or
adjustment and meets the five year limitation for replacement.
A. PARTIAL DENTURES
•
A removable cast metal artial denture e is considered an adequate restoration. If the patient
selects another course of treatment, the patient must pay the difference in cost between the
dentist's usual fees for the covered benefit and the optional treatment, plus any copayment for
the covered benefit.
If a cast metal partial denture will restore the case, the Panel Dentist will apply the difference
of the cost of such procedure toward a more complicated precision appliance which the patient
and dentist may choose to use. The patient must pay the difference in cost between the dentist's
usual fees for the covered benefit and the optional treatment plus any copayment for the
covered benefit.
An acrylic partial denture may be considered a covered benefit in cases involving extensive
periodontal disease. Patient shall pay the applicable copayment for a cast metal partial denture.
B. COMPLETE DENTURES
If, in the construction of a denture, the patient and the Panel Dentist decide on personalized
restorations or employ specialized techniques as opposed to standard procedures, the patient
must pay the difference in cost between the dentist's usual fees for the covered benefit and
optional treatment, plus any copayment for the covered benefit.
Full upper and/or lower dentures are not to exceed one each in any five year period from initial
placement. The patient is entitled to a new upper or lower denture only if the existing denture
is more than five years old and cannot be made satisfactory by either reline or repair.
SCH -C
PMI -CA 26 3T12.AT.doc
•
C. FILLINGS AND CROWNS
Crowns will be covered only if there is not enough retentive quality left in the tooth to hold a
filling. For example, the buccal or lingual walls are either fractured or decayed to the extent
that they will not hold a filling.
Porcelain or porcelain fused to metal crowns on all molars are considered optional treatment.
If performed, the patient must pay the difference in cost between the dentist's usual fees for the
covered benefit and optional treatment, plus any copayment for the covered benefit.
The DeltaCare program provides amalgam and resin restorations for treatment of caries. If the
tooth can be restored with such materials, any other restoration such as a crown or jacket is
considered optional, and if provided, the patient must pay the difference in cost between the
• dentist's usual fees for the covered benefit and optional treatment, plus any copayment for the
covered benefit.
•
A restoration is a covered benefit only when required for restorative reasons (radiographic
evidence of decay or missing tooth structure). Restorations placed for any other purposes
including but not limited to cosmetics, abrasion, attrition, erosion, restoring or altering vertical
dimension, congenital or developmental malformation of teeth, or the anticipation of future
fractures, are not covered benefits.
•
Composite resin restorations in osterior teeth th are considered optional treatment. If provided,
the patient must pay the difference in cost between the dentist's usual fees for the covered
benefit and optional treatment, plus any copayment for the covered benefit.
Porcelain crowns, porcelain fused to metal or plastic processed to metal type crowns are not
a benefit for children under sixteen years of age. An allowance will be made for an acrylic
crown. If performed, the patient must pay the difference in cost between the dentist's usual fees
for the covered benefit and optional treatment, plus any copayment for the covered benefit.
A crown placed on a specific tooth is allowable only once in a five year period from initial
placement.
A pulp cap is a benefit only on a permanent tooth with an open apex.
D. FIXED BRIDGES
A fixed bridge is considered standard dental treatment when it is necessary to replace one
missing permanent anterior tooth in a person sixteen years old or older. Such treatment will
be covered if the patient's oral health and general dental condition permits.
• Fixed bridges used to replace missing posterior teeth are . considered optional when the
abutment teeth are dentally sound and would be crowned only for the purpose of supporting
a pontic. A fixed bridge used under these circumstances is considered optional dental
treatment. The patient must pay the difference in cost between the dentist's usual fees for the
covered benefit and optional treatment, plus any copayment for the covered benefit.
SCH -C
PMI -CA 27 3T12.AT.doc
" •
•
Fixed bridges are not a benefit when provided in connection with a partial denture on the same
arch. If provided, the patient must pay the difference in cost between the dentist's usual fees
for the covered benefit and optional treatment, plus any copayment for the covered benefit.
Replacement of an existing nonfunctional bridge is limited to once in a five year period from
initial placement and shall be covered only when the replacement duplicates the original bridge.
Fixed bridges are not a benefit for patients under the age of sixteen. A fixed bridge under these
circumstances is considered optional dental treatment. If performed, the patient must pay the
difference in cost between the dentist's usual fees for the covered benefit and optional
treatment, plus any copayment for the covered benefit.
E. RECONSTRUCTION
The DeltaCare program provides coverage for procedures necessary to eliminate oral disease
and to replace missing teeth. Appliances or restorations necessary to increase vertical
dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal
splinting, gnathologic recordings, equilibration or treatment of disturbances of the
temporomandibular joint (TMJ) are not covered benefits. Extensive treatment plans involving
10 or more crowns or units of fixed bridgework is considered full mouth reconstruction and is
• not a benefit of the DeltaCare program. The program will allow for complete or partial
denture(s).
F. SPECIALIZED TECHNIQUES
Precious metal for removable appliances, precision abutments for partials or bridges (overlays,
implants, and appliances associated therewith), personalization and characterization, are all
considered optional treatment. If performed, the patient must pay the difference in cost
between the dentist's usual fees for the covered benefit and optional treatment, plus any
copayment for the covered benefit.
G. PREVENTIVE CONTROL PROGRAMS
Soft tissue management programs are not covered. The periodontal pocket charting, root
planing/scaling /curettage, oral hygiene instruction and prophylaxis are covered benefits and,
if performed as part of a soft tissue management program, will be provided for listed
copayments, if any. Irrigation, infusion, special tooth brush, etc., is considered as optional
treatment. If performed, the patient is responsible for the cost.
H. STAYPLATES
• Stayplates in conjunction with fixed or removable appliances, are only a benefit to replace
extracted anterior teeth for adults during a healing period and as anterior space maintainers for
children.
SCH -C
PMI -CA
28 3 T 12.AT.doc
0 •
• I. FRENECTOMY
The frenum can be excised when the tongue has limited mobility; or has a large diastema
between teeth; or when the frenum interferes with a prosthetic appliance.
J. PEDODONTIA
Pedodontic referrals must be preauthorized by DeltaCare. Benefits for dependent children
through age three are covered at 100% of the agreed upon fee less any applicable copayments
for covered benefits and children four years and older are at 50% of agreed upon fee less any
applicable copayments for covered services.
•
K. TREATMENT PLANNING
The objective of this Program is to see that all patients are brought to a good level of oral health
and that this level of oral health is maintained. To achieve this objective takes careful treatment
planning. Priorities have been established on the following basis:
1. Priority attention is given to those procedures that, if not done first, could have an
immediate effect on the patient's overall oral health.
• 2. Priority is next given to work such as active dental decay and periodontal problems that
would not have an immediate effect on the patient's oral health.
3. Priority is then given to replacement of missing teeth not causing a gross lack of
function.
• Exceptions are made to this treatment planning concept based on individual circumstances.
•
PMI -CA SCH -C
29 3T12.AT.doc
•
1 •
•
SCHEDULE D
GROUP VARIABLES AND PREMIUMS
A. Group Name: HCM /City of Seal Beach
B. Group Number: 3T12
C. Effective Date: May 1, 2001
D. Contract Term: 24 months
E. Eligible Present Employees: First of the month following 30 days of continuous
employment at 32 hours per week
Eligible New Employees: First of the month following 30 days of continuous
employment at 32 hours per week
F. Premiums per Month:
Plan Type: CA735
California Primary Enrollee: $15.75
California Primary Enrollee Plus
One Dependent Enrollee: $25.99
California Primary Enrollee Plus
Two or More Dependent Enrollees: $38.44
G. Remit Premium Payment to: PMI, Dept. #0170 Los Angeles, California 90084 -0170
•
SCH -D
PMI -CA 30 3T12.AT.doc
•
• SCHEDULE E
OPTIONAL CONTINUATION OF COVERAGE (COBRA OR CAL - COBRA)
The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain
employers having 20 or more employees) and the California Continuation Benefits Replacement Act
(or Cal - COBRA, pertaining to employers with 2 to 19 employees), both require that continued health
care coverage be made available to "Qualified Beneficiaries" who lose health care coverage under
the group plan as a result of a "Qualifying Event." An employee or dependent may be entitled to
continue coverage under this program, at the Qualified Beneficiary's expense, if certain conditions
are met. The period of continued coverage depends on the Qualifying Event.
DEFINITIONS
The meaning of key terms used in this section are shown below.
Qualified Beneficiary means a person enrolled in the DeltaCare plan on the day before the
Qualifying Event, including:
1. an employee and his or her dependents, or;
2. a child who is born to or placed for adoption with the employee during the period of
continued coverage, provided such child is enrolled within 30 days of birth or placement for
adoption.
Qualifying Event mean any of the following events which, except for the election of this
continued coverage, would result in a loss of coverage under the dental plan:
Event 1: The termination of employment (other than termination for gross misconduct), or
the reduction in work hours, by the employer; +'
Event 2: the employee's death;
Event 3: the employee's divorce or legal separation from his or her spouse;
Event 4: Dependents' loss of dependent status under the plan; and
Event 5: As to dependents only, the employee's entitlement to Medicare.
PERIODS OF CONTINUED COVERAGE
An employee or dependent may continue coverage for 18 months following the occurrence of
Qualifying Event 1.
This 18 month period can be extended for a total of 29 months, provided:
41) 1. a determination is made under Title II or Title XVI of the Social Security Act that
an individual is disabled on the date of the Qualifying Event or became disabled at any time
during the first 60 days of continued coverage; and
2. notice of the determination is given to the employer during the initial 18 months of continued
coverage and within 60 days of the date of the determination.
SCH -E
PMI -CA 31 3 T 12.AT.doc
•
•
• This period of coverage will end on the first of the month that begins more than 30 days g y after
the date of the final determination that the disabled individual is no longer disabled. The
employee must notify the employer /administrator within 30 days of any such determination.
If, during the 18 month continuation period resulting from Qualifying Event 1, dependents
experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for up to a total of
36 months (inclusive of the period continued under Qualifying Event 1).
Enrolled dependents may continue coverage for 36 months following the occurrence of Qualifying
Event2,3,4or5.
Under federal COBRA law only, when an employer has filed for bankruptcy under Title II, United
States Code, benefits may be substantially reduced or eliminated for retired employees and their
dependents, or the surviving spouse of a deceased retired employee. If this benefit reduction or
elimination occurs within one year before or one year after the filing, it is considered a Qualifying
Event. If the employee is the retiree, and has lost coverage because of this Qualifying Event, he or
she may choose to continue coverage until his or her death. Dependents who have lost coverage
because of this Qualifying Event may choose to continue coverage for up to 36 months following
the employee's death.
ELECTION OF CONTINUED COVERAGE
The employee's former employer shall notify PMI in writing within 30 days of Qualifying Event 1.
• A Qualified Beneficiary must notify the Administrator in writing within 60 days of Qualifying
Events 2, 3, 4, or 5. Otherwise, the option of continued coverage will be lost.
Within 14 days of receiving notice of a Qualifying Event, PMI will provide a Qualified Beneficiary
with the necessary benefits information, monthly premium charge, enrollment forms, and
instructions to allow election of continued coverage.
A ualified Beneficiary ary will then have 60 days to give PMI written notice of the election to continue
coverage. Failure to provide this written notice of election to PMI within 60 days will result in the
loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the
initial premium to PMI, which includes the premium for each month since the loss of coverage.
Failure to pay the required premium within the 45 days will result in loss of the right to continued
coverage, and any premiums received after that date will be returned to the Qualified Beneficiary.
A Qualified Beneficiary who is eligible for coverage under the federal COBRA law may not be
covered under Cal - COBRA.
CONTINUED COVERAGE BENEFITS
The benefits under the continued coverage will be the same as those provided to active employees
• and their dependents who are still enrolled in the dental plan. If the employer changes the coverage
for active employees, the continued coverage will change as well. Premiums will be adjusted to
1
reflect the changes made.
SCH -E
PMI -CA 32 3T12.AT.doc
•
1 •
S TERMINATION OF COVERAGE
A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the
following events first occurs:
1. the allowable number of consecutive months of continued coverage is reached;
2. the individual fails to pay the required premium in a timely manner;
3. the individual first obtains coverage for dental benefits after the date of the election of
continued coverage, under another group health plan (as an employee or dependent) which
does not contain or apply any exclusion or limitation with respect to any pre- existing
condition of such person, if that pre- existing condition is covered under this program;
4. the employer ceases to provide any group dental plan to its employees;
5. the individual becomes entitled to Medicare;
6. the individual moves . out of the plan's service area;
7. the individual becomes eligible for coverage under the federal COBRA law.
The employer shall notify PMI within 30 days of the date when a Qualified Beneficiary becomes so
eligible.
TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and PMI terminates prior to the time that the
continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary
under Cal -COBRA (either 30 days prior to the termination or when all Enrollees are notified
whichever is later) of that person's ability to elect continuation coverage under the employer's
subsequent dental plan, if any. The employer must notify the successor plan of the Qualified
Beneficiaries receiving continuation coverage so they may be notified of how to continue coverage
under that plan.
The continuation coverage will be provided only for the balance of the period that a Qualified
Beneficiary would have remained covered under the DeltaCare program had such program with the
former employer not terminated. The continuation coverage will terminate if a Qualified Beneficiary
fails to comply with the requirements pertaining to enrollment in, and payment of premium to the
new group benefit plan within 30 days of receiving notice of the termination of the DeltaCare
program.
OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary under Cal -COBRA may elect to change continuation coverage during any
subsequent open enrollment period, if the employer has contracted with another plan to provide
coverage to its active employees. The continuation coverage under the other plan will be provided
only for the balance of the period that a Qualified Beneficiary would have remained covered under
the DeltaCare program.
SCH -E
PMI -CA 33 3T12.AT.doc
1
• SCHEDULE F
ACCIDENT INJURY RIDER
PMI shall pay or otherwise discharge 1 00% of the Dentist's Usual, Customary and Reasonable fees not
to exceed the "Prevailing Fee" as determined by PMI or of Fees Actually Charged, whichever is less,
less any applicable patient copayment(s), for the following Dental Accident Benefits:
Services described in the Schedule of Benefits and Copayments, Schedule A, and in paragraph II of
this Rider, Schedule F are subject to the following maximum, limitation and exclusions when provided
for conditions caused directly and independently of all other causes, by external, violent and accidental
means.
I. DEFINITIONS
For the purpose of this Rider, the following additional definitions shall apply:
A. "Attending Dentist's Statement" means the standard form used to file a claim.
B. "Dental Accident Benefits" means those dental services which are provided under the terms of
• this Rider for conditions caused directly and independently of all other causes, by external,
violent and accidental means.
C. "Fee Actually Charged" means the fee for a particular dental service or procedure which a
Dentists reports to PMI on an Attending Dentist's Statement, less any portion of such fee which
is discounted, waived, rebated or which the Dentist does not in good faith attempt to collect.
D. "Prevailing Fee" means the fee for a Single Procedure which satisfies the majority of Dentists
in California, as determined by PMI.
E. "Single Procedure" means a dental procedure listed on a separate line in Schedule A and in
paragraph lI of this Rider, Schedule F.
F. Each of the words in the term "Usual, Customary and Reasonable" as used in this Rider shall
have the following meanings:
USUAL - A usual fee is the fee regularly charged and received by an individual Dentist, (i.e.,
his own usual fee). If more than one fee is charged for a given service, the fee determined to
be the usual fee shall not exceed the lowest fee which is regularly charged or which is offered
to patients.
CUSTOMARY - A fee is customary when it is within the accepted range of usual fees charged
and received by dentists of similar training for the same service within the geographic area
determined by PMI to be statistically relevant.
SCH -F
PMI -CA 34 3T12.AT.doc
1 1 1
•
REASONABLE - A fee is reasonable if it is "usual" and "customary," or if it falls above
"customary" and is justifiable due to a level of treatment superior to that customarily provided.
Additionally, a specific fee to a specific patient is reasonable if it is justifiable considering
special circumstances, or extraordinary difficulties of the case in question.
II. DENTAL ACCIDENT BENEFITS
For the purpose of this Rider, the following additional benefits shall apply:
A. Intra -oral grafting
B. Reimplantation
C. Splinting
D. Stayplate
III. MAXIMUM
The program shall provide Dental Accident Benefits for an Eligible Person up to a maximum of $1,600
• per patient per any twelve (12) month period.
IV. LIMITATION
Dental Accident Benefits shall be limited to services provided to an Eligible Person within 180 days
following the date of accident, and shall not include any services for conditions caused by an accident
occurring prior to the patient's eligibility date.
V. EXCLUSIONS
The following services are not Dental Accident Benefits:
A. Services for injuries or conditions which are benefits provided to the eligible person through
a medical carrier or are compensable under Workers' Compensation or Employers' Liability
Laws; services which are provided to the Eligible Person by any federal or state government
agency or are provided without cost to the Eligible Person by any municipality, county or other
political subdivision, except as provided in Section 1373 (a) of the California Health and Safety
Code.
• B. Services with respect to congenital (hereditary) or developmental (following birth)
malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not
limited to: cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel
hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth), and anodontia
(congenitally missing teeth).
SCH -F
PMI -CA 35 3T12.AT.doc
•
C. Services for restoring or stabilizing tooth structure lost from wear, or for rebuilding or
maintaining chewing surfaces due to teeth out of alignment or occlusion. Such services include
but are not limited to : equilibration and periodontal splinting.
D. Prosthodontic services or any Single Procedure started prior to the date the person became
eligible for such services under this Contract.
E. Prescribed drugs, pre- medication or analgesia.
F. Experimental procedures.
G. Prophylaxis.
H. All hospital costs and any additional fees charged by the. Dentist for hospital treatment.
I.. Charges for general anesthesia.
J. Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue).
K. Implants (materials implanted into or on bone or soft tissue), the removal of implants or
procedures related to the placement or removal of implants.
• L. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw)
joint or associated musculature, nerves and other tissues.
M. Replacement of existing restorations due to carious lesions.
N. Orthodontic services (treatment of malalignment of teeth and/or jaws).
SCH -F
PMI -CA 36 3T12.ATodoc
r PRIVATE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 -8311 (800) 801 -7105
APPLICATION FOR DeltaCare GROUP DENTAL SERVICE CONTRACT
The undersigned group ( "Applicant ") hereby applies for a DeltaCare GROUP DENTAL SERVICE
CONTRACT with PRIVATE MEDICAL -CARE, INC. ( "PMI") on the following terms:
I. Applicant hereby authorizes PMI to furnish the dental Benefits described in the attached Contract,
subject to all of the terms and conditions of the Contract.
II. Applicant or Enrollees agree to pay to PMI, in advance, the Premiums specified in Schedule D to
the Contract.
III. Upon acceptance of this Application by PMI, and payment of the initial Premiums, the Contract shall
be effective at 12:01 a.m. on the Effective Date shown on Schedule D and the Contract shall
continue until terminated as provided.
IV. Applicant agrees to make available to Eligible Employees or Enrollees any notices concerning
Benefits required to be furnished by PMI.
V. PMI will provide directly to each Eligible Person or Enrollee a combined Evidence of Coverage
and Disclosure Form (EOC). PMI's Enrollment materials advise Eligible Persons that an EOC
is also available upon request, prior to enrollment by contacting PMI's Customer Relations
department. A matrix which describes the program's major Benefits and coverage is included
at the beginning of the EOC and as Schedule F within this Contract. The EOC will disclose
the terms and conditions of coverage, but will constitute only a summary of the program. As
required by the California Health & Safety Code, the Contract must be consulted to determine
the exact terms and conditions of the coverage provided. A copy of the Contract will be
furnished upon request. Enrollees should read the EOC carefully. Persons with special
healthcare needs should read the section entitled "Special Needs ". Pursuant to California
Health and Safety Code, the EOC provides Enrollees with information regarding the societal
benefits of organ donation and the method whereby an Enrollee may elect to be an organ or
tissue donor. Enrollees may also obtain information about Benefits by calling PMI's Customer
Relations department at (800) 422 -4234.
VI. Applicant agrees to receive, on behalf of Enrollees, all applicable notices concerning Benefits under
this Contract.
VII. THE PREMIUMS PAYABLE UNDER THIS CONTRACT ARE SUBJECT TO INCREASE UPON
RENEWAL AFTER THE END OF THE INITIAL CONTRACT TERM OR ANY SUBSEQUENT
CONTRACT TERM.
VIII. THIS CONTRACT IS SUBJECT TO ARBITRATION IN ACCORDANCE WITH ARTICLE 6.
(Date)
(See Appendix A)
(Group Number)
City of Seal Beach
(Applicant)
City Hall, 211 Eighth Street, Seal Beach, CA 90740 -6379
(Applicant Address)
By: X ` A 2 ' 4 By:
(Authorized Sign. re) (Licensed Registered Agent)
Revised 04/11/03 CP
PMI -CA 1 02012-0047.3T12-1.AT
• •
PRIVATE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 -8311 (800) 801 -7105
DeltaCare GROUP DENTAL SERVICE CONTRACT
1N CONSIDERATION of the Application, a copy of which is attached hereto and made a part of this
DeltaCare GROUP DENTAL SERVICE CONTRACT ( "Contract ") and IN CONSIDERATION of
payment of the required Premiums, PRIVATE MEDICAL -CARE, INC. ( "PMI") agrees to provide
the Benefits described for the Contract Term shown on Schedule D and from year to year thereafter,
unless this Contract is terminated as provided. Premiums are payable in advance of the Effective
Date and thereafter as provided. This Contract is issued and delivered in the State of California, is
governed by the laws thereof, and is subject to the terms and conditions recited on the following
pages.
IN WITNESS WHEREOF, PMI has caused this Contract to be executed on:
Date: April 11, 2003
PRIVATE MEDICAL -CARE, INC.
By: /L., . ±A,
9
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ARTICLE 1. DEFINITIONS
For the purpose of this Contract, the following definitions shall apply:
1.01 "Acute Condition" means a condition requiring Emergency Services while a New Enrollee
is within thirty-five (35) miles from the facility of the assigned Contract Dentist.
1.02 "Applicant" means the employer, union or other organization or group contracting to obtain
dental Benefits.
1.03 "Benefits" mean those dental services which are provided under the terms of this Contract
as specified in Article 4 and Schedule A.
1.04 "Contract" means this agreement between PMI and Applicant including the Application for
this Contract, the attached schedules, and any appendices, endorsements or riders. This
Contract constitutes the entire agreement between the parties.
1.05 "Contract Dentist" means a Dentist who provides services in general dentistry and who has
contracted with PMI to provide Benefits to Enrollees under this Contract.
1.06 "Contract Orthodontist" means a Dentist who specializes in orthodontics, and who has
contracted with PMI to provide Benefits to Enrollees under this Contract.
1.07 "Contract Specialist" means a Dentist who provides Specialist Services and has contracted
with PMI to provide Benefits to Enrollees under this Contract.
1.08 "Contract Term" means the period commencing and terminating on the dates shown on
Schedule D, and each yearly period thereafter during which this Contract remains in effect.
1.09 "Copayment" means the amount charged to an Enrollee by a Dentist for the Benefits provided
under this Contract.
1.10 "Dentist" means a duly licensed Dentist legally entitled to practice Dentistry at the time and
in the state or jurisdiction in which services are performed.
1.11 "Effective Date" means the date this Contract becomes effective as provided in Schedule D.
1.12 "Eligibility Date" means the date upon which an Eligible Person's eligibility for Benefits
becomes effective under this Contract.
1.13 "Eligible Employee" means any employee or member of Applicant who meets the conditions
of eligibility outlined in Article 2.
1.14 "Eligible Dependent" means any of the dependents of an Eligible Employee who are eligible
to enroll for Benefits in accordance with the conditions of eligibility outlined in Article 2.
1.15 "Eligible Person" means an Eligible Employee or Eligible Dependent.
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1.16 "Emergency Services" mean only those dental services immediately required for alleviation
of severe pain, swelling or bleeding, or immediately required to avoid placing the patient's
health in serious jeopardy.
1.17 "Enrollee" means an Eligible Employee ( "Primary Enrollee ") or an Eligible Dependent
( "Dependent Enrollee ") enrolled to receive Benefits.
1.18 "New Enrollee" means an Enrollee who is enrolled less than thirty (30) days from the date
he or she is eligible for Benefits.
1.19 "Open Enrollment Period" means the period preceding the date of commencement of the
Contract Term or the 30 -day period immediately preceding the annual anniversary of the
commencement of the Contract Term or a period as otherwise requested by the Applicant and
agreed to by PMI.
1.20 "Optional" means any alternative procedure presented by the Contract Dentist that satisfies
the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the
Limitations and Exclusions of this Contract.
1.21 "Premiums" mean amounts payable by Applicant or an Enrollee as provided in Article 3 and
Schedule D.
1.22 "Special Health Care Need," means a physical or mental impairment, limitation or condition
that substantially interferes with an Enrollee's ability to obtain Benefits. Examples of such
a Special Health Care Need are (i) the Enrollee's inability to obtain access to the assigned
Contract Dentist's facility because of a physical disability and (ii) the Enrollee's inability to
comply with the Contract Dentist's instructions during examination or treatment because of
physical disability or mental incapacity.
1.23 "Specialist Services" mean services performed by a Dentist who specializes in the practice
of oral surgery, endodontics, pediatric dentistry or periodontics and which must be
preauthorized in writing by PMI.
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ARTICLE 2. ELIGIBILITY, ENROLLMENT AND CANCELLATION OF ENROLLMENT
2.01 Eligible Employees are those employees or group members described in Schedule D. New
employees shall become eligible for coverage as specified in Schedule D.
Eligible Dependents of an Eligible Employee are spouse (unless legally separated or
divorced) and unmarried dependent children from birth to age 19, or to age 23 while enrolled
as full -time students in an accredited school, college or university, provided that the student
is chiefly dependent upon the Eligible Employee for maintenance and support. Children
include step - children, adopted children and foster children, provided such children are
dependent upon the employee for support and maintenance. Dependents become eligible
coincident with the Eligible Employee, upon attainment of dependent status, or at any time
subject to a change in legal custody or lawful order to provide Benefits. Newborn infants are
eligible from and after the moment of birth. Adopted children are eligible from and after the
moment the child is placed in the physical custody of the Eligible Employee for adoption.
An unmarried dependent 19 years or over may continue to be eligible as a dependent if
incapable of self - support because of physical or mental disability that commenced prior to
reaching age 19, or prior to reaching age 23 while enrolled as a full -time student in an
accredited school, college or university, and if chiefly dependent on the Eligible Employee
for support and maintenance, provided proof of such disability and dependency is submitted
not less than 31 days prior to the dependent's attainment of the limiting age, and subsequently
as may be required by either PMI or Applicant, but not more frequently than annually after
the disabled and dependent child has attained the limiting age.
Dependents in military service are not eligible. No one may be an Eligible Dependent if
eligible as an Eligible Employee and no one may be an Eligible Dependent of more than one
Eligible Employee.
Medicare eligibility shall not affect eligibility of an Eligible Employee or Eligible
Dependent.
2.02 Eligible Employees must complete and sign enrollment forms provided by PMI during the
Open Enrollment Period in order to receive Benefits and for their Eligible Dependents to
receive Benefits. Persons not originally eligible during the Open Enrollment Period may be
enrolled immediately upon attainment of dependent status or at any time subject to a change
in legal custody or lawful order to provide Benefits. Subject to cancellation as provided
under this Contract, enrollment of Eligible Employees and any Eligible Dependents is for a
minimum period of one year.
Applicant shall compile and furnish to PMI on or prior to the first day of every month, a list
of all Primary Enrollees showing their Social Security numbers and, if applicable, location
codes and all Dependent Enrollees. PMI shall be obligated to provide Benefits only to
Primary Enrollees and their Dependent Enrollees who are enrolled and are reported on the
list of Primary Enrollees submitted by Applicant and for whom the appropriate Premiums
are paid pursuant to Article 3 and Schedule D of this Contract for the period in which
covered dental services are provided. Newborn infants are covered from the moment of birth
up to 31 days, and thereafter if notification of birth and the appropriate Premiums are
received by PMI within 31 days after the date of birth.
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2.03 Subject to any rights provided under Article 6, enrollment under this Contract may be
cancelled, or renewal of enrollment refused, in the following events:
a) Upon 30 days' notice if the Contract is terminated or not renewed.
b) Immediately upon loss of eligibility.
c) Upon 15 days' written notice if the Premiums are not paid by or on behalf of the
Enrollee on the date due. However, the Enrollee may continue to receive Benefits
during the 15 -day period and may be reinstated during the term of this Contract upon
payment of any unpaid Premiums.
d) Immediately if the Enrollee is guilty of misconduct detrimental to the delivery of
services while in the facility of a Contract Dentist.
e) Upon 15 days' written notice if the Enrollee knowingly perpetrates or permits another
person to perpetrate fraud or deception in obtaining Benefits under this Contract.
f) Upon 30 days' written notice if the Enrollee fails to pay Copayments; provided,
however, that the Enrollee may be reinstated during the term of this Contract upon
payment of all delinquent charges.
g) Upon 30 days' written notice, if (i) the Enrollee and a Contract Dentist fail to
establish a satisfactory patient- Dentist relationship, (ii) it is shown that PMI has, in
good faith, provided the Enrollee with the opportunity to select an alternative
Contract Dentist, (iii) the Enrollee has been notified in writing at least 30 days in
advance that PMI considers the patient- Dentist relationship to be unsatisfactory and
PMI specifies the changes that are necessary in order to avoid cancellation, and (iv)
the Enrollee has failed to make such changes.
Cancellation of a Primary Enrollee's enrollment shall automatically cancel the enrollment
of any of his or her Dependent Enrollees.
2.04 An Enrollee who believes that enrollment has been cancelled or not renewed because of the
Enrollee's health status or requirements for health care services, may request a review by the
Director of the California Department of Managed Health Care in accordance with Section
1365(b) of the California Health and Safety Code.
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ARTICLE 3. PREMIUMS AND COPAYMENTS
3.01 In accordance with Schedule D, Applicant agrees to pay Premiums on behalf of Primary
Enrollees and to collect Premiums by means of payroll deductions for Dependent Enrollees
voluntarily enrolled for Benefits under this Contract. Applicant shall remit one check each
period as required by Schedule D. Should an Enrollee voluntarily cancel enrollment and
subsequently desire to re- enroll dependent(s), all Premiums retroactive to the date of
cancellation (but not to exceed 12 months) must be paid before the Dependent(s) shall be re-
enrolled.
COBRA - In accordance with Schedule D, Applicant agrees to collect Premiums by means
of payroll deductions for Primary Enrollees and Dependent Enrollees voluntarily enrolled for
Benefits under this Contract. Applicant shall remit one check each period as required by
Schedule D. Should an Enrollee voluntarily cancel enrollment and subsequently desire to
re- enroll, all Premiums retroactive to the date of cancellation (but not to exceed 12 months)
must be paid before the Enrollee shall be re- enrolled.
3.02 This Contract shall not be in effect until initial Premiums are received. Subsequent Premiums
shall be payable in accordance with Schedule D.
3.03 _ PMI may change the amount of Premiums whenever the terms of this Contract are changed
by amendment or PMI's liability is changed by law or regulation. However, in the absence
of an amendment mutually agreed upon between Applicant and PMI or such a change in
liability, no change in the Premiums shall become effective within a Contract Term except
as provided in Section 3.04.
3.04 If during a Contract Term, any new tax is imposed on PMI by any government agency on the
amount of Premiums payable under this Contract or the number of the persons covered, or
if the rate of an existing tax on the amount of Premiums or the number of persons covered
is increased, the Premiums stated in Schedule D shall be increased by the amount of any such
new tax or increased taxes upon 30 days' written notice.
3.05 Upon discovery of clerical errors made by PMI with respect to enrollment data for a Primary
Enrollee, Premiums may be adjusted back to the Primary Enrollee's Enrollment Date. The
amount of credit which may be taken with respect to a Primary Enrollee shall not exceed the
Premiums for the current month in which Premiums are due, plus two (2) months of
retroactive Premiums. In addition, the total amount of credit which may be taken on any due
date shall not exceed 10% of the billed amount for that due date.
3.06 Enrollees are required to pay any Copayments listed in the Description of Benefits and
Copayments (attached as Schedule A) directly to the Dentist. Charges for broken
appointments (unless notice is received by the Dentist at least 24 hours in advance or an
emergency prevented such notice) and charges for emergency visits after normal visiting
hours are shown on Schedule A.
3.07 In the event of cancellation of enrollment by PMI (except in the case of fraud or deception
in obtaining Benefits from PMI or knowingly permitting such fraud or deception by another),
PMI shall return to Applicant the pro rata portion of the Premiums paid to PMI which
corresponds to any unexpired period for which payment had been received, together with any
amounts due on claims, if any, less any amounts owed to PMI.
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ARTICLE 4. BENEFITS, LIMITATIONS AND EXCLUSIONS
4.01 PMI shall provide the Benefits in Schedule A, subject to the Limitations and Exclusions in
Schedule B. Benefits are available to each Enrollee on the Eligibility Date.
4.02 PMI shall provide Contract Dentists at convenient locations during the term of this Contract.
A list of Contract Dentists shall be furnished to all Primary Enrollees. Enrollees may select
any Contract Dentist whose name is on said list at the time of enrollment. Enrollees in the
same family may collectively select no more than three Contract Dentist facilities. If an
' Enrollee fails to select a Contract Dentist or the Contract Dentist selected becomes
unavailable, PMI shall request the selection of another Contract Dentist or shall assign that
Enrollee to another Contract Dentist. An Enrollee may make a change to any other Contract
Dentist during the open enrollment period. Upon the approval of PMI, an Enrollee may
select another Contract Dentist if the Enrollee has a change in family status or residence or
fails to establish a satisfactory patient/doctor relationship with the Contract Dentist. The
change must be requested prior to the 21st of the month to become effective on the first day
of the following month.
4.03 The services which are Benefits shall be rendered by Contract Dentists, and PMI shall have
no obligation or liability with respect to services rendered by non - Contract Dentists, with the
exception of Emergency Services as provided in Section 4.04, or Specialist Services
recommended by a Contract Dentist, and approved in writing by PMI. All services other
• than Emergency Services or Specialist Services shall be rendered at the facility of the
Contract Dentist. Referral of Specialist Services must be by a Contract Dentist and must be
authorized in writing by PMI. All approved Specialist Services claims will be paid by PMI
less any applicable Copayments. A Contract Dentist may provide services either personally,
or through associated Dentists, or the other technicians or hygienists who may lawfully
perform the services. If an Enrollee is assigned to a dental school clinic for Specialist
Services, those services may be provided by a Dentist, a dental student, a clinician or a dental
instructor.
4.04 If an Enrollee is more than 35 miles from the facility of the assigned Contract Dentist, and
requires Emergency Services, PMI shall reimburse the Enrollee for the cost of such
treatment, less any applicable Copayments, up to a maximum of $100.00 during any 12-
month period upon submission to PMI of a verifiable claim within 90 days after such
treatment is received.
If an Enrollee has been enrolled less than 30 days, and if the Enrollee is currently
experiencing an Acute Condition, he or she should contact PMI's Customer Relations
department at (800) 422 -4234 for authorization for treatment of the condition.
If PMI determines that the circumstances of the Acute Condition require that the Enrollee
obtain treatment from a Dentist who is not one of PMI's Contract Dentists, the Enrollee will
be instructed:
a) to seek treatment immediately necessary to alleviate severe pain, swelling or
bleeding, or immediately necessary to avoid placing his or her health in serious
jeopardy;
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b) that treatment for an Acute Condition does not include any services other than
Emergency Services;
c) that PMI will reimburse the Enrollee for the cost of such treatment up to a maximum
of $100.00 during any 12 -month period;
d) that the Enrollee must submit a claim within 90 days after receiving the treatment;
and
e) that the Enrollee must visit his or her Contract Dentist for further treatment.
PMI may require a non - Contract Dentist providing treatment to an Enrollee of an Acute
Condition to agree in writing to meet the same contractual terms and conditions which are
imposed upon Dentists who have signed a contract with PMI. PMI is not liable for actions
resulting solely from the negligence, malpractice or other tortious or wrongful acts arising
out of the treatment provided by a non - Contract Dentist.
4.05 In the event that PMI fails to pay a Contract Dentist; the Enrollee shall not be liable to that
Dentist for any sums owed by PMI. In the event that PMI fails to pay a Dentist who is not
a Contract Dentist, the Enrollee may be liable ,to that Dentist for the cost of services.
4.06 Claims for Specialist Services or Emergency Services which are Benefits must be submitted
within 90 days after termination of treatment. Failure to submit a claim within such time
shall not invalidate nor reduce any claim for reimbursement if it shall be shown not to have
been reasonably possible to submit the claim within such time and that such claim was
submitted as soon as reasonably possible, but in no event later than one year from the time
otherwise required.
PMI shall acknowledge receipt of a claim within 20 working days unless payment of the
claim is made within that time. Within 30 working days after receipt of a claim, PMI shall
accept or deny the claim, in whole or in part, unless more time is required to determine
whether the claim should be accepted or denied. If more time is required, PMI shall notify
the Dentist within 30 working days of receipt of the claim of the reasons more time is
required. PMI shall notify the Dentist again 45 days thereafter of the reasons any additional
time is required to determine whether the claim should be accepted or denied.
4.07 Upon termination of a contract with a Contract Dentist, PMI shall be liable for Benefits
rendered by such Contract Dentist to an Enrollee who is under the care of such Dentist at the
time of such termination until any single procedure commenced prior to termination by such
Dentist is completed, unless PMI makes reasonable and medically appropriate provisions for
the completion of such procedure by another Contract Dentist. PMI shall give written notice
to Applicant within a reasonable time of any termination or breach of contract by, or inability
to perform of, any Contract Dentist if Applicant will be materially and adversely affected.
If an Enrollee's assigned Network Dentist's contract with PMI terminates, that Network
Dentist will complete (a) a partial or full denture for which final impressions have been
taken, and (b) all work on every tooth upon which work has started (such as completion of
root canals in progress and delivery of crowns when teeth have been prepared.)
4.08 In the absence of an amendment mutually agreed upon between Applicant and PMI, no
change in Benefits shall be made during a Contract Term.
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4.09 All Benefits shall terminate for any Enrollee as of the date that this Contract is terminated,
such person ceases to be eligible under the terms of this Contract, or such person's enrollment
is cancelled under this Contract. PMI shall not be obligated to continue to provide Benefits
to any such person in such event, except for completion of single procedures commenced
while this Contract was in effect.
4.10 A Contract Dentist is compensated by PMI through monthly capitation (an amount based on
the number of Enrollees assigned to the Dentist), and by Enrollees through required
Copayments for treatment received. A Contract Specialist is compensated by PMI through
an agreed -upon amount for each covered procedure, and by Enrollees through applicable
Copayments. In no event does PMI pay a Dentist or a Specialist any incentive as an
inducement to deny, reduce, limit or delay any appropriate treatment. An Enrollee
may obtain further information concerning compensation of providers by calling PMI
at (800) 422 -4234.
4.11 PMI does not authorize or deny services provided by a Contract Dentist. All Benefits
provided by a Contract Dentist are in accordance with dental care guidelines which establish
the standard of care to be followed by Contract Dentists. PMI's dental care guidelines are
reviewed by PMI's Dental Advisory Committee, and updated as needed. An Enrollee may
contact PMI's Customer Relations department at (800) 422 -4234 for information regarding
PMI's dental care guidelines.
4.12 An Enrollee may request a second opinion if he or she disagrees with or questions the
diagnosis and/or treatment plan determination made by his or her Contract Dentist. PMI may
also request that an Enrollee obtain a second opinion to verify the necessity and
appropriateness of dental treatment or the application of Benefits.
Second opinions will be rendered in a timely manner, appropriate to the nature of the
Enrollee's condition by a licensed Dentist. Requests involving cases of imminent and
serious health threat will be expedited (authorization approved or denied within 72 hours of
receipt of the request, whenever possible). For assistance or additional information regarding
the procedures and timeframes for second opinion authorizations, the Enrollee should contact
PMI's Customer Relations department at (800) 422 -4234 or write to PMI. Second opinions
will be provided at another Contract Dentist's facility, unless otherwise authorized by PMI's
dental consultant. PMI will only pay for a second opinion which PMI has approved or
authorized.
4.13 If an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact
PMI's Customer Relations department at (800) 422 -4234. PMI will confirm whether such
a Special Health Care Need exists, and what arrangements can be made to assist the Enrollee
in obtaining such Benefits. PMI shall not be responsible for the failure of any Contract
Dentist to comply with any law or regulation concerning treatment of persons with Special
Health Care Needs which is applicable to the Dentist.
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ARTICLE 5. COORDINATION OF BENEFITS
5.01 This Contract provides Benefits without regard to coverage by any other group insurance
policy or any other group health benefits program if the other policy or program covers
services or expenses in addition to dental care. Otherwise, Benefits under this Contract are
coordinated with such other group insurance policy or any group health benefits program.
5.02 When Benefits are coordinated with another group insurance policy or group health benefits
program, the determination of which policy or program is primary shall be governed by the
following rules:
a) The policy or program covering the patient as other than a dependent shall be primary
over the policy or program covering the patient as a dependent.
b) The policy or program covering a child as a dependent of a parent whose birthday
occurs earlier in a calendar year shall be primary over the policy or program covering
a child as a dependent of a parent whose birthday occurs later in a calendar year
(except for a dependent child whose parents are separated or divorced as described
in c) below).
c) In the case of a dependent child whose parents are legally separated or divorced:
1) If the parent with custody has not remarried, the policy or program covering
the child as a dependent of the parent with custody shall be pnmary over the
policy or program covering the child as a dependent of the parent without
custody.
2) If the parent with custody has remarried, the policy or program covering the
child as a dependent of the parent with custody shall be primary over the
policy or program covering the child as a dependent of the step - parent, and
the policy or program covering the child as a dependent of the step - parent
shall be primary over the policy or program covering the child as a dependent
of the parent without custody.
3) If there is a court decree that establishes financial responsibility for dental
services which are Benefits under this program, notwithstanding c) 1) and 2),
the policy or program covering the child as a dependent of the parent with
such financial responsibility shall be primary over any other policy or
program covering the child.
d) If the primary policy or program cannot be determined by the rules described in a),
b) or c), the policy or program which has covered the Enrollee for a longer period of
time shall be primary, with the following exception: A policy or program covering
the Enrollee as a laid -off or retired employee or the dependent of a laid -off or retired
employee shall not be primary under this rule d) over a policy or program covering
the Enrollee as an employee or the dependent of an employee. However, if the
provisions of the other policy or program do not include this exception, which results
in benefits under neither being primary, then this exception shall not apply.
5.03 An Enrollee shall provide to PMI, and PMI may release to or obtain from any insurance
company or other organization, any information about the Enrollee that is needed to
administer coordination of benefits. PMI shall, in its sole discretion, determine whether any
reimbursement to an insurance company or other organization is warranted under these
coordination of benefits provisions, and any such reimbursement paid shall be deemed to be
Benefits under this Contract. PMI shall have the right to recover from a Dentist, Enrollee,
insurance company or other organization, as PMI chooses, the amount of any Benefits paid
by PMI which exceed its obligations under these coordination of benefit provisions.
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ARTICLE 6. COMPLAINT PROCEDURE, CLAIMS APPEAL AND ARBITRATION
PMI shall provide notification if any dental services or claims are denied, in whole or in part, stating
the specific reason or reasons for the denial. If an Enrollee has any complaint regarding eligibility,
the denial of dental services or claims, the policies, procedures or operations of PMI, or the quality
of dental services performed by a Contract Dentist, he or she may call PMI's Customer Relations
department at (800) 422 4234, or the complaint may be addressed in writing to:
PMI Quality Management Coordinator
12898 Towne Center Drive
Cerritos, California 90703
and must include 1) the name of the patient, 2) the name, address, telephone number and social
security number of the Primary Enrollee, 3) the name of the Applicant and 4) the Dentist's name and
address.
Within 5 calendar days of the receipt of a complaint and the above information, the PMI Quality
Management Coordinator will forward to the complainant an acknowledgment of receipt of the
complaint. Those complaints requiring professional expertise shall be referred to a licensed PMI
dental consultant or Dental Director for review. Certain complaints may also require that the
complainant be referred to a Dentist for a clinical evaluation of the dental services provided. PMI
will respond, within 3 days of receipt, to complaints involving severe pain and/or imminent and
serious threat to a patient's health.
Within 30 days of the receipt of the complaint, PMI shall send to the complainant a written report
which describes the complaint and PMI's resolution. The report shall advise that a review of PMI's
decision shall be undertaken if a written request for an appeal of the determination is made within
30 days of the date of receipt of the report. The complainant should provide the reason for the appeal
and any additional information which may affect the case. PMI shall undertake a full and fair review
upon any request for review. PMI may require additional documents as it deems necessary or
desirable in making such a review. PMI shall provide a written response to the complainant within
30 days after PMI receives the appeal and supporting documentation.
An Enrollee may file a complaint with the Department of Managed Health Care after he or
she has completed PMI's grievance procedure or after he or she has been involved in PMI's
grievance procedure for 30 days. An Enrollee may file a complaint with the Department
immediately in an emergency situation, which is one involving severe pain and /or imminent
and serious threat to the Enrollee's health.
The California Department of Managed Health Care is responsible for regulating health care services
plans. The Department has a toll -free number (1- 888 - HMO -2219) to receive complaints regarding
health plans. The hearing and speech impaired may use the California Relay Service's toll -free
numbers [1- 800 - 735 -2929 (TTY)] or [1- 888 - 877 -5378 (TTY)] to contact the Department. The
Department's website (http: / /www.hmohelp.ca.gov) has complaint forms and instructions online.
If you have a grievance against your health plan you should first telephone your plan at
[(800) 422 -4234] and use the plan's grievance process before contacting the Department. If you
need help with a grievance involving an emergency, a grievance that has not been satisfactorily
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resolved by your plan, or a grievance that has been unresolved for more than 30 days, you may call
the Department for assistance. The plan's grievance process and the Department's complaint review
process are in addition to any other dispute resolution procedures that may be available to you, and
your failure to use these processes does not preclude your use of any other remedy provided by law.
_ Any dispute arising out of or relating to this Contract or this dental health care program, including
any disagreement with a claim determination made by PMI after exhaustion of the procedures
outlined above, or any complaint regarding the quality of dental services performed by a Contract
Dentist, is subject to arbitration in accordance with the Consumer Rules . of the American Arbitration
Association ( "AAA "). Any party to a dispute may initiate arbitration by written notice to each other
party to the dispute by filing two copies of such notice with the AAA Regional Office in San
Francisco or Los Angeles, together with the fee required by the AAA.
In the event of extreme hardship on the part of an enrollee or subscriber, and upon an application for
relief presented to the AAA, PMI shall assume all or a portion of the Enrollee's share of arbitration
fees and expenses as determined by the AAA in accordance with procedures established and
administered by the AAA.
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ARTICLE 7. GENERAL PROVISIONS
7.01 The Contract, the Contract application, and any attached schedules, appendices,
endorsements and riders, constitute the entire agreement between PMI and Applicant. No
agent has authority to amend this Contract or waive any of its provisions. No amendment
to this Contract shall be valid unless approved by an executive officer of PMI and evidenced
by endorsements.
7.02 If any portion of this Contract or any amendment thereof shall be determined by any
arbitrator, court or other competent authority to be illegal, void or unenforceable, such
determination shall not abrogate this Contract or any portion thereof other than such portion
determined to be illegal, void or unenforceable, and all other portions of this Contract shall
remain in full force and effect.
7.03 The parties agree that all questions regarding interpretation or enforcement of this Contract
shall be governed by the laws of the State of California, where the Contract is entered into
and is to be performed. PMI is subject to the requirements of Chapter 2.2 of Division 2 of
the California Health and Safety Code and of Chapter 1 of Division 1, of Title 28 of the
California Code of Regulations. Any provisions required to be in the Contract by either of
the above shall bind PMI whether or not provided in this Contract.
7.04 PMI will issue to the Applicant for delivery to each Primary Enrollee an evidence of coverage
summarizing the Benefits to which each Enrollee is entitled. If any amendment to this
Contract shall materially affect any provisions described in such evidence of coverage, new
evidences of coverage or riders showing the change shall be issued. Any direct conflict
between the evidence of coverage and this Contract shall be resolved according to the terms
most favorable to the Enrollee.
•
; 7.05 Both parties to this Contract agree to consult to the extent reasonably practical concerning
all material published or distributed relating to this Contract. No such material shall be
published or distributed which is contrary to the terms of this Contract.
7.06 Applicant shall designate in writing a representative for purposes of receiving notices from
PMI under this Contract. Applicant may change its representative at any time on 30 days'
notice to PMI. Any notice under this Contract shall be sufficient if given by either Applicant
or PMI to the other addressed as stated on the Application of this Contract, and shall be
effective 48 hours after deposit in the United States mail with postage fully prepaid. Any
notice required from PMI to any Enrollee may be given to Applicant's representative, who
shall disseminate such notice to Enrollees by next regular communication but in no event
later than 30 days after receipt thereof.
7.07 PMI shall be excused from performance under this Contract for any period and to the extent
that it is prevented from performing any services in whole or in part as a result of an act of
God, war, civil disturbance, strike, court order, or other cause beyond its reasonable control
• and which it could not have prevented by reasonable precautions.
7.08 Both parties to this Contract shall comply in all respects with all applicable federal, state and
local laws and regulations relating to administrative simplification, security, and privacy of
individually identifiable Enrollee information. Both parties agree that this Contract may be
amended as necessary to comply with federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996 or to comply with any other enacted
administrative simplification, security or privacy laws or regulations.
GENPROV
PMI -CA 14 02012-0047.3T12-1.AT
• • •
ARTICLE 8. TERMINATION AND RENEWAL
8.01 - This Contract may be terminated by PMI upon Applicant's failure (i) to furnish PMI with the
eligibility list as required by Article 2, or (ii) to pay Premiums in the amount and manner
required by Article 3, provided Applicant has been notified of such failure and at least 15
days have elapsed since such notification.
8.02 Termination at the end of a Contract Term shall be by at least 30 days' advance written notice
of termination by certified mail given by the party desiring to terminate to the other party.
In the event that PMI shall desire to change Premiums or Benefits effective at the end of any
Contract Term, advice of such changes will be given to Applicant upon at least 30 days'
written notice, and such notice shall renew the Contract for another Contract Term at the
rates and with the coverage as stated in the notice unless Applicant provides written
notification to PMI by certified mail on or before the date stated in the notice that Applicant
does not choose to renew.
8.03 Acceptance by PMI of the proper Premiums after termination of this Contract and without
requiring a new application, shall continue this Contract as though it had never terminated,
unless PMI shall, within 20 business days of receipt of such payment, either i) refuse the
payment so made, or ii) issue to Applicant a new Contract accompanied by written notice
stating clearly those respects in which the new Contract differs from this terminated Contract
in Benefits, coverage or otherwise.
TERM -REN
PMI - CA 15 02012-0047.3T12-1.AT
• •
ARTICLE 9. ATTACHMENTS
The following schedules are a part of this Contract:
Schedule A - Description of Benefits and Copayments
Schedule B - Limitations and Exclusions of Benefits
Schedule C - Non - Covered Procedures
Schedule D - Group Variables and Premiums
Schedule E - COBRA Continuation Option
Schedule F - Benefits Summary Matrix
Appendix A = Group Numbers
ATT
PMI -CA 16 02012-0047.3T12-1.AT
® � - • SCHEDULE A
•
DESCRIPTION OF BENEFITS ANDCOPAYMENTS
PLAN CA508
The benefits shown below are performed as needed and deemed necessary by the attending Contract Dentist subject
to the Limitations and Exclusions of the program. Please refer to Schedule B for further clarification of benefits.
Codes and /or text that appear in italics below are specifically intended to clarify the delivery of Benefits
under the DeltaCare program and are not to be interpreted as CDT -3 procedure codes, descriptors or
nomenclature which are under copyright by the American Dental Association.
ENROLLEE
Code Description PAYS
D0100 -D0999 I. Diagnostic
09800 Office visit, per visit (in addition to other services) No Cost
D0120 Periodic oral evaluation No Cost
D0140 Limited oral evaluation _ problem focused No Cost
D0150 Comprehensive oral evaluation No Cost
D0160 Detailed and extensive oral evaluation - problem focused No Cost
D0170 ,Re- evaluation - limited, problem focused
(Established patient; not post - operative visit) No Cost
D0210 Intraoral radiographs - complete series (including bitewings)
- limited to 1 series every 24 months No Cost
D0220 Intraoral - periapical first film No Cost
D0230 Intraoral - periapical, each additional film No Cost
D0240 Intraoral - occlusal film No Cost
D0270 Bitewing radiograph - single film No Cost
D0272 Bitewings radiographs - two films No Cost
D0274 Bitewings radiographs - four films - limited to 1 series every 6 months No Cost
D0330 Panoramic film No Cost
D0460 Pulp vitality tests No Cost
D0470 Diagnostic casts No Cost
D0501 Histopathologic examinations only if peOrrined after a
prior approved biopsy (D7286) by an oral surgeon No Cost
D1000 -D1999 II. Preventive
D1110 Prophylaxis cleaning- adult - 1 per 6 month period No Cost
D1120 Prophylaxis cleaning- child - 1 per 6 month period No Cost
D1201 Topical application of fluoride (including prophylaxis) - child
- to age 19; 1 per 6 month period No Cost
D1203 Topical application of fluoride (prophylaxis not included) - child
- to age 19; 1 per 6 month period No Cost
D1330 Oral hygiene instructions No Cost
D1351 Sealant - per tooth - limited to permanent molars through age 15 $ 10.00
D1510 Space maintainer - fixed - unilateral $ 15.00
D1515 Space maintainer - fixed - bilateral $ 15.00
D1520 Space maintainer - removable - unilateral $ 15.00
D1525 Space maintainer - removable - bilateral $ 15.00
D1550 Recementation of space maintainer
•
No Cost
SCH -A
•
S- A- CA(508) 17 02012- 0047.3T12 -1.AT
Q •
•
•
ENROLLEE
Code Description PAYS
D2000 -D2999 III. Restorative
Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.
* Optional is defined as any alternative procedure presented by the Contract Dentist that sati f es the same dental need as a covered
procedure, is chosen by the Enrollee, and is subject to the Limitations and Exclusions of the program. The applicable charge to the
Enrollee is the difference between the Contract Dentist's `filed fee "for the Optional procedure and the covered procedure, plus any
applicable Copayment or material / laboratory upgrade for the covered procedure. Optional treatment does not apply when alternative
choices are benefits. `Filed fees" mean the Contract Dentist's fees on file with PMI. Questions regarding the DeltaCar' program
should be directed to PMI's Customer Relations department at (800) 422 -4234.
1 An amalgam is the benefit.
2 Base or noble metal is the benefit. High noble metal (precious), if used, will be charged to the Enrollee at the additional maximum
cost to the Enrollee of $100.00 per tooth. If a cast post and core is made of high noble metal, an additional fee up to $ 100.00 per
tooth may be charged for the upgraded post and core.
3 Porcelain and other tooth - colored materials on molars are considered a material upgrade with a maximum additional charge to
the Enrollee of $150.00.
4 Coverage of replacement is subject to a limitation requiring the existing restoration to be 5+ years old.
D2110 Amalgam - one surface, primary No Cost
D2120 Amalgam - two surfaces, primary No Cost
• D2130 Amalgam - three surfaces, primary No Cost
D2131 Amalgam - four or more surfaces, primary No Cost
D2140 Amalgam - one surface, permanent No Cost
D2150 Amalgam - two surfaces, permanent No Cost
D2160 Amalgam - three surfaces, permanent No Cost
D2161 Amalgam - four or more surfaces, permanent No Cost
D2330 Resin -based composite - one surface, anterior No Cost
D2331 Resin -based composite - two surfaces, anterior No Cost
D2332 Resin -based composite - three surfaces, anterior No Cost
D2335 Resin -based composite - four or more surfaces or
involving incisal angle (anterior) No Cost
D2336 Resin -based composite crown, anterior - primary No Cost
D2380 Resin -based composite - one surface, posterior - primary * Optional
D2381 Resin -based composite - two surfaces, posterior - primary * Optional
D2382 Resin -based composite - three or more surfaces, posterior - primary * 1 Optional
D2385 Resin -based composite - one surface, posterior - permanent * Optional
D2386 Resin -based composite - two surfaces, posterior - permanent * 1 Optional
D2387 Resin -based composite - three surfaces, posterior - permanent* 1 Optional
D2388 Resin -based composite - four or more surfaces, posterior - permanent * Optional
D2510 Inlay - metallic - one surface 2,4 No Cost
D2520 Inlay - metallic - two surfaces 2,4 No Cost
D2530 Inlay - metallic - three or more surfaces 2,4 No Cost
D2542 Onlay - metallic - two surfaces 2,4 No Cost
D2543 Onlay - metallic - three surfaces 2,4 • No Cost
D2544 Onlay - metallic - four or more surfaces 2,4 No Cost
D2610 Inlay - porcelain /ceramic - one surface * 4 Optional
D2620 Inlay - porcelain /ceramic - two surfaces * 4 Optional
D2630 Inlay - porcelain /ceramic - three or more surfaces * 4 Optional
D2642 Onlay - porcelain /ceramic - two surfaces * 4 Optional
D2643 Onlay - porcelain /ceramic - three surfaces * 4 Optional
D2644 Onlay - porcelain /ceramic - four or more surfaces * 4 Optional
D2650 Inlay - resin -based composite composite /resin - one surface * 4 Optional
D2651 Inlay - resin -based composite composite /resin - two surfaces * 4 Optional
SCH -A
S- A- CA(508) 18 02012-0047.3T12-1.AT
0 • ^
' ENROLLEE
Code Description PAYS
D2652 Inlay - resin -based composite composite /resin - three
or more surfaces * 4 Optional
D2662 Onlay - resin -based composite composite /resin - two surfaces * 4 Optional
D2663 Onlay - resin -based composite composite /resin - three surfaces * 4 Optional
D2664 Onlay - resin -based composite composite /resin - four
or more surfaces * 4 Optional
D2710 Crown - resin (laboratory) 3,4 $ 45.00
D2720 Crown - resin with high noble metal 2,3,4 $ 75.00
D2721 Crown - resin with predominantly base metal 34 • $ 75.00
D2722 Crown - resin with noble metal 3,4 $ 75.00
D2740 Crown - porcelain /ceramic substrate 3,4 $ 75.00
D2750 Crown - porcelain fused to high noble metal 2,3,4 $ 75.00
D2751 Crown - porcelain fused to predominantly base metal 3,4 $ 75.00
D2752 Crown - porcelain fused to noble metal 3,4 $ 75.00
D2780 Crown - 3 /4 cast high noble metal 2,4 $ 75.00
D2781 Crown - 3 /4 cast predominantly base metal 4 • $ 75.00
D2782 Crown - 3 /4 cast noble metal 4 $ 75.00
D2790 Crown - full cast high noble metal 2,4 $ 75.00
D2791 Crown - full cast predominantly base metal 4 $ 75.00
D2792 Crown _ full cast noble metal 4 $ 75.00
D2910 Recement inlay No Cost
D2920 Recement crown No Cost
D2930 Prefabricated stainless steel crown - primary tooth No Cost
D2931 Prefabricated stainless steel crown - permanent tooth No Cost
D2932 Prefabricated resin crown - anterior primary tooth $ 10.00
D2933 Prefabricated stainless steel crown with
resin window - anterior primary tooth $ 10.00
D2940 Sedative filling $ 10.00
D2950 Core buildup, including any pins $ 10.00
' D2951 Pin retention - per tooth, in addition to restoration $ 10.00
D2952 Cast post and core in addition to crown - includes canal preparation 2 $ 10.00
D2953 Each additional cast post - same tooth - includes canal preparation 2 • $ 10.00
D2954 Prefabricated post and core in addition to crown - base
metal post; includes canal preparation $ 10.00
D2957 Each additional prefabricated post - same tooth - base
- metal post; includes canal preparation $ 10.00
D2970 Temporary crown (fractured tooth) - palliative treatment only $ 10.00
D2980 Crown repair $ 10.00
D3000 -D3999 IV. Endodontics
•
5 A benefit for permanent teeth only.
D3110 Pulp cap - direct (excluding final restoration) No Cost
D3120 . Pulp cap - indirect (excluding final restoration) No Cost
D3220 • Therapeutic pulpotomy (excluding final restoration) - removal of pulp
I . coronal to the dentinocemental junction and application of medicament No Cost
D3221 • Gross pulpal debridement, primary and permanent teeth $ 7.00
D3230 Pulpal therapy (resorbable filling) - anterior,
, primary tooth (excluding final restoration) $ 7.00
D3240 - Pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration) $ 7.00
D3310 Root canal = anterior (excluding final restoration) 5 - $ 40.00
SCH -A
• S- A- CA(508) 19 02012-0047.3T12-1.AT
m o 4
ENROLLEE
Code Description PAYS
D3320 Root canal - bicuspid (excluding final restoration) 5 $ 80.00
D3330 Root canal - molar (excluding final restoration) 5 $120.00
D3346 Retreatment of previous root canal therapy - anterior 5 $ 55.00
D3347 Retreatment of previous root canal therapy - bicuspid 5 $ 95.00
D3348 Retreatment of previous root canal therapy - molar 5 $135.00
D3410 Apicoectomy / periradicular surgery - anterior 5 $ 50.00
D3421 Apicoectomy /periradicular surgery - bicuspid (first root) 5 $ 50.00
D3425 Apicoectomy / periradicular surgery - molar (first root) 5 $ 50.00
D3426 Apicoectomy / periradicular surgery (each additional root) 5 No Cost
D3430 Retrograde filling - per root 5 $ 50.00
D3450 Root amputation, per root - not covered in
conjunction with procedure D3920 5 No Cost
D4000 -D4999 V. Periodontics
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D4210 Gingivectomy or gingivoplasty - per quadrant $100.00
D4211 Gingivectomy or gingivoplasty - per tooth -fewer than 6 teeth $ 20.00
D4220 Gingival curettage, surgical - per quadrant $ 10.00
D4240 Gingival flap procedure, including root planing - per quadrant $100.00
D4260 Osseous surgery (including flap entry and closure) - per quadrant $200.00
D4341 Periodontal scaling and root planing, per quadrant - limited
to 4 quadrants during any 12 consecutive months $ 10.00
D4355 Full mouth debridement to enable comprehensive periodontal evaluation
and diagnosis - limited to 1 treatment in any 12 consecutive months $ 10.00
D4910 Periodontal maintenance procedures (following active therapy)
- limited to 1 treatment each 6 month period $ 8.00
D5000 -D5899 VI. Prosthodontics (removable)
6 Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee
continues to be eligible and the service is provided at the Contract Dentist's facilig where the denture was originally delivered.
' Limited to 1 per denture during any 12 consecutive months.
8 Coverage of replacement is subject to a limitation requiring the existing denture to be 5+ years old.
D5110 Complete denture - maxillary 6,8 $ 95.00
D5120 Complete denture - mandibular 6,8 $ 95.00
D5130 Immediate denture - maxillary 68 $110.00
D5140 Immediate denture - mandibular 6,8 $110.00
D5211 Maxillary partial denture - resin base
(including any conventional clasps, rests and teeth) 6,8 $105.00
D5212 Mandibular partial denture - resin base
(including any conventional clasps, rests and teeth) 68 $105.00
D5213 Maxillary partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) 6,8 $110.00
D5214 Mandibular partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) 68 $110.00
D5410 Adjust complete denture - maxillary 6 $ 5.00
D5411 Adjust complete denture - mandibular 6 $ 5.00
D5421 Adjust partial denture - maxillary 6 $ 5.00
D5422 Adjust partial denture - mandibular 6 $ 5.00
D5510 Repair broken complete denture base $ 15.00
D5520 Replace missing or broken teeth - complete denture (each tooth) $ 10.00
D5610 Repair resin denture base $ 15.00
SCH -A
S- A- CA(508) 20 02012- 0047.3T 12 -1.AT
z n • •
ENROLLEE
Code Description PAYS
•
D5620 Repair cast framework $ 15.00
D5630 Repair or replace broken clasp $ 15.00
D5640 Replace broken teeth - per tooth $ 10.00
D5650 Add tooth to existing partial denture $ 10.00
D5660 Add clasp to existing partial denture $ 10.00
D5710 Rebase complete maxillary denture 7 $ 40.00
D5711 Rebase complete mandibular denture 7 $ 40.00
D5720 Rebase maxillary partial denture 7 $ 40.00
D5721 Rebase mandibular partial denture 7 $ 40.00
D5730 Reline complete maxillary denture (chairside) 7 $ 20.00
D5731 Reline complete mandibular denture ( chairside) 7 $ 20.00
D5740 Reline maxillary partial denture (chairside) 7 $ 20.00
D5741 Reline mandibular partial denture (chairside) 7 $ 20.00
D5750 Reline complete maxillary denture (laboratory) 7 $ 40.00
D5751 Reline complete mandibular denture (laboratory) 7 $ 40.00
D5760 Reline maxillary partial denture (laboratory) 7 $: 40.00
D5761 Reline mandibular partial denture (laboratory) 7 $ 40.00
D5820 Interim partial denture (maxillary) - limited to initial placement of interim
partial denture /stayplate to replace extracted anterior teeth during healing 6 No Cost
D5821 Interim partial denture (mandibular) - limited to initial placement of interim
partial denture /stayplate to replace extracted anterior teeth during healing 6 No Cost
D5850 Tissue conditioning, maxillary 67 No Cost
D5851 Tissue conditioning, mandibular 67 No Cost
D5900 -D5999 VII. Maxillofacial Prosthetics - refer to Schedule C, Non - Covered Procedures
D6000 -D6199 VIII. Implant Services - refer to Schedule C, Non - Covered Procedures
D6200 -D6999 IX. Prosthodontics, fixed (each retainer and each pontic constitutes a unit in a fixed
partial denture [bridge]).
* Optional is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered
procedure, is chosen by the Enrollee, and is subject to the Limitations and Exclusions of the program. The applicable charge to the
Enrollee is the difference between the Contract Dentist's filed fee "for the Optional procedure and the covered procedure, plus any
applicable Copayment or material / laboratory upgrade for the covered procedure. Optional treatment does not apply when alternative
choices are benefits. `Filed fees" mean the Contract Dentist's fees on file with PMI. Questions regarding the DeltaCare program
should be directed to PMI's Customer Relations department at (800) 4224234.
2 Base or noble metal is the benefit. High noble metal (precious), if used, will be charged to the Enrollee at the additional maximum
cost to the Enrollee of,$100.00 per tooth. If a cast post and core is made of high noble metal, an additional fee up to 8100.00 per
tooth may be charged for the upgraded post and core.
-3 Porcelain and other tooth - colored materials on molars are considered a material upgrade with a maximum additional charge to the
Enrollee of 8150.00.
9 Coverage of replacement is subject to a limitation requiring the existing bridge to be 5 +, years old.
D6210 Pontic - cast high noble metal 2,9 $ 75.00
D6211 Pontic - cast predominantly base metal 9 $ 75.00
D6212 Pontic - cast noble metal 9 $ 75.00
D6240 Pontic - porcelain fused to high noble metal 2,3,9 $ 75.00
D6241 Pontic - porcelain fused to predominantly base meta1 $ 75.00
D6242 Pontic - porcelain fused to noble metal 3,9 • $ 75.00
D6245 Pontic - porcelain /ceramic * 9 Optional
D6250 Pontic - resin with high noble metal 2,3,9 $ 75.00
D6251 Pontic - resin with predominantly base metal 3,9 $ 75.00
SCH -A
S- A- CA(508) 21 02012- 0047.3T12 -1.AT
rV q ` • •
ENROLLEE
Code Description PAYS
D6252 Pontic - resin with noble metal 3,9 $ 75.00
D6519 Inlay /onlay - porcelain /ceramic * 9 Optional
•
D6520 Inlay - metallic - two surfaces 29 No Cost
D6530 Inlay - metallic - three or more surfaces 2,9 No Cost
D6543 Onlay - metallic - three surfaces 29 No Cost
D6544 Onlay - metallic - four or more surfaces Z No Cost
D6720 Crown - resin with high noble metal 2,3,9 $ 75.00
D6721 Crown - resin with predominantly base metal 3,9 $ 75.00
D6722 Crown - resin with noble metal 3,9 $ 75.00
D6740 Crown - porcelain /ceramic * 9 Optional
D6750 Crown - porcelain fused to high noble metal 2,3,9 $ 75.00
D6751 Crown - porcelain fused to predominantly base metal 3 ' 9 $ 75.00
D6752 Crown - porcelain fused to noble metal 3,9 $ 75.00
D6780 Crown - 3 /4 cast high noble metal 2,9 $ 75.00
D6781 Crown - 3 /4 cast predominantly base metal 9 $ 75.00
D6782 Crown - 3 /4 cast noble metal 9 $ 75.00
D6790 Crown - full cast high noble metal 2,9 $ 75.00
D6791 Crown - full cast predominantly base metal 9 $ 75.00
D6792 Crown - full cast noble metal 9 $ 75.00
D6930 Recement fixed partial denture No Cost
D6940 Stress breaker 9 No Cost
D6970 Cast post and core in addition to fixed partial denture retainer
- includes canal preparation 2 $ 10.00
D6971 Cast post as part of fixed partial denture retainer - includes canal preparation 2 $ 10.00
D6972 Prefabricated post and core in addition to fixed partial denture retainer .
- base metal post; includes canal preparation $ 10.00
D6973 Core buildup for retainer, including any pins $ 10.00
D6976 Additional cast post - same tooth - includes canal preparation 2 $ 10.00
D6977 Each additional prefabricated post - same tooth - base
metal post; includes canal preparation $ 10.00
D6980 Fixed partial denture repair $ 15.00
D7000 -D7999 X. Oral and Maxillofacial Surgery '
Includes preoperative and postoperative evaluations and treatment under local anesthetic.
D7110 Single tooth No Cost
D7120 Each additional tooth No Cost
D7130 Root removal - exposed roots No Cost
D7210 Surgical removal of erupted tooth requiring elevation of
mucoperiosteal flap and removal of bone and /or section of tooth No Cost
D7220 Removal of impacted tooth - soft tissue No Cost
D7230 Removal of impacted tooth - partially bony $ 45.00
D7240 Removal of impacted tooth - completely bony $ 65.00
D7241 Removal of impacted tooth - completely bony, with unusual
surgical complications $ 65.00
D7250 Surgical removal of residual tooth roots (cutting procedure) No Cost
D7286 Biopsy of oral tissue - soft (all others) - does not include
histopathologic examination or other pathology laboratory procedures No Cost
D7310 Alveoloplasty in conjunction with extractions - per quadrant $ 35.00
D7320 Alveoloplasty not in conjunction with extractions - per quadrant $ 50.00
D7471 Removal of exostosis - per site No Cost
D7510 Incision and drainage of abscess - intraoral soft tissue No Cost
SCH -A
S- A- CA(508) 22 02012-0047.3T12-1.AT
e • , , • •
ENROLLEE
Code Description PAYS
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure No Cost
D8000 -D8999 XI. Orthodontics
10 Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for 08237 "Start -up fee."
Beyond 24 months of active treatment, an additional monthly fee of $75.00 applies.
11 In the event comprehensive orthodontic treatment is not required or is declined by the Enrollee, a fee of $25.00 will apply. The
Enrollee is also responsible for any incurred orthodontic diagnostic record fees.
12 Includes adjustments and /or office visits up to 24 months. After 24 months, a monthly fee of $75.00 applies.
D8070 Comprehensive orthodontic treatment of the transitional dentition
- child or adolescent to age 19 10 $1600.00
D8080 Comprehensive orthodontic treatment of the adolescent dentition
- adolescent to age 19 $1600.00
D8090 Comprehensive orthodontic treatment of the adult dentition
- adults, including dependent adults covered as full -time students 1° $1800.00
08237 Start -up fee, which includes initial examination, diagnosis,
consultation and initial banding $ 350.00
D8660 Pre - orthodontic treatment visit - not to be charged with any other
consultation procedures(s) No Cost
D8680 Orthodontic retention (removal of appliances, construction and
placement of retainers) 12 No Cost
D9000 -D9999 XII. Adjunctive General Services
D9110 Palliative (emergency) treatment of dental pain - minor procedure $ 5.00
D9211 Regional block anesthesia No Cost
D9212 Trigeminal division block anesthesia No Cost
D9215 Local anesthesia No Cost
D9310 Consultation (diagnostic services provided by a dentist or
physician other than practitioner providing treatment) No Cost
D9430 Office visit for observation (during regularly scheduled hours) - no
other services performed $ 5.00
D9440 Office visit - after regularly scheduled hours $ 20.00
00125 Failed appointment without 24 hour notice - per 15 minutes of appointment time $ 10.00
Procedures not listed above are not covered however may be available at the Contract Dentist's "filed fees ".
"Filed fees" means the Contract Dentist's fees on file with PMI. Questions regarding these fees should be
directed to PMI's Customer Relations department at (800) 422 -4234.
SCH -A
S- A- CA(508) 23 02012- 0047.3T 12 -1.AT
• •
SCHEDULE B
•
LIMITATIONS OF BENEFITS
1. Full mouth x -rays are limited to one set every twenty -four consecutive months and include any
combination of periapicals, bitewings and /or panoramic film;
2. Bitewing x -rays are limited to not more than one series of four films in any six month period;
3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits;
4. If a biopsy (D7286) is prior- approved by PMI to an oral surgeon, then histopathologic examination
(D0501) of the resulting biopsy specimen is covered and available at no additional cost;
5. Prophylaxis or periodontal maintenance following active therapy is limited to one procedure each
six month period;
6. Benefits for sealants include the application of sealants only to permanent first and second molars
with no decay, with no restorations and with the occlusal surface intact, for first molars through
age nine and second molars through age fifteen. Benefits for sealants do not include the repair or
replacement of a sealant on any tooth within three years of its application;
7. A filling is a benefit for the removal of decay, for minor repairs of tooth structure or to replace a
lost filling;
8. A crown is a benefit when there is insufficient tooth structure to support a filling or to replace an
existing crown that is non - functional or non - restorable and meets the five year limitation
(Limitation #12);
9. A covered metallic inlay, onlay, crown or fixed partial denture (bridge) using base or noble metal
is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead,
the maximum additional cost of this material upgrade is $100.00 per tooth or pontic. For a cast
post and core, the benefit is for base or noble metal. If the Enrollee elects to have a high noble
metal cast post and core instead, the maximum additional cost of this material upgrade is $100.00
per tooth;
10. For molars, a covered inlay, onlay, crown, or unit of a fixed partial denture (bridge) is metallic
without porcelain or other tooth - colored material. If the Enrollee elects to have porcelain,
porcelain- fused -to- metal, resin or resin - with -metal used instead, the maximum additional cost for
this tooth- colored material upgrade is $150.00 per molar;
11. If a porcelain margin is also chosen by the Enrollee for a covered porcelain- fused -to -metal crown,
the maximum additional cost for this laboratory upgrade is $75.00;
SCH -B
S- B- CA(508) 24 02012- 0047.3T12 -1.AT
• i
•
12. The replacement of an existing inlay, onlay, crown, fixed partial denture (bridge) or a '
removable full or partial denture is covered when:
a. The existing restoration /bridge /denture is no longer functional and cannot be made functional
by repair or adjustment, and
b. Either of the following:
- The existing non - functional restoration /bridge /denture was placed five or more years
prior to its replacement, or
- If an existing partial denture is less than five years old, but must be replaced by a new
partial denture due to the loss of a natural tooth, which cannot be replaced by adding
another tooth to the existing partial denture;
13. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a
vital primary tooth;
14. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy,
apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth;
r-
15. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract
Dentist is not performing root canal therapy;
16. Periodontal scaling and root planing are limited to four quadrants during any twelve month period;
17. Full mouth debridement (gross scale) is limited to one treatment in any twelve month period;
18. Coverage for the placement of a fixed partial denture (bridge) requires that:
a. No cantilevered posterior pontic (prosthetic tooth) be included; and
b. Either of the following:
- The sole tooth to be replaced in the arch is a permanent tooth, which cannot be replaced
by adding another tooth to an existing removable partial denture; or
• - The new bridge would replace an existing, non - functional bridge (see Limitation #12); or
- Each abutment tooth to be crowned meets Limitation #8;
19. Relines, tissue conditioning and rebases are limited to one per denture during any twelve
consecutive months;
20. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited
to:
- The replacement of extracted anterior teeth for adults during a healing period when the
• teeth cannot be added to an existing partial denture; or
- The replacement of permanent tooth /teeth for children under sixteen years of age;
21. Retained primary teeth shall be covered as primary teeth;
22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes
a large diastema between teeth or it interferes with a prosthetic appliance;
23. Benefits provided by a pediatric Dentist are limited to children through age seven following an
attempt by the assigned Contract Dentist to treat the child and upon prior authorization by PMI,
less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will
be considered on an individual basis;
SCH -B
S- B- CA(508) 25 0201210047.3T12 -1.AT
• Y , •
24. In cases of accidental injury, benefits available are described in Schedule B, Accident Injury Benefit.
Damages to the hard and soft tissues of the oral cavity from normal masticatory (chewing)
function, exclusive attrition and normal wear, will be covered as described in Schedules A,
Description of Benefits and Copayments; and B, Limitations and Exclusions of Benefits;
25. Soft tissue management programs are limited to periodontal pocket charting, root planing, scaling,
curettage, oral hygiene instruction, periodontal maintenance and /or prophylaxis. If an Enrollee
declines non - covered services within a soft tissue management program, it does not eliminate or
alter other covered benefits;
26. A new removable partial, complete or immediate denture includes after delivery adjustments and
tissue conditioning at no additional cost for the first six months after placement if the Enrollee
continues to be eligible and the service is provided at the Contract Dentist's facility where the
denture was originally delivered;
27. An Optional procedure is defined as any alternative procedure presented by the Contract
Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee,
and is subject to the Limitations and Exclusions of the program. The applicable charge to
the Enrollee is the difference between the Contract Dentist's "filed fee" for the Optional
procedure and the covered procedure, plus any applicable Copayment or material /laboratory
upgrade for the covered procedure. Optional treatment does not apply when alternative
choices are benefits. Optional procedures include:
- The use of a tooth- colored material when restoring a posterior tooth with a filling, inlay
or onlay; and
- Units in a fixed partial denture (bridge) made of porcelain /ceramic, which is not fused to
and supported by underlying cast metal.
"Filed fee" means the Contract Dentist's fees on file with PMI. Questions regarding these fees should be
. directed to PMI's Customer Relations depatunent at (800) 422 -4234.
•
SCH -B
S- B- CA(508) 26 02012-0047.3T12-1.AT
• •
EXCLUSIONS OF BENEFITS
1. All procedures as shown on Schedule C, Non - Covered Procedures;
2. ' Dental conditions arising out of and due to Enrollee's employment for which Worker's
Compensation is paid. Services that are provided to the Enrollee by state government or agency
thereof, or are provided without cost to the Enrollee by any municipality, county or other
subdivision, except as provided in Section 1373(a) of the California Health and Safety Code;
3. All related fees for admission, use, or stays in a hospital, out - patient surgery center, extended care
facility, or other similar care facility;
4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures
(bridges);
5. Dental expenses incurred in connection with any dental procedures started after termination of
eligibility for coverage;
6. Dental expenses incurred in connection with any dental procedure started before the Enrollee's
eligibility with the DeltaCare program. Examples include: teeth prepared for crowns, root canals •
in progress, orthodontics;
7. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and
dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or
birth abnormalities;
8. Dispensing of drugs not normally supplied in a dental facility;
9. Any procedure that in the professional opinion of the Contract Dentist or PMI's dental consultant:
a. has poor prognosis for a successful result and reasonable longevity based on the condition of
the tooth or teeth and /or surrounding structures, or
b. is inconsistent with generally accepted standards for dentistry;
10. Dental services received from any dental facility other than the assigned Contract Dentist including
the services of a dental specialist, unless expressly authorized in writing by PMI or as cited under
Article 4.04. To obtain written authorization, the Enrollee should call PMI's Customer Relations
department at (800) 422 -4234;
11. Consultations for non - covered benefits;
12. Implant placement or removal, appliances placed on or services associated with implants, including
but not limited to prophylaxis and periodontal treatment;
13. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial
dentures (bridges) for children under sixteen years of age;
14. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering
vertical dimension, congenital or developmental malformation of teeth;
SCH -B
S- B- CA(508) 27 02012- 0047.3T 12 -1.AT
• • •
15. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth
structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings,
equilibration or treatment of disturbances of the temporomandibular joint (TMJ);
16. An initial treatment plan which involves the removal and reestablishment of the occlusal contacts
of ten or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of
these is considered to be full mouth construction under the DeltaCare program. Crowns, onlays
and fixed partial dentures associated with such a treatment plan are not covered benefits. This
exclusion does not affect any other benefits;
17. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures,
porcelain denture teeth, precision abutments for removable partials or fixed partial dentures
(overlays, implants, and appliances associated therewith) and personalization and characterization
of complete and partial dentures;
18. Extraction of teeth, when teeth are asymptomatic /non - pathologic (no signs or symptoms of
pathology or infection), including but not limited to the removal of third molars and orthodontic
extractions;
19. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent;
20. Treatment required by reason of war declared or undeclared.
SCH -B
S- B- CA(508) 28 02012-0047.3T12-1.AT
.
• •
ORTHODONTIC LIMITATIONS
The DeltaCare program provides coverage for orthodontic treatment plans provided through PMI's
Contract Orthodontists. The start-up fees and the cost to the Enrollee for the treatment plan are listed
in Schedule A, Description of Benefits and Copayments and subject to the following:
1. Orthodontic treatment must be provided by the Contract Orthodontist;
2. Benefits cover twenty -four months of active comprehensive orthodontic treatment. Included is
the initial examination, diagnosis, consultation, initial banding, twenty -four months of active
treatment, de- banding and the retention phase of treatment. The retention phase includes the
initial construction, placement and adjustment to retainers and office visits for a maximum of two
years;
3. Treatment plans extending beyond twenty -four months of active treatment, or twenty -four months
of the retention phase of treatment will be subject to a monthly office visit fee to the Enrollee not
to exceed $75.00 per month;
4. Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of
cancellation or termination be receiving any orthodontic treatment, the Enrollee and not PMI will
be responsible for payment of any balance due for treatment provided after cancellation or
termination. In such a case the Enrollee's payment shall be based on a maximum of $2,800.00 for
covered dependent children to age nineteen and $3,000.00 for covered adults and dependent
children to age twenty - three. The amount will be prorated over the number of months to
completion of the treatment and, will be payable by the Enrollee on such terms and conditions as
are arranged between the Enrollee and the Contract Orthodontist;
5. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and
consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a
consultation fee of $25.00 in addition to diagnostic record fees.
6. Three recementations or replacements of a bracket /band on the same tooth or a total of five
rebracketings /rebandings on different teeth during the covered course of treatment are benefits.
If any additional recementations or replacements of brackets /bands are performed, the Enrollee
is responsible for the cost at the Contract Orthodontist's usual and customary fee;
7. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the
permanent teeth in an effort to make the Enrollee's occlusion as ideal as possible. This treatment
usually requires complete fixed appliances; however, when the Contract Orthodontist deems it
suitable, a European or removable appliance therapy may be substituted at the same Copayments
amount as for fixed appliances.
•
SCH -B
S- B- CA(508) 29 02012- 0047.3T12 -1.AT
•
•
ORTHODONTIC EXCLUSIONS
1. Pre -, mid- and post - treatment records which include cephalometric x -rays, tracings, photographs
and study models;
2. Lost, stolen or broken orthodontic appliances;
3. Retreatment of orthodontic cases;
4. Changes in treatment necessitated by accident of any kind, and /or lack of Enrollee cooperation;
5. Surgical procedures incidental to orthodontic treatment;
6. Myofunctional therapy;
7. Surgical procedures related to cleft palate, micrognathia, or macrognathia;
8. Treatment related to temporomandibnlar joint disturbances;
9. Supplemental appliances not routinely used in typical comprehensive orthodontics;
10. Restorative work caused by orthodontic treatment;
11. Phase I orthodontics/ as well as activator appliances and minor treatment for tooth guidance
and /or arch expansion;
12. Extractions solely for the purpose of orthodontics;
13. Treatment in progress at inception of eligibility;
14. Transfer after banding has been initiated;
15. Composite bands, lingual adaptation of orthodontic bands, and other specialized or cosmetic
alternatives to standard fixed and removable orthodontic appliances.
13 Phase 1 orthodontics is defined as early treatment including interceptive orthodontia prior to the development
of late mixed dentition.
SCH -B
S- B- CA(508) 30 02012- 0047.3T12 -1.AT
• •
ACCIDENT INJURY BENEFIT
An accident injury is damage to the hard and soft tissue of the mouth caused directly and independently
of all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal
chewing function is covered under Schedule A, Description of Benefits and Copayments.
PMI will pay up to 100% of the Contract Dentist's "filed fees ", for expenses an Enrollee incurs for an
accident injury, less any applicable Copayment(s), up to a Maximum of $1,600.00 in any twelve month
period. •
Accident injury benefits include the following procedure in addition to those listed in Schedule A,
Description of Benefits and Copayments.
CODE
D7270 Tooth reimplantation and /or stabilization of accidentally evulsed or displaced tooth and /or
alveolus - includes splinting and /or stabilization.
Payment of accident injury benefits is subject to Schedule B, Limitations and Exclusions of Benefits,
in addition to the following provisions:
MAXIMUM
Accident injury benefits will be provided for each Enrollee up to a maximum of $1,600.00 in any twelve
month period.
•
LIMITATION
Accident injury benefits are limited to services provided as a result of an accident which occurred (a)
while the Enrollee was covered under the DeltaCare program, or (b) while the Enrollee was covered
under another DeltaCare program, and if the benefits for the expenses incurred would have been paid 1
if the Enrollee had remained covered under that program.
EXCLUSIONS
In addition to Schedule B, Limitations #13, #15, #20, #21 and #24 and Exclusions #1 -9, #11 -15
and #18 -20, the following exclusions apply:
1. Prophylaxis;
2. Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue);
3. Replacement of existing restorations due to decay;
4. Orthodontic services (treatment of malalignment of teeth and /or jaws);
5. Replacement of existing restorations, crowns, bridges, dentures and other dental or orthodontic
appliances damaged by accident injury.
"Filed fees" means the Contract Dentist's fees on file with PMI. Questions regarding these fees
should be directed to PMI's Customer Relations department at (800) 422 -4234.
SCH -B
S B- CA(508) 31 _ 02012- 0047.3T 12 -1.AT
.
a . •
SCHEDULE C
NON - COVERED PROCEDURES
The following procedures are not covered under the DeltaCare program. However, these
procedures are available at the Contract Dentist's "filed fees."
Non- Covered Procedures
D0250 Extraoral - first film
•
D0260 Extraoral - each additional film
D0277 Vertical bitewings - 7 to 8 films
D0290 Posterior - anterior or lateral skull and facial bone survey film
D0310 Sialography
D0320 Temporomandibular joint arthrogram, including injection
D0321 Other temporomandibular joint films, by report
D0322 Tomographic survey
D0340 Cephalometric film
D0350 Oral /facial images (includes intra and extraoral images)
D0415 . Bacteriologic studies for determination of pathologic agents
D0425 Caries susceptibility tests
D0472 Accession of tissue, gross examination, preparation and transmission of written report
D0473 Accession of tissue, gross and microscopic examination, preparation
and transmission of written report
D0474 Accession of tissue, gross and microscopic examination, including assessment of
surgical margins for presence of disease, preparation and transmission of written report
D0480 Processing and interpretation of cytologic smears, including the preparation and
transmission of written report
D0502 Other oral pathology procedures, by report
D0999 Unspecified diagnostic procedure, by report
D1204 Topical application of fluoride (prophylaxis not included) - adult
D1205 Topical application of fluoride (including prophylaxis) - adult
D1310 Nutritional counseling for control of dental disease
D1320 Tobacco counseling for the control and prevention of oral disease
D2337 Resin -based composite crown, anterior - permanent
D2410 Gold foil - one surface
D2420 Gold foil - two surfaces
D2430 Gold foil - three surfaces
D2783 Crown - 3 /4 porcelain /ceramic
D2799 Provisional crown
D2955 Post removal (not in conjunction with endodontic therapy)
D2960 Labial veneer (resin laminate) - chairside
D2961 Labial veneer (resin laminate) - laboratory
D2962 Labial veneer (porcelain laminate) - laboratory
D2999 Unspecified restorative procedure, by report
D3331 Treatment of root canal obstruction; non - surgical access
D3332 Incomplete endodontic therapy; inoperable or fractured tooth
D3333 Internal root repair of perforation defects
D3351 Apexification /recalcification - initial visit (apical closure /calcific repair of perforations,
root resorption, etc.)
D3352 Apexification /recalcification - interim medication replacement (apical closure /calcific
repair of perforations, root resorption, etc.)
D3353 Apexification/recalcification - final visit (includes completed root canal therapy -
apical closure /calcific repair of perforations, root resorption, etc.)
D3460 Endodontic endosseous implant
D3470 Intentional reimplantation (including necessary splinting)
D3910 Surgical procedure for isolation of tooth with rubber dam
D3920 Hemisection (including any root removal), not including root canal therapy
D3950 Canal preparation and fitting of preformed dowel or post
"Filed fee" means the Contract Dentist's fees on file with PMI. Questions regarding these fees should be directed to
PMI's Customer Relations department at (800) 422 -4234.
SCH -C
S- C- CA(508) 32 02012- 0047.3T12 -1.AT
D3999 Unspecified endodontic procedure, by report
D4245 Apically positioned flap .
D4249 Clinical crown lengthening - hard tissue
D4263 Bone replacement graft - first site in quadrant
D4264 Bone replacement graft - each additional site in quadrant .
D4266 Guided tissue regeneration - resorbable barrier, per site .i ,
D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure '
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedure (including donor site surgery)
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area)
D4320 Provisional splinting - intracoronal
D4321 Provisional splinting - extracoronal .
D4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle
into diseased crevicular tissue, per tooth, by report
D4920 Unscheduled dressing change (by someone other than treating dentist)
D4999 Unspecified periodontal procedure, by report
D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth)
D5810 Interim complete denture (maxillary)
D5811 Interim complete denture (mandibular)
D5860 Overdenture - complete, by report
D5861 • Overdenture - partial, by report
D5862 Precision attachment, by report
D5867 Replacement of replaceable part of semi - precision or precision attachment (male or female component)
D5875 Modification of removable prosthesis following implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete) .
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis '
D5919 Facial prosthesis
D5922 Nasal septal prosthesis ,
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement '
D5927 Auricular prosthesis, replacement
• D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement .
. D5931 Obturator prosthesis, surgical
D5932 Obturator prosthesis, definitive
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with guide flange
D5935 Mandibular resection prosthesis without guide flange .
D5936 Obturator prosthesis, interim
•
D5937 Trismus appliance (not for TMD treatment)
D5951 Feeding aid .
D5952 \ Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult,
D5954 Palatal augmentation prosthesis
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim .
D5959 Palatal lift prosthesis, modification .
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator .
D5986 Fluoride gel carrier
' SCH -C
S- C- CA(508) , 33 02012- 0047.3T12 -1.AT .
•
•
b ♦ • •
D5987 Commissure splint •
D5988 Surgical splint •
D5999 Unspecified maxillofacial prosthesis, by report
. D6010 Surgical placement of implant body: endosteal implant
D6020 Abutment placement or substitution: endosteal implant
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
D6055 Dental implant supported connecting bar
D6056 Prefabricated abutment •
D6057 Custom abutment
D6058 Abutment supported porcelain /ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble crown)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain /ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) •
D6068 Abutment supported retainer for porcelain /ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal'FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
• D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, high noble
metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, high noble metal)
D6078 Implant /abutment supported fixed denture for completely edentulous arch
D6079 Implant /abutment supported fixed denture for partially edentulous arch
D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of
prosthesis and abutments and reinsertion of prosthesis
D6090 Repair implant supported prosthesis, by report •
. D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6199 Unspecified implant procedure, by report
D6545 Retainer - cast metal for resin bonded fixed prosthesis •
D6548 Retainer - porcelain /ceramic for resin bonded fixed prosthesis
D6783 Crown - % porcelain /ceramic
D6920 Connector bar
D6950 Precision attachment
D6975 Coping - metal
D6999 Unspecified, fixed prosthodontic procedure, by report
D7260 Oroantral fistula closure
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and /or
stabilization)
D7280 Surgical exposure of impacted or unerupted tooth for orthodontic reasons
(including orthodontic attachments) -
D7281 Surgical exposure of impacted or unerupted tooth to aid eruption •
D7285 Biopsy of oral tissue - hard (bone, tooth)
D7290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy, by report
D7340 Vestibuloplasty - ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - ridge, extension (including soft tissue grafts, muscle reattachment, revision
of soft tissue attachment and management of hypertrophied and hyperplastic tissue)
D7410 Radical excision - lesion diameter up to 1.25 cm
D7420 Radical excision - lesion diameter greater than 1.25 cm
D7430 Excision of benign tumor - lesion diameter up to 1.25 'cm
D7431 Excision of benign tumor - lesion diameter greater than 1.25 cm
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm
SCH -C
S- C- CA(508) 34 02012-0047.3T12-1.AT
• •
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm
D7450 Removal of odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451 Removal of odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7460 Removal of nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7461 Removal of nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7465 Destruction of lesion(s) by physical or chemical method, by report
D7480 Partial ostectomy (guttering or saucerization)
D7490 Radical resection of mandible with bone graft
D7520 Incision and drainage of abscess - extraoral soft tissue
D7530 Removal of foreign body, skin, or subcutaneous alveolar tissue
D7540 Removal of reaction - producing foreign bodies, musculoskeletal system
D7550 Sequestrectomy for osteomyelitis
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
D7610 Maxilla - open reduction (teeth immobilized, if present)
D7620 Maxilla - closed reduction (teeth immobilized, if present)
D7630 Mandible - open reduction (teeth immobilized, if present)
D7640 Mandible - closed reduction (teeth immobilized, if present)
D7650 Malar and /or zygomatic arch - open reduction
D7660 Malar and /or zygomatic arch - closed reduction
D7670 Alveolus - stabilization of teeth, 'closed reduction splinting
D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches
D7710 Maxilla - open reduction
D7720 Maxilla - closed reduction
D7730 Mandible - open reduction
D7740 Mandible - closed reduction
D7750 Malar and /or zygomatic arch - open reduction
D7760 Malar and /or zygomatic arch - closed reduction
D7770 Alveolus - stabilization of teeth, open reduction splinting
D7780 Facial bones - complicated reduction with fixation and multiple surgical approaches
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with /without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction •
D7860 ' Arthrotomy
D7865 Arthoplasty
D7870 Arthrocentesis
D7871 Non - arthroscopic lysis and lavage
D7872 Arthroscopy - diagnosis, with or without biopsy •
D7873 Arthroscopy - surgical: lavage and lysis of adhesions
D7874 Arthroscopy - surgical: disc repositioning and stabilization
D7875 Arthroscopy - surgical: synovectomy
D7876 Arthroscopy - surgical: discectomy
D7877 Arthroscopy - surgical: debridement
D7880 Occlusal orthotic device, by report
D7899 Unspecified TMD therapy, by report
D7910 Suture of recent small wounds up to 5 cm
D7911 Complicated suture - up to 5 cm
D7912 Complicated suture - greater than 5 cm
D7920 Skin grafts (identify defect covered, location and type of graft)
D7940 Osteoplasty - for orthognathic deformities
D7941 Osteotomy - mandibular rami
D7943 Osteotomy - mandibular rami with bone graft; includes obtaining bone graft
D7944 Osteotomy - segmented or subapical - per sextant or quadrant
D7945 Osteotomy - body of mandible
D7946 LeFort I (maxilla - total)
D7947 LeFort I (maxilla - segmented)
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) -
without bone graft
SCH -C
S- C- CA(508) 35 02012- 0047.3T12 -1.AT
• .
D7949 LeFort II or LeFort III - with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones -
autogenous or nonautogenous, by report
D7955 Repair of maxillofacial soft and hard tissue defect
D7970 Excision of hyperplastic tissue - per arch
D7971 Excision of pericoronal gingiva
D7980 Sialolithotomy •
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
• D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft - mandible or facial bones, by report
D7996 Implant - mandible for augmentation purposes (excluding alveolar ridge), by report
D7997 Appliance removal ( not by dentist who placed appliance), includes removal of archbar
D7999 Unspecified oral surgery procedure, by report
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
D8670 Periodic orthodontic treatment visit (as part of contract)
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
D8692 Replacement of lost or broken retainer
D8999 Unspecified orthodontic procedure, by report
D9210 Local anesthesia not in conjunction with operative or surgical procedures
D9220 General anesthesia - first 30 minutes
D9221 General anesthesia - each additional 15 minutes
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide
D9241 Intravenous sedation /analgesia - first 30 minutes
D9242 Intravenous sedation /analgesia, each additional 15 minutes
D9248 Non - intravenous conscious sedation
D9410 House /extended care facility call
D9420 Hospital call
D9610 Therapeutic drug injection, by report
D9630 Other drugs and /or medicaments, by report
D9910 Application of desensitizing medicament
D9911 Application of desensitizing resin for cervical and /or root surface, per tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post- surgical) - unusual circumstances, by report
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9950 Occlusion analysis - mounted case
D9951 Occlusal adjustment - limited
D9952 Occlusal adjustment - complete
D9970 Enamel microabrasion
D9971 Odontoplasty 1 -2 teeth; includes removal of enamel projections
D9972 External bleaching - per arch
D9973 External bleaching - per tooth
D9974 Internal bleaching - per tooth
D9999 Unspecified adjunctive procedure, by report
SCH -C
S- C- CA(508) 36 02012- 0047.3T 12 -1.AT
• •
SCHEDULE D
GROUP VARIABLES AND PREMIUMS
A. Group Name: City of Seal Beach
B. Group Number: (See Appendix A)
C. Effective Date: June 1, 2003
D. Contract Term: 19 Months
E. Eligible Present Employees: As defined by the Applicant.
Eligible New Employees: As defined by the Applicant.
F. Premiums per Month:
Plan Type: CA508
California Primary Enrollee: $16.89
California Primary Enrollee Plus
One Dependent Enrollee: $27.87
California Primary Enrollee Plus
Two or More Dependent Enrollees: $41.23
G. Remit Premium Payment to: PMI, Dept. #0170, Los Angeles, California 90084 -0170
Revised 04/11/03 SCH -D
PMI -CA 37 02012- 0047.3T 12 -1.AT
m • •
SCHEDULE E
COBRA CONTINUATION OPTION
Enrollees who lose coverage under this Contract due to certain "Qualifying Events" are entitled to elect
continued coverage at their own expense.
Primary Enrollees and Dependent Enrollees losing coverage due to either of the following Qualifying
Events may elect to continue coverage for 18 months following the month in which the event occurs:
a. A Primary Enrollee's termination of employment (other than for gross misconduct) or;
b. A Primary Enrollee's reduction in work hours to less than any minimum required to be eligible
under this Contract.
A Primary Enrollee who is entitled to continue coverage as a result of Qualifying Event (a) or (b) above
may continue that coverage, for himself or herself and any Dependent Enrollees, for 29 months if the
Primary Enrollee is determined under Title II or Title XVI of the Social Security Act to have been
disabled at the time the Qualifying Event occurred or to have become so disabled within 60 days after
such event occurred. The Primary Enrollee must notify the Applicant during the initial 18 months and
within 60 days after the date of determination, and extended coverage for disability will terminate on
the first day of the month that begins more than 30 days after the date of final determination that the
Primary Enrollee is no longer disabled.
A Dependent Enrollee who has elected to continue coverage because (i) Qualifying Event (a) or (b)
occurred to the Primary Enrollee, and (ii) the Primary Enrollee did not elect continued coverage for that
Dependent Enrollee, and who is or becomes disabled within 60 days after that event, may also continue
coverage, for himself or herself and any other Dependent Enrollees, for 29 months, subject to the notice
and termination requirements described above with respect to the Primary Enrollee.
Dependent Enrollees losing coverage due to any of the following Qualifying Events may elect to
continue coverage for 36 months following the month in which the event occurs:
a. A Primary Enrollee's death;
b. A divorce or legal separation from a Primary Enrollee;
' A dependent child's ceasing to qualify as an Eligible Dependent under this contract; or
d. A Primary Enrollee's qualification for Medicare benefits.
Anyone who is entitled to elect continued coverage based on more than one Qualifying Event will be
limited to continued coverage for a total of 36 months following the date of the first Qualifying Event.
A proceeding in a case under Title 11, United States Code with respect to the Applicant, which results
in a substantial elimination of coverage under this Contract (within one year before or one year after
the date of commencement of the proceeding) of a retired employee (who retired on or before the date
SCH -E
PMI -CA 38 02012-0047.3T12-1.AT
•
�' • •
of substantial elimination of coverage), of the spouse and dependent children of a retired employee, or
of the surviving spouse of a retired employee, is a Qualifying Event, and the individuals losing
coverage may elect to continue coverage until death (in the case of the retired employee or the surviving
spouse of the retired employee) or for 36 months after the death of the retired employee (in the case of
the spouse and dependent children of the retired employee).
The Applicant must be notified within 60 days after a divorce or legal separation, or if a dependent
child loses eligibility. Otherwise, the option of continued coverage based on one of these events will
be lost.
Once aware of a Qualifying Event, the Applicant shall notify the affected persons about their rights to
elect continued coverage. This notice shall include the amount of monthly premium Applicant will
charge them for continued coverage. Qualifying persons must advise Applicant within 60 days after
receiving such notice, or 60 days after losing coverage due to the Qualifying Event, whichever is later.
Persons desiring continued coverage will then have 45 days to pay the initial installment of premiums
which includes the premiums for all months since the Qualifying Event.
Continued coverage is the same as for Enrollees under this Contract. If coverage and or premiums are
modified for Enrollees under this Contract, they will also be modified in the same manner for persons
with continued coverage.
A person's continued coverage elected under this Contract will terminate at the end of the month in
which any of the following events first occurs:
a. The allowable number of months of continued coverage (i.e. 18, 29 or 36 months) expires.
b. This Contract terminates.
c. Premiums are not paid for the person as required.
d. The person becomes eligible for dental benefits under another group health plan (as an
employee or otherwise) which does not contain any exclusion or limitation with respect to any
preexisting condition of such person.
e. The person becomes eligible for Medicare benefits.
Once continued coverage terminates, it cannot be reinstated.
SCH -E
PMI -CA 39 02012- 0047.3T12 -1.AT
•
SCHEDULE F
INFORMATION CONCERNING BENEFITS UNDER THE, DeltaCare PROGRAM
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE
BENEFITS AND IS A SUMMARY ONLY. THE COMBINED EVIDENCE OF COVERAGE
AND DISCLOSURE FORM AND THIS PLAN CONTRACT SHOULD BE CONSULTED
FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
(A) Deductibles None
(B) Lifetime Maximums None
(C) Professional Services An Enrollee may be required to pay a Copayment amount
for each procedure as shown in the Schedule of Benefits and
Copayments, subject to the Limitations and Exclusions.
Copayments range by category of service.
Examples are as follows:
Diagnostic Services No Cost
Preventive Services No Cost - $ 15.00
Restorative Services No Cost - $ 75.00
Endodontic Services No Cost - $ 135.00
Periodontic Services $ 8.00 - $ 200.00
Prosthodontic Services No Cost - $ 110.00
Oral and Maxillofacial Surgery No Cost - $ 65.00
Orthodontic Services No Cost - $1800.00
Adjunctive General Services No Cost - $ 20.00
NOTE: Some services may not be covered. Certain services
may be covered only if provided by specified providers, or
may be subject to an additional charge.
Limitations apply to the frequency with which some services
may be obtained. For example: cleanings are limited to once
in each 6 month period; replacement of complete dentures,
crowns and bridges is limited to once in any 5 year period;
sealant benefits are available only once in any 3 years.
(D) Outpatient Services Not Covered
(E) Hospitalization Services Not Covered
(F) Emergency Health Coverage The Enrollee may receive a maximum Benefit of up to $100
during each 12 months for out -of -area emergency services.
(G) Ambulance Services Not Covered
(H) Prescription Drug Services Not Covered
(I) Durable Medical Equipment Not Covered
(J) Mental Health Services Not Covered
(K) Chemical Dependency Services Not Covered
(L) Home Health Services Not Covered
(M) Other Not Covered
Each individual procedure within each category listed above, and which is covered under the
Program has a specific Copayment, which is shown in Schedule A, Description of Benefits and
Copayments, in the Combined Evidence of Coverage and Disclosure Form and this Contract.
SCH -F -508
PMI -CA 40 02012-0047.3T12-1.AT
J u • v .
cy 04-
•
APPENDIX A
Group # Group Name
02012 -0047 City of Seal Beach
02012 -0055 City of Seal Beach - COBRA
APPENDIX
PMI -CA 41 02012- 0047.3T12 -1.AT
•
•
•
PRIVATE MEDICAL -CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924 -8311 (800) 801 -7105
•
• AMENDMENT
TO
•
DeltaCare GROUP DENTAL SERVICE CONTRACT
THIS AGREEMENT is made by and between PRIVATE MEDICAL -CARE, INC. and City of
Seal Beach, DeltaCare Group #02012 - 0047 & #02012 -0055 (COBRA), for the purpose of amending the
original Group Dental Service Contract effective January 1, 2005 as follows:
1. Article 1, DEFINITIONS, Paragraph 1.22 through 1.24, shall be amended to read:
1.22 "Registered Domestic Partners" are defined as same sex partners, who are both at least
18 years of age or older, and opposite sex partners when one or both partners are over
the age of 62 and entitled to Social Security benefits. Registered Domestic Partners are
• required to register with the Secretary of State of the State of California a Declaration of
Domestic Partnership. A Registered Domestic Partner is subject to the same terms and
conditions as any other dependent enrolled under this Contract. Registered Domestic
Partners are eligible for continuation of coverage under COBRA.
1.23 • "Special Health Care Need," means a physical or mental impairment, limitation or
condition that substantially interferes with an Enrollee's ability to obtain Benefits.
Examples of such a Special Health Care Need are (i) the Enrollee's inability to obtain
access to the assigned Contract Dentist's facility because of a physical disability and (ii)
the Enrollee's inability to comply with the Contract Dentist's instructions during
examination or treatment because of physical disability or mental incapacity.
1.24 "Specialist Services" mean services performed by a Dentist who specializes in the
practice of oral surgery, endodontics, pediatric dentistry or periodontics and which must
be preauthorized in writing by PMI.
2. Article 2, ELIGIBILITY, ENROLLMENT AND CANCELLATION OF ENROLLMENT,
Item 2.01 shall be amended as follows:
2.01 Eligible Employees are those employees or group members described in Schedule -D.
New employees shall become eligible for coverage as specified in Schedule D.
Eligible Dependents of an Eligible Employee are spouse (unless legally separated or
divorced) or Registered Domestic Partner (until such partnership is terminated by either
or both parties) and unmarried dependent children from birth to age 19, or to age 23
while enrolled as full -time students in an accredited school, college or university,
• provided that the student is chiefly dependent upon the Eligible Employee for
maintenance and support. Children include step - children, adopted children, foster
children and children of a Registered Domestic Partner, provided such children are
dependent upon the employee for support and maintenance. Dependents become
eligible coincident with the Eligible Employee, upon attainment of dependent status, or
at any time subject to a change in legal custody or lawful order to provide Benefits.
Newborn infants are eligible from and after the moment of birth. Adopted children are
eligible from and after the moment the child is placed in the physical custody of the •
Eligible Employee for adoption.
04/25/2005 Page 2 of 2 02012- 0047.AD
•
•
An unmarried dependent 19 years or over may continue to be eligible as a dependent if
incapable of self - support because of physical or mental disability that commenced prior
to reaching age 19, or prior to reaching age 23 while enrolled as a full-time student in an
accredited school, college or university, and if chiefly dependent on the Eligible
Employee for support and maintenance, provided proof of such disability and
dependency is submitted not less than 31 days prior to the dependent's attainment of
the limiting age, and subsequently as may be required by either PMI or Applicant, but
not more frequently than annually after the disabled and dependent child has attained
the limiting age.
Dependents in military service are not eligible. No one may be an Eligible Dependent if
eligible as an Eligible Employee and no one may be an Eligible Dependent of more
than one Eligible Employee.
Medicare eligibility shall not affect eligibility of an Eligible Employee or Eligible
Dependent.
•
3. Schedule E, COBRA CONTINUATION OPTION, first paragraph, shall be amended as follows:
Enrollees who lose coverage under this Contract due to certain "Qualifying Events" are entitled to
elect continued coverage at their own expense. Registered Domestic Partners and their children are
eligible for COBRA coverage.
All other aspects of the Group Dental Service Contract currently in effect remain the same.
IN WITNESS WHEREOF the parties have executed this Contract and have affixed their signatures on
the 7 (1t4 day of 5(fp, u , 2005.
• City of Seal Beach PRIVATE MEDICAL -CARE, INC.
DeltaCare Group #02012 -0047 & 02012 -0055 (COBRA)
•
By: � hgA661- AYAZ�� 04/22/05 ���( B : �,0. rah a�
G'1 y
Signature and e Sigt4ture and Date
211 8th Street Vice President, Research
Address Title
Seal Beach CA 90740
City State Zip
•
04/25/2005 Page 2 of 2 02012- 0047.AD
•
•
AMENDMENT NO. 1 TO AGREEMENT
GROUP #7809
AGREEMENT dated January 1, 2005, between CITY OF SEAL BEACH and DELTA DENTAL
OF CALIFORNIA "Delta," is hereby amended, effective January 1, 2005, as follows:
•
Paragraph 2.4 is amended to read:
2.4 Dependents are the Primary Enrollee's legal spouse or registered domestic partner
and unmarried dependent children from birth to age 19, or to age 23 if enrolled as
full -time students in an accredited school, college or university. Children include
stepchildren, children of a registered domestic partner, adopted children, children
placed for adoption and foster children, provided they depend upon the Primary
Enrollee for support and maintenance. The Dependents of Primary Enrollees are
eligible to enroll on the same date that the employee, of whom they are a
Dependent, becomes a Primary Enrollee. Later - acquired Dependents become eligible
as soon as they acquire dependent status.
Registered domestic partners are defined as same sex partners, who are both at least
18 years of age and opposite sex partners when one or both partners are over the age
of 62 and entitled to Social Security Benefits. Registered domestic partners are
required to register with the Secretary of State of the State of California a Declaration
of Domestic Partnership. A registered domestic partner is subject to the same terms
and conditions as any other Dependent enrolled under this Contract. Registered
domestic partners are eligible for continuation of coverage under COBRA.
DATED: April 6, 2005
CITY OF SEAL BEACH: DELTA DENTAL OF CALIFORNIA:
By. 41
.0.-- By: (
MavA60 - 1,1L Vice President, Sales
et. Z
By: By:
Vice President
Underwriting & Actuarial
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• Delta Dental PPO Plan
For Employees of
CITY OF SEAL BEACH
Group No. 7809
Effective Date: January 1, 2007
• •
USING THIS BOOKLET
•
This booklet has been written with you in mind. It is designed to help you make the most of your Delta
Dental plan. This combined Evidence of Coverage/Disclosure form discloses the terms and conditions of
your coverage.
The Combined Evidence of Coverage/Disclosure form should be read completely and carefully and
individuals with special health care needs should read carefully those sections that apply to them (see
CHOICE OF DENTISTS AND PROVIDERS section). You have a right to review it prior to your enrollment.
Please read the "DEFINITIONS" section. It will explain to you any words that have special or technical
meanings under your group Contract. A copy of the Contract will be furnished upon request.
Please read this summary of your dental Benefits carefully. Keep in mind that YOU means the ENROLLEES
whom Delta Dental covers. WE, US and OUR always refers to Delta Dental of California (Delta Dental).
If you have any questions about your coverage that are not answered here, please check with your
personnel office, or with Delta Dental.
DELTA DENTAL OF CALIFORNIA
100 First Street
San Francisco, CA 94105
For claims, eligibility and benefits inquiries, or additional information, call Delta Dental's Customer Service
department toll-free at: 1-800-765-6003 or contact us on our web site: www.deltadentalca.org
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE
CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO
YOU UPON REQUEST
This Combined Evidence of Coverage/Disclosure Form constitutes only a
summary of the dental plan. The dental Contract must be consulted to
determine the exact terms and conditions of coverage.
1
• •
TABLE OF CONTENTS
DEFINITIONS 3
WHO IS COVERED? 4
WHO ARE YOUR ELIGIBLE DEPENDENTS? 4
ENROLLING YOUR DEPENDENTS 5
COVERAGE COSTS 5
WHEN YOU ARE NO LONGER COVERED 5
CANCELING THIS PLAN 5
YOUR BENEFITS 6
LIMITATIONS 7
EXCLUSIONS/SERVICES WE DO NOT COVER 8
OTHER CHARGES 9
COVERED FEES 9
CHOICE OF DENTISTS AND PROVIDERS 10
CONTINUITY OF CARE 11
PUBLIC POLICY PARTICIPATION BY ENROLLEES. 11
INTERNATIONAL DENTIST REFERRAL SERVICE 11
SAVING MONEY ON YOUR DENTAL BILLS 12
YOUR FIRST APPOINTMENT 12
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE 12
PREDETERMINATIONS 12
REIMBURSEMENT PROVISIONS 13
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST 14
SECOND OPINIONS 14
ORGAN AND TISSUE DONATION 15
GRIEVANCE PROCEDURE AND CLAIMS APPEAL 15
IF YOU HAVE ADDITIONAL COVERAGE 16
OPTIONAL CONTINUATION OF COVERAGE (COBRA) 16
NOTICE OF PRIVACY PRACTICES: Confidentiality of your health care information 19
2
• •
DEFINITIONS
Certain words that you will see in this booklet have specific meanings. These definitions should make your
dental plan easier to understand.
Benefits - those dental services available under the Contract and which are described in this booklet.
Contract - the written agreement between your employer or sponsoring group and Delta Dental to
provide dental Benefits. The Contract, together with this booklet, forms the terms and conditions of the
Benefits you are provided.
Covered Services - those dental services to.which Delta Dental will apply Benefit payments, according to
the Contract.
Delta Dental PPO Dentist - a Dentist with whom Delta Dental has a written agreement to provide
services at the in-network level for Enrollees in this Delta Dental PPO Plan.
Delta Dental Dentist - a Dentl3t-who has signed an agreement with Delta Dental or a Participating Plan,
agreeing to provide services under the terms and conditions established by Delta Dental or the
Participating Plan.
Dependent - a Primary Enrollee's Dependent who is eligible to enroll for Benefits in accordance with the
conditions of eligibility outlined in this booklet.
Effective Date - the date this plan starts.
Enrollee - A Primary Enrollee or Dependent enrolled to receive Benefits or a person who chooses to pay
for OPTIONAL CONTINUATION OF COVERAGE.
•
Maximum - the greatest dollar amount Delta Dental will pay for covered procedures in any calendar year
and lifetime for Orthodontic Benefits.
Participating Plan - Delta Dental and any other member of the Delta Dental Plans Association with
whom Delta Dental contracts for assistance in administering your Benefits.
Premiums - the money paid to Delta Dental each month for you and your Dependents' dental coverage.
Primary Enrollee - any group member or employee who is eligible to enroll for Benefits in accordance
with the conditions of eligibility outlined in this booklet.
Single Procedure - a dental procedure to which a separate Procedure Number has been assigned by the
American Dental Association in the current version of Common Dental Terminology (CDT).
Usual, Customary and Reasonable (UCR) -
A Usual fee is the amount which an individual dentist regularly charges and receives for a given service or
the fee actually charged, whichever is less.
A Customary fee is within the range of usual fees charged and received for a particular service by dentists
of similar training in the same geographic area.
A Reasonable fee schedule is reasonable if it is Usual and Customary. Additionally, a specific fee to a
specific patient is reasonable if it is justifiable considering special circumstances, or extraordinary
difficulty, of the case in question.
3
• •
WHO IS COVERED?
All regular employees are required to enroll and will become eligible to receive Benefits on the first day of
the month following 30 days of continuous full-time employment.
Retirees residing out of state are eligible for this plan and will received the Delta Dental PPO in-network
level of Benefits.
You are not eligible if you are not reporting to work on a regular basis and are not actively employed.
Coverage resumes on the first day of the month after you return to active employment, report to work
regularly and amounts due to Delta Dental for coverage have been paid. But, coverage can continue
without interruption if your employer continues to report you as a Primary Enrollee and amounts due Delta
Dental for your coverage continue to be paid.
Coverage is reinstated on the day employment is resumed for Enrollees that are members of the National
Guard or a military reserve unit absent from work due to active military duty. Any waiting period applied
as a result of ai Enrollee's absence from active employment due to service in the National Guard or
military reserve unit shall be waived.
Family and Medical Leave Act of 1993
You can continue your coverage if you take a leave governed by the Family and Medical Leave Act of
1993. If you do not continue your coverage during the governed leave, it will be reinstated at the same
Benefit level you received before your leave.
Uniformed Services Employment and Re-employment Rights Act of 1994
You can continue coverage for up to 24 months, if you take a leave governed by the Uniformed Services
Employment and Re-employment Rights Act of 1994. If you make this election, you must submit any
Premiums necessary, which may include administrative costs, to your employer. If you do not continue your
coverage during a military leave, it will be reinstated at the same Benefit level you received before your
leave.
WHO ARE YOUR ELIGIBLE DEPENDENTS?
• Your legal spouse or registered domestic partner, as defined below;
• Your unmarried dependent children until their 19th birthday;
• Your unmarried dependent children until their 23rd birthday if enrolled full-time in an accredited
school, college or university;
• An unmarried dependent child aged 19 or older who is incapable of self-support because of a physical
or mental handicap that occurred before he or she turned 19, if the child is mostly dependent on you
for support. Proof of this handicap must be given to Delta or your employer within 31 days, if it is
requested. Proof will not be required more than once a year after the child has reached age 21.
"Dependent children" also means stepchildren, adopted children, children of a registered domestic partner,
children placed for adoption and foster children, provided that they are dependent upon you for support
and maintenance.
Registered domestic partners are defined as same sex partners, who are both at least 18 years of age and
opposite sex partners when one or both partners are over the age of 62 and entitled to Social Security
benefits. Registered domestic partners are required to register with the Secretary of State of the State of
California a Declaration of Domestic Partnership. A registered domestic partner is subject to the same
terms and conditions as any other Dependent enrolled under this Contract. Registered domestic partners
are eligible for continuation of coverage under COBRA.
4
• •
Dependent coverage is also extended to any child who is recognized under a Qualified Medical Child
Support Order (QMCSO).
No Dependent in the military service is eligible.
ENROLLING YOUR DEPENDENTS
A payroll deduction is required for your enrolled Dependents. Your group can only provide coverage for
your Dependents if at least half of the Primary Enrollees who have Dependents enroll all of them in this
plan.
Your Dependents must be enrolled when you first become eligible or on the first day of the month after
they become Dependents. However, Dependents who are covered under another group dental plan are not
required to enroll under this Delta Dental plan. If the other coverage ends, the Dependents may enroll
under this plan within 30 days of the loss of the other coverage. Proof of prior coverage is required.
Dependent children up to four years of age may be enrolled at the beginning of any Contract year
including the Contract year immediately following their fourth birthday. If you drop coverage for your
Dependents, you may not re-enroll them in this plan.
COVERAGE COSTS
Your employer pays Delta Dental a monthly Premium for coverage of you and your enrolled Dependents.
You do not pay for your own coverage, but a payroll deduction is made for your share of the monthly
Premium required for your Dependent's coverage. Your employer can tell you how much you must
contribute for the costs of dependent coverage.
The amount of the Premium may change at each renewal of the Contract between your employer and
Delta Dental. Premiums will not increase during the contract year unless new taxes or tax rates are
imposed upon Delta Dental for this plan or unless there is an agreement between your employer and Delta
Dental to change the Premiums.
WHEN YOU ARE NO LONGER COVERED
1. If you stop working for your employer, your dental coverage will end on the last day of the month
in which you stop working, unless you qualify for and pay for OPTIONAL CONTINUATION OF
COVERAGE. Your Dependents' coverage ends when yours does, or as soon as they are no longer
Dependents, unless they choose to pay for OPTIONAL CONTINUATION OF COVERAGE.
2. When the Contract between Delta Dental and your employer is discontinued or canceled, your
coverage ends immediately.
CANCELING THIS PLAN
Delta Dental may cancel this plan only on an anniversary date (period after the plan first takes effect or at
the end of each renewal period thereafter), or:
1. If your employer does not make payment to Delta Dental as required by the Contract;
2. If fewer than 10 people are reported eligible for three months or more;
3. If your employer does not give Delta Dental a list of who is eligible;
4. If your employer does not allow Delta Dental to inspect its records, if this is required by your group
Contract.
5
•
If you believe that this plan has been terminated or not renewed due to your health status or
requirements for health care services (or that of your Dependents), you may request a review by the
California Director of the Department of Managed Health Care.
If the Contract is terminated for any cause, Delta Dental is not required to predetermine services beyond
the termination date or to pay for services provided after the termination date, except for Single
Procedures begun while the Contract was in effect which are otherwise Benefits under the Contract.
If this plan is canceled, you and your Dependents have no right to renewal or reinstatement of your
Benefits.
YOUR BENEFITS
Your dental plan covers several categories of Benefits, when the services are provided by a licensed
dentist, and when they are necessary and customary under the generally accepted standards of dental
practice.
Delta Dental will provide payment for these services at the percentage indicated up to a Maximum of
$2,000 for each Enrollee in each calendar year.
Payment for Orthodontic Benefits for dependent children is limited to a lifetime Maximum of $1,000.
An agreement between your employer and Delta Dental is required to change Benefits during the term of
the Contract.
The following Benefits are limited to the applicable percentages of dentist's fees or allowances specified
below. You are required to pay the balance of any such fee or allowance, known as the "patient
copayment." If the dentist discounts, waives or rebates any portion of the patient copayment to the
Enrollee, Delta Dental only provides as Benefits the applicable allowances reduced by the amount that
such fees or allowances are discounted, waived or rebated.
I. DIAGNOSTIC AND PREVENTIVE BENEFITS
100% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Diagnostic - oral exa minations (including initial examinations, periodic examinations and
emergency examinations); x-rays; diagnostic casts; examination of biopsied tissue; palliative
(emergency) treatment of dental pain; specialist consultation
Preventive - prophylaxis (cleaning); fluoride treatment; space maintainers
II. BASIC BENEFITS
80% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Oral surgery - extractions and certain other surgical procedures, including pre- and post-operative
care
Restorative - amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious
lesions (visible destruction of hard tooth structure resulting from the process of dental decay)
Endodontic - treatment of the tooth pulp
Periodontic - treatment of gums and bones that support the teeth
Sealants - topically applied acrylic, plastic or composite material used to seal developmental
grooves and pits in teeth for the purpose of preventing dental decay
6
• •
Adjunctive General Services - general anesthesia; office visit for observation; office visit after
regularly scheduled hours; therapeutic drug injection; treatment of post-surgical complications
(unusual circumstances); limited occlusal adjustment
III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Crowns, Inlays, Onlays and Cast Restorations are Benefits only if they are provided to treat cavities
which cannot be restored with amalgam, silicate or direct composite (resin) restorations.
IV. PROSTHODONTIC BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Construction or repair of fixed bridges, partial dentures and complete dentures are Benefits if
provided to replace missing, natural teeth.
V. ORTHODONTIC BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Procedures using appliances or surgery to straighten or realign teeth, which otherwise would not
function properly.
LIMITATIONS
1. Only the first two oral examinations, including office visits for observation and specialist
consultations, or combination thereof, in a calendar year are Benefits while you are eligible under
any Delta Dental plan.
2. Full-mouth x-rays are Benefits once in a five-year period while you are eligible under any Delta
Dental plan.
3. Bitewing x-rays are provided on request by the dentist, but no more than twice in any calendar
year for children to age 18 or once in any calendar year for adults age 18 and over, while you are
eligible under any Delta Dental plan.
4. Diagnostic casts are a Benefit only when made in connection with subsequent orthodontic
treatment covered under this plan.
5. Only the first two cleanings, fluoride treatments, or Single Procedures which include cleaning, or
combination thereof, in any calendar year are Benefits while you are eligible under any Delta
Dental plan.
6. Sealant Benefits include the application of sealants only to permanent first molars through age
eight and second molars through age 15 if they are without caries (decay) or restorations on the
occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any
tooth within two years of its application.
7. Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of
bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta
Dental's payment is limited to the cost of the equivalent amalgam restorations.
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8. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five
years, while you are a patient under any Delta Dental plan, unless Delta Dental determines that
replacement is required because the restoration is unsatisfactory as a result of poor quality of care,
or because the tooth involved has experience extensive loss or changes to tooth structure or
supporting tissues since the replacement of the restoration.
9. Prosthodontic appliances are Benefits only once every five years, while you are eligible under any
Delta Dental plan, unless Delta Dental determines that there has been such an extensive loss of
remaining teeth or a change in supporting tissues that the existing appliance cannot be made
satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental plan will
be made if it is unsatisfactory and cannot be made satisfactory.
10. Delta Dental will pay the applicable percentage of the dentist's fee for a standard partial or
complete denture. A standard partial or complete denture is defined as a removable prosthetic
appliance provided to replace missing natural, permanent teeth that are made from accepted
materials and by conventional methods.
11. Implants (appliances inserted into bone or soft tissue in the jaw, usually to anchor a denture) are
not covered by your plan. However, if implants are provided along with a revered prosthodontic
appliance, Delta Dental will allow the cost of a standard partial or complete denture toward the cost
of the implants and the prosthodontic appliances when the prosthetic appliance is completed. If
Delta Dental makes such an allowance, we will not pay for any replacement for five years following
the completion of the service.
12. If you select a more expensive plan of treatment than is customarily provided, or specialized
techniques, an allowance will be made for the least expensive, professionally acceptable,
alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee for the
customary or standard treatment and you are responsible for the remainder of the dentist's fee.
For example: a crown where an amalgam filling would restore the tooth; or a precision denture
where a standard denture would suffice.
13. Orthodontic coverage is limited to eligible dependent children.
14. If orthodontic treatment is begun before you become eligible for coverage, Delta Dental's payments
will begin with the first payment due to the dentist following your eligibility date.
15. Delta Dental's orthodontics payments will stop when the first payment is due to the dentist
following either a loss of eligibility, or if treatment is ended for any reason before it is completed.
16. X-rays and extractions that might be necessary for orthodontic treatment are not covered by
Orthodontic Benefits, but may be covered under Diagnostic and Preventive or Basic Benefits.
17. Delta Dental will pay the applicable percentage of the Dentist's fee for a standard orthodontic
treatment plan involving surgical and/or non-surgical procedures. If you select specialized
orthodontic appliances or procedures chosen for aesthetic considerations an allowance will be made
for the cost of a standard orthodontic treatment plan and you are responsible for the remainder of
the Dentist's fee.
EXCLUSIONS/SERVICES WE DO NOT COVER
Delta Dental covers a wide variety of dental care expenses, but there are some services for which we do
not provide Benefits. It is important for you to know what these services are before you visit your dentist.
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Delta Dental does not provide benefits for:
1. Services for injuries or conditions that are covered under Workers' Compensation or Employer's
Liability Laws.
2. Services that are provided to the Enrollee by any Federal or State Governmental Agency or are
provided without cost to the Enrollee by any municipality, county or other political subdivision,
except Medi-Cal benefits.
3. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental
defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and
teeth that are discolored or lacking enamel.
4. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for
rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for
stabilizing the teeth. Exa mples of such treatment are equilibration and periodontal splinting.
5. Any Single Procedure, bridge, denture or other prosthodontic service that was started before the
Enrollee was covered by this plan.
6. Prescribed drugs, or applied therapeutic drugs, premedication or analgesia.
7. Experimental procedures.
8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by
the Dentist for treatment in any such facility.
9. Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures.
10. Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts").
11. Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants,
except as provided under LIMITATIONS.
12. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw)
joints or associated muscles, nerves or tissues.
13. Replacement of existing restoration for any purpose other than active tooth decay.
14. Intravenous sedation, occlusal guards and complete occlusal adjustment.
15. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this plan.
OTHER CHARGES
Delta Dental's co-payment for your Benefits is shown in this Evidence of Coverage under the caption titled
"YOUR BENEFITS." If dental services are provided by a Delta Dental Dentist or a Delta Dental PPO Dentist,
you are responsible for your co-payment only. If the dental services you receive are provided by a dentist
who is not a Delta Dental Dentist or Delta Dental PPO Dentist, you are responsible for the difference
between the amount Delta Dental pays and the amount charged by the non-Delta Dental dentist.
COVERED FEES
It is to your advantage to select a dentist who is a Delta Dental Dentist, since a lower percentage of the
dentist's fees may be covered by this plan if you select a dentist who is not a Delta Dental Dentist.
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S
A list of Delta Dental Dentists (see DEFINITIONS) is available in a directory at your group benefits office,
or by calling 1-800-765-6003.
Payment to a Delta Dental PPO Dentist will be based on the applicable percentage of the lesser of the Fee
Actually Charged, the dentist's accepted Usual, Customary and Reasonable Fee on file with Delta Dental,
or a fee which the dentist has contractually agreed upon with Delta Dental to.accept for treating enrollees
under this plan.
Payment to a Delta Dental Dentist will be based on the applicable percentage of the lesser of the Fee
Actually Charged, or the accepted fee that the dentist has on file with Delta Dental.
Payment for services by a California dentist, or an out-of-state dentist, who is not a Delta Dental Dentist
will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee that
satisfies the majority of Delta Dental Dentists.
Payment for services by a dentist located outside the United States will be based on the applicable
percentage of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental
dentists.
CHOICE OF DENTISTS AND PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT
GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Nearly 23,400 dentists in active practice in California are Delta Dental Dentists. About 12,300 of these
Delta Dental Dentists are also Delta Dental PPO Dentists. You are free to choose any dentist for treatment,
but it is to your advantage to choose a Delta Dental Dentist. This is because his or her'fees are approved
in advance by Delta Dental. Delta Dental Dentists have treatment forms on hand and will complete and
submit the forms to Delta Dental free of charge.
If you choose a Delta Dental PPO Dentist, you will receive all of the advantages of going to a Delta Dental
Dentist, and you may have a higher level of Benefits for certain services.
If you go to a non-Delta Dental Dentist, Delta Dental cannot assure you what percentage of the charged
fee may be covered. Claims for services from non-Delta Dental Dentists may be submitted to Delta Dental
at P.O. Box 997330, Sacramento, CA 95899-7330.
Dentists located outside the United States are not Delta Dental Dentists. Claims submitted by out-of-
country dentists are translated by Delta Dental staff and the currency is converted to U.S. dollars. Claims
submitted by out-of-country dentists for patients residing in California are referred to Delta Dental's
Quality Review department for processing. Delta Dental may require a clinical examination to determine
the quality of the services provided, and Delta Dental may decline to reimburse you for Benefits if the
services are found to be unsatisfactory.
A list of Delta Dental PPO Dentists and Delta Dental Dentists can be obtained by calling 1-800-765-6003.
This list will identify those dentists who can provide care for individuals who have mobility impairments or
have special health care needs. You can obtain specific information about Delta Dental PPO Dentists and
Delta Dental Dentists by using our web site - www.deltadentalca.orq or calling the Delta Dental Customer
Service department at the number listed on page 1. A printed list of the Delta Dental PPO Dentists and
Delta Dental Dentists in your area is also available by calling 1-800-765-6003.
Services from dental school clinics may be provided by students of dentistry or instructors who are not
licensed by the state of California.
Delta Dental shares the public and professional concern about the possible spread of HIV and other
infectious diseases in the dental office. However, Delta Dental cannot ensure your dentist's use of
precautions against the spread of such diseases, or compel your dentist to be tested for HIV or to disclose
test results to Delta Dental, or to you. Delta Dental informs its panel dentists about the need for clinical
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precautions as recommended by recognized health authorities on this issue. If you should have questions
about your dentist's health status or use of recommended clinical precautions, you should discuss them
with your dentist.
CONTINUITY OF CARE
Current Enrollees:
Current Enrollees may have the right to the benefit of completion of care with their terminated Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of
your terminated Delta Dental Dentist. We are not required to continue your care with that dentist if you
are not eligible under our policy or if we cannot reach agreement with your terminated Delta Dental
Dentist on the terms regarding your care in accordance with California law.
New Enrollees:
A new Enrollee may have the right to the qualified benefit of completion_of care with their non-Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of
your current provider. We are not required to continue your care with that dentist if you are not eligible
under our policy or if we cannot reach agreement with your non-Delta Dental Dentist on the terms
regarding your care in accordance with California law. This policy does not apply to new enrollees of an
individual subscriber contract.
PUBLIC POLICY PARTICIPATION BY ENROLLEES
Delta Dental's Board of Directors includes Enrollees who participate in establishing Delta Dental's public
policy regarding Enrollees through periodic review of Delta Dental's Quality Assessment program reports
and communications from Enrollees. Enrollees may submit any suggestions regarding Delta Dental's public
policy in writing to: Delta Dental of California, Customer Service Department, P. O. Box 997330,
Sacramento, CA 95899-7330.
INTERNATIONAL DENTIST REFERRAL SERVICE
You can receive your covered dental care when you are outside of the United States through a partnership
between Delta Dental and International SOS Assistance, Inc. I-SOS provides referrals to 3,200 dentist or
dental clinics in nearly 200 countries worldwide. English-speaking operators are available around the
clock to help you find a dentist. For more information, check our web site at www.deltadentalca.org or
call (800) 523-6586 from the US. Once you leave the US, you can call I-SOS at (215) 942-8226—collect.
When you see an I-SOS dentist, you must pay for your treatment at the time of service and get a detailed
receipt from the dentist. In addition to providing the dentist's name and address (including country), this
receipt should describe the services performed by the dentist and indicate the tooth or teeth that were
treated. It should also indicate whether the dentist's charges were billed in U.S. dollars or another
currency.
Once we receive your claim, we will reimburse you subject to the terms and conditions of your Delta
Dental coverage. Reimbursement is based on the out-of-network benefit provided through your group
plan. As with any dental plan, this reimbursement may not cover the entire cost of the treatment
rendered.
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SAVING MONEY ON YOUR DENTAL BILLS
You can keep your dental expenses down by practicing the following:
1. Compare the fees of different dentists;
2. Use a Delta Dental Dentist;
3. Have your dentist obtain predetermination from Delta Dental for any treatment over $300;
4. Visit your dentist regularly for checkups;
5. Follow your dentist's advice about regular brushing and flossing;
6. Avoid putting off treatment until you have a major problem; and
7. Learn the facts about overbilling. Under this plan, you must pay the dentist your copayment share
(see YOUR BENEFITS). You may hear of some dentists who offer to accept insurance payments as
"full payment."—You should know that these dentists may do so by overcharging your plan and
may do more work than you need, thereby increasing plan costs. You can help keep your dental
Benefits intact by avoiding such schemes.
YOUR FIRST APPOINTMENT
During your first appointment, be sure to give your dentist the following information:
1. Your Delta Dental group number (on the front of this booklet);
2. The employer's name;
3. Primary Enrollee's social security number (which must also be used by Dependents);
4. Primary Enrollee's date of birth;
5. Any other dental coverage you may have.
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE
If you or a family member has special needs, you should ask your dentist about accessibility to their office
or clinic at the time you call for an appointment. Your dentist will be able to tell you if their office is
accessible taking into consideration the specific requirements of your needs.
Routine or urgent care may be obtained from any licensed-dentist during their normal office hours. Delta
Dental does not require prior authorization before seeking treatment for urgent or after-hours care. You
may plan in advance, for treatment for urgent, emergency or after-hours care by asking your dentist how
you can contact the dentist in the event you or a family member may need urgent care treatment or
treatment after normal business hours. Many dentists have made prior arrangements with other dentists
to provide care to you if treatment is immediately or urgently needed. You may also call the local dental
society that is listed in your local telephone directory if your dentist is not available to refer you to another
dentist for urgent, emergency or after-hours care.
PREDETERMINATIONS
After an examination, your dentist will talk to you about treatment you may need. The cost of treatment
is something you may want to consider. If the service is extensive and involves crowns or bridges, or if
the service will cost more than $300, we encourage you to ask your dentist to request a predetermination.
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A predetermination does not guarantee payment. It is an estimate of the amount Delta Dental
will pay if you are eligible and meet all the requirements of your plan at the time the treatment
you have planned is completed.
In order to receive predetermination, your dentist must send a claim form to us listing the proposed
treatment. Delta Dental will send your dentist a Notice of Predetermination that estimates how much you
will have to pay. After you review the estimate with your dentist and decide to go ahead with the
treatment plan, your dentist returns the statement to us for payment when treatment has been
completed.
Computations are estimates only and are based on what would be payable on the date the Notice of
Predetermination is issued if the patient is eligible. Payment will depend on the patient's eligibility and the
remaining annual Maximum when completed services are submitted to Delta Dental.
Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you
have any concerns about the predetermination, let us know before treatment begins so your questions can
be answered before you incur any charges.
REIMBURSEMENT PROVISIONS
A Delta Dentist will file the claim for you. You do not have to file a claim or pay Delta Dental's co-payment
for covered services if provided by a Delta Dental Dentist. Delta Dental of California's agreement with our
Delta Dental Dentists makes sure that you will not be responsible to the dentist for any money we owe.
If the covered service is provided by a dentist who is not a Delta Dental Dentist, you are responsible for
filing the claims and paying your dentist. Claims should be filed with Delta Dental of California at P. O. Box
997330, Sacramento, CA 95899-7330 and Delta Dental will reimburse you. However, if for any reason we
fail to pay a dentist who is not a Delta Dental Dentist, you may be liable for that portion of the cost.
Payments made to you are not assignable (in other words, we will not grant requests to pay non-Delta
Dental Dentists directly).
Payment for claims exceeding $500 for services provided by dentists located outside the United States
may, at Delta Dental's option, be conditioned upon a clinical evaluation at Delta Dental's request (see
Second Opinions). Delta Dental will not pay Benefits for such services if they are found to be
unsatisfactory.
Delta Dental does not pay Delta Dental Dentists any incentive as an inducement to deny, reduce, limit or
delay any appropriate service. If you wish to know more about the method of reimbursement to Delta
Dental Dentists, you may call Delta Dental's Customer Service department for more information.
Payment for any Single Procedure that is a Covered Service will only be made upon completion of that
procedure. Delta Dental does not make or prorate payments for treatment in progress or incomplete
procedures. The date the procedure is completed governs the calculation of any Deductible (and
determines when a charge is made against any Maximum) under your plan.
If there is a difference between what your dentist is charging you and what Delta Dental says your portion
should be, or if you are not satisfied with the dental work you have received, contact Delta Dental's
Customer Service department. We may be able to help you resolve the situation.
Delta Dental may deny payment of a claim for services submitted more than 12 months after the date the
services were provided. If a claim is ci?nied due to a Delta Dental Dentist's failure to make a timely
submission, you shall not be liable to that dentist for the amount which would have been payable by Delta
Dental (unless you failed to advise the dentist of your eligibility at the time of treatment).
The process Delta Dental uses to determine or deny payment for services is distributed to all Delta Dental
Dentists. It describes in detail the dental procedures covered as Benefits, the conditions under which
coverage is provided, and the limitations and exclusions applicable to the plan. Claims are reviewed for
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eligibility and are paid according to these processing policies. Those claims which require additional review
are evaluated by Delta Dental's dentist consultants. If any claims are not covered, or if limitations or
exclusions apply to services you have received from a Delta Dental Dentist, you will be notified by an
adjustment notice on the Notice of Payment or Action. You may contact Delta Dental's Customer Service
department for more information regarding Delta Dental's processing policies.
Delta Dental uses a method called "first-in/first-out" to begin processing your claims. The date we receive
your claim determines the order in which processing begins. For example, if you receive dental services in
January and February, but we receive the February claim first, processing begins on the February claim
first.
Incomplete or missing data can affect the date the claim is paid. If all information necessary to complete
claim processing has not been provided, payment could be delayed until any missing or incomplete data is
received by Delta Dental.
Unless the services are exempt, you are required to pay the deductible on the first claim for which
processing is completed in a calendar year. Your deductible is normally paid on the first service subject to
a deductible listed on a claim with multiple services.
The order in which your claims are processed and paid by Delta Dental may also impact your annual
maximum. For example, if a claim with a later date of service is paid and your annual maximum for the
year has been reached then a claim with an earlier date of service in the same calendar year will not be
paid.
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST
If you have questions about the services you receive from a Delta Dental Dentist, we recommend that you
first discuss the matter with your dentist. If you continue to have concerns, call our Quality Review
department at 1-800-765-6003. If appropriate, Delta Dental can arrange for you to be examined-by one
of our consulting dentists in your area. If the consultant recommends the work be replaced or corrected,
Delta Dental will intervene with the original dentist to either have the services replaced or corrected at no
additional cost to you or obtain a refund. In the latter case, you are free to choose another dentist to
receive your full Benefit.
SECOND OPINIONS
Delta Dental obtains second opinions through Regional Consultant members of its Quality Review
Committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate
treatment that is proposed or has been provided.
Delta Dental will authorize such an examination prior to treatment when necessary to make a Benefits
determination in response to a request for a Predetermination of treatment cost by a dentist. Delta Dental
will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of
care provided. Delta Dental will notify the Enrollee and the treating dentist when a second opinion is
necessary and appropriate, and direct the Enrollee to the Regional Consultant selected by Delta Dental to
perform the clinical examination. When Delta Dental authorizes a second opinion through a Regional
Consultant, Delta Dental will pay for all charges.
Enrollees may otherwise obtain second opinions about treatment from any dentist they choose, and claims
for the examination may be submitted to Delta Dental for payment. Delta Dental will pay such claims in
accordance with the Benefits of the plan.
This is only a summary of Delta Dental's policy on second opinions. A copy of Delta Dental's
formal policy is available from Delta Dental's Customer Service department upon request.
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ORGAN AND TISSUE DONATION
Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of
transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants
far exceeds availability. If you are interested in organ donation, please speak to your physician. Organ
donation begins at the hospital when a patient is pronounced brain dead and identified as a potential
organ donor. An organ procurement organization will become involved to coordinate the activities.
GRIEVANCE PROCEDURE AND CLAIMS APPEAL
If you have any questions about the services received from a Delta Dental Dentist, we recommend that
you first discuss the matter with your Dentist. If you continue to have concerns, you may call or write us.
We will provide notifications if any dental services or claims are denied, in whole or part, stating the
specific reason or reasons for denial. Any questions of ineligibility should first be handled directly between
you and your group. If you have any question or complaint regarding the denial of dental services or
claims, the policies, procedures and operations of Delta Dental, or the quality of dental services performed
by a Delta Dental Dentist, you may call us toll-free at 1-800-765-6003, contact us on our web site:
www.deltadentaica.org or write us at P. O. Box 997330, Sacramento, CA 95899-7330, Attention:
Customer Service Department.
If your claim has been denied or modified, you may file a request for review (a grievance) with us within
180 days after receipt of the denial or modification. If in writing, the correspondence must include your
group name and number, the Primary Enrollee's name and social security number, the inquirer's telephone
number and any additional information that would support the claim for benefits. Your correspondence
should also include a copy of the treatment form, Notice of Payment and any other relevant information.
Upon request and free of charge, we will provide the Enrollee with copies of any pertinent documents that
are relevant to the claim, a copy of any internal rule, guideline, protocol, and/or explanation of the
scientific or clinical judgment if relied upon in denyhg or modifying the claim.
Our review will take into account all information, regardless of whether such information was submitted or
considered initially. Certain cases may be referred to one of our regional consultants, to a review
committee of the dental society or to the state dental association for evaluation. Our review shall be
conducted by a person who is neither the individual who made the original claim denial, nor the
subordinate of such individual, and we will not give deference to the initial decision. If the review of a
claim denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a
clinical judgment in applying the terms of the contract terms, we shall consult with a dentist who has
appropriate training and experience. The identity of such dental consultant is available upon request.
We will provide the Enrollee a written acknowledgement within five calendar days of receipt of the request
for review. We will make a written decision within 30 calendar days of receipt of the request for review.
We will respond, within three calendar days of receipt, to complaints involving severe pain and imminent
and serious threat to a patient's health. You may file a complaint with the Department of Managed Health
Care after you have completed Delta Dental's grievance procedure or after you have been involved in
Delta Dental's grievance procedure for 30 calendar days. You may file a complaint with the Department
immediately in an emergency situation, which is one involving severe pain and/or imminent and serious
threat to the Enrollee's health.
The California Department of Managed Health Care is responsible for regulating health care service plans.
If you have a grievance against Delta Dental, your health plan, you should first telephone Delta Dental at
1-800-765-6003 and use Delta Dental's grievance process before contacting the department. Utilizing
this grievance procedure does not prohibit any potential legal rights or remedies that may be available to
you. If you need help with a grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30
calendar days, you may call the department for assistance. You may also be eligible for an Independent
Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of
medical decisions made by a health plan related to the medical necessity of a proposed service or
treatment, coverage decisions for treatments that are experimental or investigational in nature and
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payment disputes for emergency or urgent medical services. The department also has a toll-free
telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech
impaired. The department's Internet Web site ittp://www.hmohelp.ca.gOV) has complaint
forms, IMR application forms and instructions online.
IMR has limited application to your dental program. You may request IMR only if your dental claim
concerns a life-threatening or seriously debilitating condition(s) and is denied or modified because it was
deemed an experimental procedure.
If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the
Enrollee may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for
further review of the claim or if the Enrollee has questions about the rights,under ERISA. The Enrollee may
also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is:
U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue,
N.W. Washington, D.C. 20210.
IF YOU HAVE ADDITIONAL COVERAGE
It is to your advantage to let your dentist and Delta Dental know if you have dental coverage in addition
to this Delta Dental plan. Most dental carriers cooperate with one another to avoid duplicate payments,
but still allow you to make use of both plans - sometimes paying 100% of your dental bill. For example,
you might have some fillings that cost $100. If the primary, carrier usually pays 80% for these services, it
would pay $80. The secondary carrier might usually pay 50% for this service. In this case, since
payment is not to exceed the entire fee charged, the secondary carrier pays the remaining $20 only.
Since this method pays 100% of the bill, you have no out-of-pocket expense.
Be sure to advise your dentist of all plans under which you have dental coverage and have him or her
complete the dual coverage portion of the claim form, so that you will receive all benefits to which you are
entitled. For further information, contact the Delta Dental Customer Service department at the number in
the USING THIS BOOKLET section.
OPTIONAL CONTINUATION OF COVERAGE (COBRA)
Please examine your options carefully before declining this coverage. You should be aware
that companies selling individual health insurance typically require a review of your medical
history that could result in a higher premium or you could be denied coverage entirely.
The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers
having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal-COBRA,
pertaining to employers with two to 19 employees), both require that continued health care coverage be
made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result
of a "Qualifying Event." You may be entitled to continue coverage under this plan, at your expense, if
certain conditions are met. The period of continued coverage depends on the Qualifying Event and
whether you are covered under federal COBRA or Cal-COBRA.
DEFINITIONS
The meaning of key terms used in this section are shown below and apply to both federal and Cal-COBRA.
Qualified Beneficiary means:
1. You and/or your Dependents who are enrolled in the Delta Dental plan on the day before the
Qualifying Event, or
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2. A child who is born to or placed for adoption with you during the period of continued coverage,
provided such child is enrolled within 30 days of birth or placement for adoption.
Qualifying Event means any of the following events which, except for the election of this continued
coverage, would result in a loss of coverage under the dental plan:
Event 1. The termination of employment (other than termination for gross misconduct) or the
• reduction in work hours, by your employer;
Event 2. Your death;
Event 3. Your divorce or legal separation from your spouse;
Event 4. Your Dependents' loss of dependent status under the plan; and
Event 5. As to your Dependents only, your entitlement to Medicare.
You means the Primary Enrollee.
PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying
Event 1 occurs.
This 18-month period can be extended for a total of 29 months, provided:
1. A determination is made under Title II or Title XVI of the Social Security Act that an individual is
disabled on the date of the Qualifying Event or becomes disabled at any time during the first 60
days of continued coverage; and
2. Notice of the determination is given to the employer during the initial 18 months of continued
coverage and within 60 days of the date of termination.
This period of coverage will end on the first day of the month that begins more than 30 days after the
date of the final determination that the disabled individual is no longer disabled. You must notify your
employer or Delta Dental within 30 days of any such determination.
If, during the 18-month continuation period resulting from Qualifying Event 1, your Dependents, who are
Qualified Beneficiaries, experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for
up to a total of 36 months (inclusive of the period continued under Qualifying Event 1).
Your Dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the
occurrence of Qualifying Events 2, 3, 4 or 5.
When an employer has filed for bankruptcy under Title II, United States Code, Benefits may be
substantially reduced or eliminated for retired employees and their Dependents, or the surviving spouse of
a deceased retired employee. If this Benefit reduction or elimination occurs within one year before or one
year after filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost
coverage because of this Qualifying Event, he or she may choose to continue coverage until his or her
death. The Primary Enrollee's Dependents who have lost coverage because of this Qualifying Event may
choose to continue coverage for up to 36 months following the Primary Enrollee's death.
17
• •
PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (groups of 2 - 19)
In the case of Cal-COBRA, Delta Dental will act as the administrator. Notification and Premium payments
should be made directly to Delta Dental. Notifications and payments should be delivered by first-class
mail, certified mail or other reliable means of delivery.
Individuals who are eligible for coverage under the federal COBRA law are not eligible for coverage under
Cal-COBRA. The employer must notify Delta Dental in writing within 30 days of the date when the
employer becomes subject to COBRA.
Qualified Beneficiaries may continue coverage for 36 months following the month in which Qualifying
Events 1, 2, 3, 4 or 5 occur.
If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary is
determined under Title II or Title XVI of the Social Security Act to be disabled on the date of the Qualifying
Event or became disabled at any time during the first 60 days of continuation coverage, and notice of the
determination is given to the employer during the initial period of continuation coverage and within 60
days of the date of the social security determination letter, the Qualified Beneficiary may continue
coverage for a total of 36 months following the month in which Qualifying Event 1 occurs.
This period of coverage will end on the first of the month that begins more than 30 days after the date of
the final determination that the disabled individual is no longer disabled. The Qualified Beneficiary must
notify the employer or administrator within 30 days of any such determination.
If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary
experiences Qualifying Events 2, 3, 4 or 5, he or she must notify the employer within 60 days of the
second Qualifying Event and has a total of 36 months continuation coverage after the date of the first
•
Qualifying Event.
Delta Dental shall notify the Primary Enrollee of the date his or her continued coverage will terminate. This
termination notification will be sent during the 180-day period prior to the end of coverage.
ELECTION OF CONTINUED COVERAGE
A Qualified Beneficiary will have 60 days from a Qualifying Event to give Delta Dental written notice of the
election to continue coverage.
Upon written notice, Delta Dental will provide a Qualified Beneficiary with the necessary Benefits
information, monthly Premium charge, enrollment forms and instructions to allow election of continued
coverage. Failure to provide this written notice of election to Delta Dental within 60 days will result in the
loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the initial
Premium to Delta Dental, which includes the Premium for each month since the loss of coverage. Failure
to pay the required Premium within the 45 days will result in the loss of the right to continue coverage,
and any Premiums received after that will be returned to the Qualified Beneficiary.
CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to active employees and
their Dependents who are still enrolled in the dental plan. If the employer changes the coverage for active
employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes
made.
18
• • .
TERMINATION OF CONTINUED COVERAGE
•
A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the following
events first occur:
1. The allowable number of consecutive months of continued coverage is reached;
2. Failure to pay the required Premiums in a timely manner;
3. The employer ceases to provide any group dental plan to its employees;
4. The individual first obtains coverage for dental Benefits, after the date of the election of continued
coverage, under another group health plan (as an employee or Dependent) which does not contain
or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if
that pre-existing condition is covered under this plan; or
5. Entitlement to Medicare.
Once continued coverage ends, it cannot be reinstated.
TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the time that the
continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary either
30 days prior to the termination or when all Enrollees are notified, whichever is later, of the ability to elect
continuation of coverage under the employer's subsequent dental plan, if any. The continuation coverage
will be provided only for the balance of the period that a Qualified Beneficiary would have remained
covered under the Delta Dental plan had such plan with the former employer not terminated. The
employer shall notify the successor plan in writing of the Qualified Beneficiaries receiving continuation
coverage so they may be notified of how to continue coverage. The continuation coverage will terminate if
a Qualified Beneficiary fails to comply with the requirements pertaining to enrollment in and payment of
Premiums to the new group benefit plan.
OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment
period, if the employer has contracted with another plan to provide coverage to its active employees. The
continuation coverage under the other plan will be provided only for the balance of the period that a
Qualified Beneficiary would have remained under the Delta Dental plan.
NOTICE OF PRIVACY PRACTICES: Confidentiality of your health care
information
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
This notice is required by law to tell you how Delta Dental of California and its affiliates ("Delta Dental")
protect the confidentiality of your health care information in our possession. Protected Health Information
(PHI) is defined as any individually identifiable information regarding a patient's healthcare history;
mental or physical condition; or treatment. Some examples of PHI include your name, address, telephone
and/or fax number, electronic mail address, social security number or other identification number, date of
birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives,
uses and discloses your PHI to administer your benefit plan or as permitted or required by law. Any other
disclosure of your PHI without your authorization is prohibited.
19
• •
We must follow the privacy practices that are described in this notice, but also comply with any stricter
requirements under federal or state law that may apply to our administration of your benefits. However,
we may change this notice and make the new notice effective for all of your PHI that we maintain. If we
make any substantive changes to our privacy practices, we will promptly change this notice and
redistribute to you within 60 days of the change to our practices. You may also request a copy of this
notice anytime by contacting the address or phone number at the end of this notice. You should receive a
copy of this notice at the time of enrollment in a Delta Dental program, and we will notify you of how you
can receive a copy of this notice every three years.
Permitted Uses and Disclosures of Your PHI
We are permitted to use or disclose your PHI without your prior authorization for the following purposes.
These permitted uses and/or disclosures include disclosures to you, uses and/or disclosures for purposes
of health care treatment, payment of claims, billing of premiums, and other health care operations. If your
benefit plan is sponsored by your employer or another party, we may provide PHI to your employer or
that sponsor for purposes of administering your benefits. We may disclose PHI to third parties that
perform services for Delta Dental in the administration of your benefits. These parties are required by law
to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may te disclosed to an
affiliate that performs services for Delta Dental in the administration of your benefits. These affiliates have
implemented privacy policies and procedures and comply with applicable federal and state law.
We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to notify or
assist in notifying a family member, another person, or a personal representative of your condition, to
assist in disaster relief efforts, and to report victims of abuse, neglect, or domestic violence. Other
permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial,
administrative, or other law enforcement purposes, information about decedents to coroners, medical
examiners and funeral directors, for research purposes, for organ donation purposes, to avert a serious
threat to health or safety, for specialized government functions such as military and veterans activities, for
workers compensation purposes, and for use in creating summary information that can no longer be
traced to you. Additionally, with certain restrictions, we are permitted to use and/or disclose your PHI for
underwriting. We are also permitted to incidentally use and/or disclose your PHI during the course of a
permitted use and/or disclosure, but we must attempt to keep incidental uses and/or disclosures to a
minimum. We use administrative, technical, and physical safeguards to maintain the privacy of your PHI,
and we must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish
the purpose of the use and/or disclosure.
Examples of Uses and Disclosures of Your PHI for Treatment, Payment or Healthcare
Operations
Such activities may include but are not limited to: processing your claims, collecting enrollment
information and premiums, reviewing the quality of health care you receive, providing customer service,
resolving your grievances, and sharing payment information with other insurers. Additional examples
include the following.
• Uses and/or disclosures of PHI in facilitating treatment.
For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested
by your provider.
• Uses and/or disclosures of PHI for payment.
For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor.
• Uses and/or disclosures of PHI for health care operations.
For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our
network of providers.
20
• •
Disclosures Without an Authorization
We are required to disclose your PHI to you or your authorized personal representative (with certain
exceptions), when required by the U. S. Secretary of Health and Human Services to investigate or
determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your
PHI without your prior authorization in response to the following:
• Court order;
• Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its
lawful authority;
• Subpoena in a civil action;
• Investigative subpoena of a government board, commission, or agency;
• Subpoena in an arbitration;
• Law enforcement search warrant; or
• Coroner's request during investigations
Disclosures Delta Dental Makes With Your Authorization
Delta Dental will not use or disclose your PHI without your prior authorization if the law requires your
authorization. You can later revoke that authorization in writing to stop any future use and disclosure. The
authorization will be obtained from you by Delta Dental or by a person requesting your PHI from Delta
Dental.
Your Rights Regarding PHI
You have the right to request an inspection of and obtain a copy of your PHI. You.may access
your PHI by contacting the appropriate Delta Dental office. You must include (1) your name, address,
telephone number and identification number and (2) the PHI you are requesting. Delta Dental may charge
a reasonable fee for providing you copies of your PHI. Delta Dental will only maintain that PHI that we
obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or X-rays, is
returned by Delta Dental to the dentist after we have completed our review of that information. You may
need to contact your health care provider to obtain PHI that Delta Dental does not possess.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or
state law. In some circumstances, you may have a right to have this decision reviewed. Please contact the
privacy office as noted below if you have questions about access to your PHI.
You have the right to request a restriction of your PHI. You have the right to ask that we limit how
we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we
accept your request, we will put any limits in writing and abide by them except in emergency situations.
You may not limit the uses and disclosures that we are legally required or allowed to make.
You have the right to correct or update your PHI. This means that you may request an amendment
of PHI about you for as long as we maintain this information. In certain cases we may deny your request
for an amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy
of any such rebuttal. If your PHI was sent to us by another, we may refer you to that person to amend
your PHI. For example, we may refer you to your dentist to amend your treatment chart or to your
employer, if applicable, to amend your enrollment information. Please contact the privacy office as noted
below if you have questions about amending your PHI.
You have the right to request or receive confidential communications from us by alternative
means or at a different address. We will agree to a reasonable request if you tell us that discbsure of
your PHI could endanger you. You may be required to provide us with a statement of possible danger, a
different address, another method of contact or information as to how payment will be handled. Please
make this request in writing to the privacy office as noted below.
21
• •
You have the right to receive an accounting of certain disclosures we have made, if any, of your
PHI. This right does not apply to disclosures for purposes of treatment, payment, or health care
operations or for information we disclosed after we received a valid authorization from you. Additionally,
we do not need to account for disclosures made to you, to family members or friends involved in your
care, or for notification purposes. We do not need to account for disclosures made for national security
reasons or certain law enforcement purposes, disclosures made as part of a limited data set, incidental
disclosures, or disclosures made prior to April 14, 2003. Please contact the privacy office as noted below if
you would like to receive an accounting of disclosures or if you have questions about this right.
You have the right to get this notice by e-mail. You have the right to get a copy of this notice by e-
mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy
of this notice.
Complaints
You may complain to us or to the U. S. Secretary of Health and Human Services if you believe that Delta
Dental has violated your privacy rights. You may file a complaint with us by notifying the privacy office as
noted below. We will not retaliate against you for filing a complaint.
Contacts
Delta Dental of California offers and administers fee-for-service dental programs for groups headquartered
in the state of California.
You may contact the Privacy Department at the address and telephone number listed below for further
information about the complaint process or any of the information contained in this notice.
Delta Dental Subscriber Services
P.O. Box 997330
Sacramento, CA 95899-7330
(877) 335-8273
This notice is effective on and after July 1, 2006.
22
•
AMENDMENT NO. 2 TO AGREEMENT
RENEWAL
GROUP #7809
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and
DELTA DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January
1, 2007 as follows:
Paragraph 1.4 is amended to read:
1.4 "Contract Term" means the period beginning on effective date and ending on
December 31, 2008 and each subsequent yearly period during which this Contract
remains in effect.
Paragraph 2.11 is amended to include:
Coverage is reinstated on the day employment is resumed for Enrollees that are
members of the National Guard or a military reserve unit absent from work due to
active military duty. Any waiting period applied as a result of an Enrollee's absence
from active employment due to service in the National Guard or military reserve unit
shall be waived.
•
Paragraph 3.1 is amended to read:
3.1 Within 10 days after receipt of Delta Dental's invoice, The Contractholder agrees to
pay the following monthly Premiums to Delta Dental, at the address shown on the first
page of this Contract, for all of the Contractholder's Primary Enrollees and their
Dependents who are Enrollees as set forth in Article 2 of this Contract: $46.31 for
each Primary Enrollee without Dependents; $77.59 for each Primary Enrollee with one
enrolled Dependent; and $125.14 for each Primary Enrollee with two or more enrolled
Dependents. The Contractholder agrees to bear the cost of such Premiums without
withholding or otherwise charging Primary Enrollees for their coverage. Primary
Enrollees agree to bear the entire cost of coverage of their enrolled Dependents.
Contractholder agrees to pay the invoiced amount. Eligibility adjustments reported to
Delta Dental after the date the invoice is prepared will be reflected on the subsequent
month's invoice. Such adjustments are limited to the three -month period prior to the
most current month for which the Contractholder provides eligibility data.
Paragraph 4.7, sections (f) is amended to read:
(f) Sealant Benefits include the application of sealants only to permanent first
molars through age eight and second molars through age 15 if they are without
caries (decay), or restorations on the occlusal surface. Sealant Benefits do
not include the repair or replacement of a sealant on any tooth within two
years of its application.
. •
Article 8 "Other Delta Dental Obligations" is amended to include the following paragraph:
8.7 Enrollees have access to dental care when they are outside of the United States
through Delta Dental's partnership with International SOS Assistance, Inc. (I -SOS). I-
SOS is a worldwide network of dentists and dental clinics. English- speaking operators
are available around the clock to answer questions and assist with scheduling care.
Delta Dental coverage outside the United States is the same as Delta Dental coverage
within the United States and is determined by the Contractholder's plan design. Claims
that result from services received out -of- country are paid at the out -of- network
level. Access to the 1-SOS network is offered through a partnership agreement and
• will not be available if the agreement terminates.
CITY OF SEAL BEACH _
Date Amendment Signed: O /Z6' ill
c4
Sig ture )15s2
A& & -
Printed Name
I bait )')MAGI \ 1a 4
Title
DATE: January 17, 2007
DELTA DENTAL OF CALIFORNIA:
�;��/
Belinda Martinez
Senior Vice President
Sales /Marketing
Kenneth E. Bernardi
Vice President
Underwriting & Actuarial
•
•
AMENDMENT NO. 3 TO AGREEMENT .
GROUP #7809
•
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and
DELTA DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January
1, 2008 as follows:
•
Throughout the Contract, the term "Delta Preferred Option" is amended to read "Delta Dental
PPO" and the term "DPO" is amended to read "PPO ".
Paragraph 3.1 is amended to read:
•
3.1 Within 10 days after 'receipt of Delta Dental's invoice, the Contractholder agrees to
pay the following monthly Premiums to Delta Dental, at the address shown on the first
page of this Contract, for all of the Contractholder's Primary Enrollees and their
Dependents who are Enrollees as set forth in Article 2 of this Contract: $43.99 for
each Primary Enrollee without Dependents; $82.39 for each Primary Enrollee with one
enrolled Dependent; and $122.41 for each Primary Enrollee with two or more enrolled
Dependents. The Contractholder agrees to bear the cost of such Premiums without
withholding or otherwise charging Primary Enrollees for their coverage. Primary
Enrollees agree to bear the entire cost of coverage of their enrolled Dependents.
Contractholder agrees to pay the invoiced amount. Eligibility adjustments reported to
Delta Dental after the date the invoice is prepared will be reflected on the subsequent
month's invoice. Such adjustments are limited to the three -month period prior to the
most current month for which the Contractholder provides eligibility data.
Paragraph 4.2 is amended to include the following note:
Note on additional Benefits during pregnancy - When an Enrollee is pregnant,
Delta Dental will pay for additional services to help improve the oral health of the
Enrollee during the pregnancy. The additional services each calendar year while the
Enrollee is covered under this Contract include: one additional oral exam and either
• one additional routine cleaning or one additional periodontal scaling and root planing
per quadrant. Written confirmation of the pregnancy must be provided by the Enrollee
or her dentist when the claim is submitted.
Paragraph 4.5 is amended to read:
4.5 PROSTHODONTIC BENEFITS. Delta Dental agrees to pay 50% of the Dentist's Usual,
Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or
50% of the Delta Dental PPO Dentist's Fee for the construction or repair of fixed
bridges, partial or .complete dentures to replace missing, natural teeth; for implant
surgical placement and removal; and for implant supported prosthetics, including
implant repair and re- cementation.
(11- 05 -07)
• •
Sub- paragraphs (a), (e) and (i) of Paragraph 4.7 are amended to read:
(a) Only the first two oral examinations, including initial, periodic, and emergency
examinations, office visits for observations and specialist consultations, or
combination thereof, provided to an Enrollee in a calendar year while he or she
• is an Enrollee under any Delta Dental plan are Benefits under this plan. See
note on additional Benefits during pregnancy.
(e) A prophylaxis (cleaning) or Single Procedure that includes a prophylaxis is a
Benefit twice each calendar year under any Delta Dental plan. See note on
additional Benefits during pregnancy.
Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and
periodontal prophylaxes are covered as a Basic Benefit.
Periodontal scaling and root planing is a Benefit once for each quadrant each
24 -month period. See note on additional Benefits during pregnancy.
Fluoride treatment is a Benefit twice each calendar year under any Delta
Dental plan.
(1) Prosthodontic appliances and implants that were provided under any Delta
Dental plan will be replaced only after five years have passed, except when
Delta Dental determines that there is such extensive loss of remaining teeth or
change in supporting tissues that the existing fixed bridge, partial denture or
complete denture cannot be made satisfactory. Replacement of a
prosthodontic appliance or implant supported prosthesis not provided under a
Delta Dental plan will be covered if it is unsatisfactory and cannot be made
satisfactory. Implant removal is limited to one for each tooth during the
Enrollee's lifetime whether provided under a Delta Dental or any other dental
care plan.
Paragraph 4.7 (k) is hereby deleted.
Paragraph 4.8 (k) is hereby deleted.
Sub- paragraph 6 of Paragraph 7.11 is amended to read:
IMR is generally not applicable to a dental plan, unless that plan covers services
related to the practice of medicine or offered pursuant to a contract with a health
plan providing medical, surgical or hospital services.
•
(11- 05 -07) •
•
•
•
PRIVATE MEDICAL-CARE, INC.
12898 Towne Center Drive, Cerritos, California 90703
(562) 924-8311 (800) 801-7105
AMENDMENT
TO
APPLICATION FOR DeltaCare GROUP DENTAL SERVICE CONTRACT
THIS AGREEMENT is made by and between PRIVATE MEDICAL-CARE, INC. and City of Seal
Beach, DeltaCare Group #(See Appendix A), for the purpose of amending the original Group Dental
Service Contract effective January 1,2006 as follows:
1. Appendix A shall be amended to include City of Seal Beach—Retirees, Group #02012-0070.
2. The term of the Contract for City of Seal Beach — Retirees shall be from January 1, 2006
through December 31,2006.
3. City of Seal Beach shall provide a list of eligible employees for Group #02012-0070 each month
commencing January 1,2006.
All other aspects of the Group Dental Service Contract currently in effect remain the same.
IN WITNESS WHEREOF the parties have executed this Contract and have affixed their signatures on
the it day of WHEREOF_ ,2006.
City of Seal Beach PRIVATE MEDICAL-CARE, INC.
DeltaCare Group #(See Appendix A)
C By: l t1k( n � /�hL�Jj "I� By: anuary 12 2006
Signature and(Tide Signature and Date
211 8th Street Vice President, Research
Address Tide
Seal Beach CA 90740
City State Zip
01/13/2006 02012-0047-2AD
•
APPENDIX A
(Effective 01/06)
Group # Group Name
02012-0047 City of Seal Beach
02012-0055 City of Seal Beach— COBRA
02012-0070 City of Seal Beach—Retirees
01/11/2006 02012-0047-2.AD
• •
CITY OF SEAL BEACH
GROUP NUMBER #7809
Date Amendment Signed: 01 / l' Jo
caw
By:
Si nature
N2D cmtemy
Printed Name
ilAdAG fr
Title
DATE: November 5, 2007
DELTA DENTAL OF CALIFORNIA:
Belinda Martinez
Senior Vice President
Sales /Marketing
Kenneth E. Bernardi
Vice President
Underwriting & Actuarial
(11- 05 -07)
a
• •
AMENDMENT NO. 4 TO AGREEMENT
RENEWAL
GROUP #7809
REVISED
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and DELTA
DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January 1, 2009, as
follows:
Paragraph 1.4 is amended to read:
1.4 "Contract Term" means the period beginning on January 1, 2009, and ending on December 31,
2010 and each subsequent yearly period during which this Contract remains in effect.
Sub - paragraph 1 of Paragraph 3.1 is amended to read:
3.1 Within 10 days after receipt of Delta Dental's invoice, the Contractholder agrees to pay the
following monthly Premiums to Delta Dental, at the address shown on the first page of this
Contract, for all of the Contractholder's Primary Enrollees and their Dependents who are
Enrollees as set forth in Article 2 of this Contract:
$46.59 for each Primary Enrollee without Dependents;
$87.25 for each Primary Enrollee with one enrolled Dependent; and
$129.63 for each Primary Enrollee with two or more enrolled Dependents.
The Contractholder agrees to bear the cost of such Premiums without withholding or otherwise
charging Primary Enrollees for their coverage. Primary Enrollees agree to bear the entire cost of
coverage of their enrolled Dependents.
Paragraph 9.3 is amended to read:
9.3 A party choosing to terminate this Contract at the end of a Contract Term must give at least
60 days written notice of termination to the other party. If Delta Dental wants to change the
Premiums or Benefits effective at the beginning of the next Contract Term, Delta Dental will
give at least 120 days advance written notice of such changes to the Contractholder. Such an
advance notice will have the effect of a notice of termination as of the end of the Contract
Term, unless the Contractholder agrees to the new Contract provisions.
755067
i • •
CITY OF SEAL BEACH
DELTA DENTAL GROUP #7809
Date Amendment Signed: )/../.4,--t-t G-""j �D ?-009
By:
Signa e
A.)t Ls
Printed Name
7/4/4-704-6- ,t4 -� r If r
Title
DATE: December 3, 2008
DELTA DENTAL OF CALIFORNIA
Belinda Martinez
Senior Vice President
Sales /Marketing
Kenneth E. Bernardi
Vice President
Underwriting & Actuarial
755067
. •
APPENDIX B
CODE ON DENTAL PROCEDURES AND NOMENCLATURE
NOTE: All the listed procedures may not be benefits under the terms of your contract. Refer to your
contract for your specific benefits.
DO10O - DO999 DIAGNOSTIC
Clinical oral evaluations
D0120 Periodic oral evaluation - established patient
D0140 Limited oral evaluation — problem focused
DO145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150 Comprehensive oral evaluation — new or established patient
D0160 Detailed and extensive oral evaluation — problem focused, by report
D0170 Re-evaluation — limited, problem focused (established patient; not post-operative visit)
D0180 Comprehensive periodontal evaluation — new or established patient
Radiographs/diagnostic imaging (including interpretation)
D0210 Intraoral — complete series (including bitewings)
D0220 Intraoral — periapical first film
D0230 Intraoral — periapical each additional film
D0240 Intraoral — occlusal film
D0250 Extraoral — first film
D0260 Extraoral — each additional film
D0270 Bitewing — single film
D0272 Bitewings — two films
DO273 Bitewings - three films
D0274 Bitewings — four films
D0277 Vertical bitewings — 7 to 8 films
D0290 Posterior — anterior or lateral skull and facial bone survey film
D0310 Sialography
D0320 Temporomandibular joint arthrogram, including injection
D0321 Other temporomandibular joint films, by report
D0322 Tomographic survey
D0330 Panoramic film
D0340 Cephalometric film
D0350 Oral/facial photographic images
D0360 Cone beam ct - craniofacial data capture
D0362 Cone beam - two-dimensional image reconstruction using existing data, includes
multiple images
D0363 Cone beam - three-dimensional image reconstruction using existing data, includes
multiple images
Tests and examinations
D0415 Collection of microorganisms for culture and sensitivity
D0416 Viral culture
D0421 Genetic test for susceptibility to oral diseases
D0425 Caries susceptibility tests
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including
premalignant and malignant lesions, not to include cytology or biopsy procedures
D0460 Pulp vitality tests
D0470 Diagnostic casts
CDT2011 (Eff. 01-O1-11)
• S
Oral pathology laboratory
D0472 Accession of tissue, gross examination, preparation and transmission of written report
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of
written report
D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical
margins for presence of disease, preparation and transmission of written report
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
D0479 Tissue in-situ hybridization, including interpretation
D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and
transmission of written report
D0481 Electron microscopy - diagnostic
D0482 Direct immunofluorescence
D0483 Indirect immunofluorescence
D0484 Consultation on slides prepared elsewhere
D0485 Consultation, including preparation of slides from biopsy material supplied by referring
source
D0486 Accession of brush biopsy sample, microscopic examination, preparation and transmission of
written report
D0502 Other oral pathology procedures, by report
D0999 Unspecified diagnostic procedure, by report
D1000 - D1999 PREVENTIVE
Dental prophylaxis
D1110 Prophylaxis — adult
D1120 Prophylaxis — child through age 13
Topical fluoride treatment (office procedure)
D1203 Topical application of fluoride (prophylaxis not included) — child through age 13
D1204 Topical application of fluoride (prophylaxis not included) — adult
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
Other preventive services
D1310 Nutritional counseling for control of dental disease
D1320 Tobacco counseling for the control and prevention of oral disease
D1330 Oral hygiene instructions
D1351 Sealant — per tooth
D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth
Space maintenance (passive appliances)
D1510 Space maintainer — fixed — unilateral
D1515 Space maintainer — fixed — bilateral
D1520 Space maintainer — removable — unilateral
D1525 Space maintainer — removable — bilateral
D1550 Recementation of space maintainer
D1555 Removal of fixed space maintainer
D2000 - D2999 RESTORATIVE
Amalgam restorations (including polishing)
D2140 Amalgam — one surface, primary or permanent
D2150 Amalgam — two surfaces, primary or permanent
D2160 Amalgam — three surfaces, primary or permanent
D2161 Amalgam — four or more surfaces, primary or permanent
•
CDT2011 (Eff. 01-01-11)
e
Resin-based composite restorations-direct
D2330 Resin-based composite — one surface, anterior
D2331 Resin-based composite — two surfaces, anterior
D2332 Resin-based composite — three surfaces, anterior
D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite — one surface, posterior
D2392 Resin-based composite — two surfaces, posterior
D2393 Resin-based composite — three surfaces, posterior
D2394 Resin-based composite — four or more surfaces, posterior
Gold foil restorations
D2410 Gold foil — one surface
D2420 Gold foil — two surfaces
D2430 Gold foil — three surfaces
Inlay/onlay restorations
D2510 Inlay — metallic — one surface
D2520 Inlay — metallic — two surfaces
D2530 Inlay — metallic — three or more surfaces
D2542 Onlay — metallic — two surfaces
D2543 Onlay — metallic — three surfaces
D2544 Onlay — metallic — four or more surfaces
D2610 Inlay — porcelain/ceramic — one surface
D2620 Inlay — porcelain/ceramic — two surfaces
D2630 Inlay — porcelain/ceramic — three or more surfaces
D2642 Onlay — porcelain/ceramic — two surfaces
D2643 Onlay — porcelain/ceramic — three surfaces
D2644 Onlay — porcelain/ceramic — four or more surfaces
D2650 Inlay — resin-based composite — one surface
D2651 Inlay — resin-based composite — two surfaces
D2652 Inlay — resin-based composite — three or more surfaces
D2662 Onlay — resin-based composite — two surfaces
D2663 Onlay — resin-based composite — three surfaces
D2664 Onlay — resin-based composite — four or more surfaces
Crowns — single restorations only
D2710 Crown — resin-based composite (indirect)
D2712 Crown — 3/4 resin-based composite (indirect)
D2720 Crown — resin with high noble metal
D2721 Crown — resin with predominantly base metal
D2722 Crown — resin with noble metal
D2740 Crown — porcelain/ceramic substrate
D2750 Crown — porcelain fused to high noble metal
D2751 Crown — porcelain fused to predominantly base metal
D2752 Crown — porcelain fused to noble metal
D2780 Crown — 3/4 cast high noble metal
D2781 Crown — 3/4 cast predominantly base metal
D2782 Crown — 3/4 cast noble metal
D2783 Crown — 3/4 porcelain/ceramic
D2790 Crown — full cast high noble metal
D2791 Crown — full cast predominantly base metal
D2792 Crown — full cast noble metal
D2794 Crown — titanium
D2799 Provisional crown
CDT2011 (Eff. 01-01-11)
. •
Other restorative services
D2910 Recement inlay, onlay, or partial coverage restoration
D2915 Recement cast or prefabricated post and core
D2920 Recement crown
D2930 Prefabricated stainless steel crown — primary tooth
D2931 Prefabricated stainless steel crown — permanent tooth
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown with resin window
D2934 Prefabricated esthetic coated stainless steel crown — primary tooth
D2940 Sedative filling
D2950 Core buildup, including any pins
D2951 Pin retention — per tooth, in addition to restoration
D2952 Post and core in addition to crown, indirectly fabricated
D2953 Each additional indirectly fabricated post — same tooth
D2954 Prefabricated post and core in addition to crown
D2955 Post removal (not in conjunction with endodontic therapy)
D2957 Each additional prefabricated post — same tooth
D2960 Labial veneer (resin laminate) — chairside
D2961 Labial veneer (resin laminate) — laboratory
D2962 Labial veneer (porcelain laminate) — laboratory
D2970 Temporary crown (fractured tooth)
D2971 Additional procedures to construct new crown under existing partial denture framework
D2975 Coping
D2980 Crown repair, by report
D2999 Unspecified restorative procedure, by report
D3000 - D3999 ENDODONTICS
Pulp capping
D3110 Pulp cap — direct (excluding final restoration)
D3120 Pulp cap — indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp corona) to the
dentinocemental junction and application of medicament
D3221 Pulpal debridement, primary and permanent teeth
D3222 Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development
D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration)
D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration)
Endodontic therapy on primary teeth (including treatment plan, clinical procedures and follow-
up care)
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration)
D3330 Endodontic therapy, molar tooth (excluding final restoration)
D3331 Treatment of root canal obstruction; non-surgical access
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3333 Internal root repair of perforation defects
Endodontic retreatment
D3346 Retreatment of previous root canal therapy — anterior
D3347 Retreatment of previous root canal therapy — bicuspid
D3348 Retreatment of previous root canal therapy — molar
CDT2011 (Eff. 01-01-11)
• •
Apexification/recalcification procedures
D3351 Apexification/recalcification/pupal regeneration — initial visit (apical closure/calcific repair of
perforations, root resorption, pulp space disinfection, etc.)
D3352 Apexifcation/recalcification/pulpal regeneration — interim medication replacement (apical
closure/calcific repair of perforations, root resorption, pulpal space disinfection, etc.)
D3353 Apexification/recalcification — final visit (includes completed root canal therapy — apical
closure/calcific repair of perforations, root resorption, etc.)
Apicoectomy/periradicular services
D3410 Apicoectomy/periradicular surgery — anterior
D3421 Apicoectomy/periradicular surgery — bicuspid (first root)
D3425 Apicoectomy/periradicular surgery — molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling — per root
D3450 Root amputation — per root
D3460 Endodontic endosseous implant
D3470 Intentional reimplantation (including necessary splinting)
Other endodontic procedures
D3910 Surgical procedure for isolation of tooth with rubber dam
D3920 Hemisection (including any root removal), not including root canal therapy
D3950 Canal preparation and fitting of preformed dowel or post
D3999 Unspecified endodontic procedure, by report
D4000 - D4999 PERIODONTICS
Surgical services (including usual post-operative care)
D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per
quadrant
D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per
quadrant
D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant
D4231 Anatomical crown exposure - one to three teeth per quadrant
D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or bounded
teeth spaces per quadrant
D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or bounded
teeth spaces per quadrant
D4245 Apically positioned flap
D4249 Clinical crown lengthening — hard tissue
D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth or
bounded teeth spaces per quadrant
D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or
bounded teeth spaces per quadrant
D4263 Bone replacement graft — first site in quadrant
D4264 Bone replacement graft — each additional site in quadrant
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration — resorbable barrier, per site
D4267 Guided tissue regeneration — nonresorbable barrier, per site (includes membrane removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area)
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
CDT2011 (Eff. 01-01-11)
• •
Non-surgical periodontal service
D4320 Provisional splinting — intracoronal
D4321 Provisional splinting — extracoronal
D4341 Periodontal scaling and root planing — four or more teeth per quadrant
D4342 Periodontal scaling and root planing, — one to three teeth, per quadrant
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased
crevicular tissue, per tooth, by report
Other periodontal services
D4910 Periodontal maintenance
D4920 Unscheduled dressing change (by someone other than treating dentist)
D4999 Unspecified periodontal procedure, by report
D5000 - D5899 PROSTHODONTICS (REMOVABLE)
Complete dentures (including routine post-delivery care)
D5110 Complete denture — maxillary
D5120 Complete denture — mandibular
D5130 Immediate denture — maxillary
D5140 Immediate denture — mandibular
Partial dentures (including routine post-delivery care)
D5211 Maxillary partial denture — resin base (including any conventional clasps, rests and teeth)
D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and teeth)
D5213 Maxillary partial denture — cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth)
D5214 Mandibular partial denture — cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth)
D5225 Maxillary partial denture — flexible base (including any clasps, rests and teeth)
D5226 Mandibular partial denture — flexible base (including any clasps, rests and teeth)
D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth)
Adjustments to dentures
D5410 Adjust complete denture — maxillary
D5411 Adjust complete denture — mandibular
D5421 Adjust partial denture — maxillary
D5422 Adjust partial denture — mandibular
Repairs to complete dentures
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth — complete denture (each tooth)
Repairs to partial dentures
D5610 Repair resin denture base
D5620 Repair cast framework
D5630 Repair or replace broken clasp
D5640 Replace broken teeth — per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
Denture rebase procedures
D5710 Rebase complete maxillary denture
D5711 Rebase complete mandibular denture
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
CDT2011 (Eff. 01-01-11)
• •
Denture reline procedures
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline maxillary partial denture (laboratory)
D5761 Reline mandibular partial denture (laboratory)
Interim prosthesis
D5810 Interim complete denture (maxillary)
D5811 Interim complete denture (mandibular)
D5820 Interim partial denture (maxillary)
D5821 Interim partial denture (mandibular)
Other removable prosthetic services
D5850 Tissue conditioning — maxillary
D5851 Tissue conditioning — mandibular
D5860 Overdenture — complete, by report
D5861 Overdenture — partial, by report
D5862 Precision attachment, by report
D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female
component)
D5875 Modification of removable prosthesis following implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
D5900 – D5999 MAXILLOFACIAL PROSTHETICS
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis, replacement
D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical
D5932 Obturator prosthesis, definitive
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with guide flange
D5935 Mandibular resection prosthesis without guide flange
D5936 Obturator prosthesis, interim
D5937 Trismus appliance (not for TMD treatment)
D5951 Feeding aid
D5952 Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult
D5954 Palatal augmentation prosthesis
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim
CDT2011 (Eff. 01-01-11)
D5959 Palatal lift prosthesis, modification
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier
D5987 Commissure splint
D5988 Surgical splint
D5999 Unspecified maxillofacial prosthesis, by report
D6000 — D6199 IMPLANT SERVICES
D6010 Surgical placement of implant body: endosteal implant
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
Implant supported prosthetics
D6053 Implant/abutment supported removable denture for completely edentulous arch
D6054 Implant/abutment supported removable denture for partially edentulous arch
D6055 Dental implant supported connecting bar
D6056 Prefabricated abutment — includes placement
D6057 Custom abutment — includes placement
D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble
metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or
high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
D6078 Implant/abutment supported fixed denture for completely edentulous arch
D6079 Implant/abutment supported fixed denture for partially edentulous arch
Other implant services
D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis
and abutments and reinsertion of prosthesis
D6090 Repair implant supported prosthesis, by report
D6091 Replacement of semi-precision or precision attachment (male or female component) of
implant/abutment supported prosthesis, per attachment
D6092 Recement implant/abutment supported crown
D6094 Abutment supported crown — (titanium)
CDT2011 (Eff. 01-01-11)
• •
D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6190 Radiographic/surgical implant index, by Report
D6093 Recement implant/abutment supported fixed partial denture
D6194 Abutment supported retainer crown for FPD — (titanium)
D6199 Unspecified implant procedure, by report
D6200 — D6999 PROSTHODONTICS, FIXED
(Each retainer and each pontic constitutes a unit in a fixed partial denture)
Fixed partial denture pontics
D6205 Pontic — indirect resin based composite
D6210 Pontic — cast high noble metal
D6211 Pontic — cast predominantly base metal
D6212 Pontic — cast noble metal
D6214 Pontic — titanium
D6240 Pontic — porcelain fused to high noble metal
D6241 Pontic — porcelain fused to predominantly base metal
D6242 Pontic — porcelain fused to noble metal
D6245 Pontic — porcelain/ceramic
D6250 Pontic — resin with high noble metal
D6251 Pontic — resin with predominantly base metal
D6252 Pontic — resin with noble metal
D6253 Provisional pontic
Fixed partial denture retainers — inlays/ onlays
D6545 Retainer — cast metal for resin bonded fixed prosthesis
D6548 Retainer — porcelain/ceramic for resin bonded fixed prosthesis
D6600 Inlay — porcelain/ceramic, two surfaces
D6601 Inlay — porcelain/ceramic, three or more surfaces
D6602 Inlay — cast high metal, two surfaces
D6603 Inlay — cast high metal, three or more surfaces
D6604 Inlay — cast predominantly base metal, two surfaces
D6605 Inlay — cast predominantly base metal, three or more surfaces
D6606 Inlay — cast noble metal, two surfaces
D6607 Inlay — cast noble metal, three or more surfaces
D6608 Onlay — porcelain/ceramic, two surfaces
D6609 Onlay — porcelain/ceramic, three or more surfaces
D6610 Onlay — cast high noble metal, two surfaces
D6611 Onlay — cast high noble metal, three or more surfaces
D6612 Onlay — cast predominantly base metal, two surfaces
D6613 Onlay — cast predominantly base metal, three or more surfaces
D6614 Onlay — cast noble metal, two surfaces
D6615 Onlay — cast noble metal, three or more surfaces
D6624 Inlay — titanium
D6634 Onlay — titanium
Fixed partial denture retainers — crowns
D6710 Crown — indirect resin based composite
D6720 Crown — resin with high noble metal
D6721 Crown — resin with predominantly base metal
D6722 Crown — resin with noble metal
D6740 Crown — porcelain/ceramic
D6750 Crown — porcelain fused to high noble metal
D6751 Crown — porcelain fused to predominantly base metal
D6752 Crown — porcelain fused to noble metal
D6780 Crown — 3/4 cast high noble metal
CDT2011 (Elf. 01-01-11)
• •
D6781 Crown — 3/4 cast predominantly base metal
D6782 Crown — 3/4 cast noble metal
D6783 Crown — 3/4 porcelain/ceramic
D6790 Crown — full cast high noble metal
D6791 Crown — full cast predominantly base metal
D6792 Crown — full cast noble metal
D6793 Provisional retainer crown
D6794 Crown — titanium
Other fixed partial denture services
D6920 Connector bar
D6930 Recement fixed partial denture
D6940 Stress breaker
D6950 Precision attachment
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated
D6972 Prefabricated post and core in addition to fixed partial denture retainer
D6973 Core buildup for retainer, including any pins
D6975 Coping — metal
D6976 Each additional indirectly fabricated post — same tooth
D6977 Each additional prefabricated post — same tooth
D6980 Fixed partial denture repair, by report
D6985 Pediatric partial denture, fixed
D6999 Unspecified, fixed prosthodontic procedure, by report
D7000 - D7999 ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7111 Extraction, coronal remnants — deciduous tooth
07140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative
care)
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated
D7220 Removal of impacted tooth — soft tissue
D7230 Removal of impacted tooth — partially bony
D7240 Removal of impacted tooth — completely bony
D7241 Removal of impacted tooth — completely bony, with unusual surgical complications
D7250 Surgical removal of residual tooth roots (cutting procedure)
Other surgical procedures
D7260 Oroantral fistual closure
D7261 Primary closure of a sinus perforation
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or
stabilization)
D7280 Surgical access of an unerupted tooth
D7282 Mobilization of erupted or malpositioned tooth to aid eruption
D7283 Placement of device to facilitate eruption of impacted tooth
D7285 Biopsy of oral tissue — hard (bone, tooth)
D7286 Biopsy of oral tissue — soft
D7287 Exfoliative cytological sample collection
D7288 Brush biopsy — transepithelial sample collection
D7290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report
D7292 Surgical placement: temporary anchorage device [screw retained plate] requiring
surgical flap
CDT2011 (Eff. 01-01-11)
• •
D7293 Surgical placement: temporary anchorage device requiring surgical flap
D7294 Surgical placement: temporary anchorage device without surgical flap
Alveoloplasty — surgical preparation of ridge for dentures
D7310 Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces, per
quadrant
D7311 Alveoloplastyin.conjunction with extractions — one to three teeth or tooth spaces, per
quadrant
D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth spaces, per
quadrant
D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per
quadrant
Vestibuloplasty
D7340 Vestibuloplasty — ridge extension (secondary epithelialization)
D7350 Vestibuloplasty — ridge extension (including soft tissue grafts, muscle reattachment,
revision of soft tissue attachment and management of hypertrophied and hyperplastic
tissue)
Surgical excision of of soft tissue lesions
D7410 Excision of benign lesion up to 1.25 cm
D7411 Excision of benign lesion greater than 1.25 cm
D7412 Excision of benign lesion, complicated
D7413 Excision of malignant lesion up to 1.25 cm
D7414 Excision of malignant lesion greater than 1.25 cm
D7415 Excision of malignant lesion complicated
D7465 Destruction of lesion(s) by physical or chemical method, by report
Surgical excision of intra-osseous lesions
D7440 Excision of malignant tumor — lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm
D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm
D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm
D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm
D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm
Excision of bone tissue
D7471 Removal of lateral exostosis (maxilla or mandible)
D7472 Removal of torus palatinus
D7473 Removal of torus manibularis
D7485 Surgical reduction of osseous tuberosity
D7490 Radical resection of maxilla or mandible
Surgical incision
D7510 Incision and drainage of abscess — intraoral soft tissue
D7511 Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of
multiple fascial spaces)
D7520 Incision and drainage of abscess — extraoral soft tissue
D7521 Incision and drainage of abscess — extraoral soft tissue — complicated (includes drainage of
multiple fascial spaces)
D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
CDT2011 (Eff. 01-01-11)
•
Treatment of fractures — simple
D7610 Maxilla — open reduction (teeth immobilized, if present)
D7620 Maxilla — closed reduction (teeth immobilized, if present)
D7630 Mandible — open reduction (teeth immobilized, if present)
D7640 Mandible — closed reduction (teeth immobilized, if present)
D7650 Malar and/or zygomatic arch — open reduction
D7660 Malar and/or zygomatic arch — closed reduction
D7670 Alveolus — closed reduction, may include stabilization of teeth
D7671 Alveolus — open reduction, may include stabilization of teeth
D7680 Facial bones — complicated reduction with fixation and multiple surgical approaches
Treatment of fractures — compound
D7710 Maxilla — open reduction
D7720 Maxilla — closed reduction
D7730 Mandible — open reduction
D7740 Mandible — closed reduction
D7750 Malar and/or zygomatic arch — open reduction
D7760 Malar and/or zygomatic arch — closed reduction
D7770 Alveolus — open reduction splinting stabilization of teeth
D7771 Alveolus — closed reduction stabilization of teeth
D7780 Facial bones — complicated reduction with fixation and multiple surgical approaches
Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with/without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non-arthroscopic lysis and lavage
D7872 Arthroscopy — diagnosis, with or without biopsy
D7873 Arthroscopy — surgical: lavage and lysis of adhesions
D7874 Arthroscopy — surgical: disc repositioning and stabilization
D7875 Arthroscopy — surgical: synovectomy
D7876 Arthroscopy — surgical: discectomy
D7877 Arthroscopy — surgical: debridement
D7880 Occlusal orthotic device, by report
D7899 Unspecified TMD therapy, by report
Repair of traumatic wounds
D7910 Suture of recent small wounds up to 5 cm
Complicated suturing (reconstruction requiring delicate handling of tissues and wide
undermining for meticulous closure)
D7911 Complicated suture — up to 5 cm
D7912 Complicated suture — greater than 5 cm
Other repair procedures
D7920 Skin graft (identify defect covered, location and type of graft)
D7940 Osteoplasty — for orthognathic deformities
CDT2011 (Eff. 01-01-11)
• •
D7941 Osteotomy — mandibular rami
D7943 Osteotomy — mandibular rami with bone graft; includes obtaining the graft
D7944 Osteotomy — segmented or subapical
D7945 Osteotomy — body of mandible
D7946 LeFort I (maxilla — total)
D7947 LeFort I (maxilla — segmented)
D7948 LeFort II or LeFort III (osteoplasty of
facial bones for midface hypoplasia or retrusion) — without bone graft
D7949 LeFort II or LeFort III — with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or
nonautogenous, by report
D7951 Sinus augmentation with bone or bone substitutes
D7953 Bone replacement graft for ridge preservation — per site
D7955 Repair of maxillofacial soft and/or hard tissue defect
D7960 Frenulectomy - also known as frenectomy or frenotomy — separate procedure not incidental
to another procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue — per arch
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous tuberosity
D7980 Sialolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft — mandible or facial bones, by report
D7996 Implant — mandible for augmentation purposes (excluding alveolar ridge), by report
D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar
D7998 Intraoral placement of a fixation device not in conjunction with a fracture
D7999 Unspecified oral surgery procedure, by report
D8000 - D8999 ORTHODONTICS
Limited orthodontic treatment
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
Interceptive orthodontic treatment
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
Minor treatment to control harmful habits
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
Other orthodontic services
D8660 Pre-orthodontic treatment visit
D8670 Periodic orthodontic treatment visit (as part of contract)
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer[s])
CDT2011 (Eff. 01-01-11)
• •
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
D8692 Replacement of lost or broken retainer
D8693 Rebonding or recementing; and/or repaid, as required, of fixed retainers
D8999 Unspecified orthodontic procedure, by report
D9OOO - D9999 ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
D9110 Palliative (emergency) treatment of dental pain — minor procedure
D9120 Fixed partial denture sectioning
Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia
D9220 Deep sedation/general anesthesia — first 30 minutes
D9221 Deep sedation/general anesthesia — each additional 15 minutes
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide
D9241 Intravenous conscious sedation/ analgesia — first 30 minutes
D9242 Intravenous conscious sedation/ analgesia — each additional 15 minutes
D9248 Non-intravenous conscious sedation
Professional consultation
D9310 Consultation (diagnostic service provided by dentist or physician other than requesting
dentist or physician
Professional visits
D9410 House/extended care facility call
D9420 Hospital call
D9430 Office visit for observation (during regularly scheduled hours) — no other services
performed
D9440 Office visit — after regularly scheduled hours
D9450 Case presentation, detailed and extensive treatment planning
Drugs
D9610 Therapeutic parenteral drug, single administration
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
D9630 Other drugs and/or medicaments, by report
Miscellaneous services
D9910 Application of desensitizing medicament
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post-surgical) — unusual circumstances, by report
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9942 Repair and/or reline of occlusal guard
D9950 Occlusion analysis — mounted case
D9951 Occlusal adjustment — limited
D9952 Occlusal adjustment — complete
D9970 Enamel microabrasion
D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections
CDT2011 (Eff. 01-01-11)
D9972 External bleaching — per arch
D9973 External bleaching — per tooth
D9974 Internal bleaching — per tooth
D9999 Unspecified adjunctive procedure, by report
Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental
Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the copyright of
the American Dental Association, and have been accepted as the standard for data transmission purposes
under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental's
administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the
then-current version of CDT whether or not a revised Appendix B is provided.
CDT2011 (Eff. 01-01-11)
• •
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Delta Dental PPO Plan
For Employees of
CITY OF SEAL BEACH
Group No. 7809
Effective Date: January 1, 2008
• •
USING THIS BOOKLET
This booklet has been written with you in mind. It is designed to help you make the most of your Delta
Dental plan. This combined Evidence of Coverage/Disclosure form discloses the terms and conditions of
your coverage.
The Combined Evidence of Coverage/Disclosure form should be read completely and carefully and
individuals with special health care needs should read carefully those sections that apply to them (see
CHOICE OF DENTISTS AND PROVIDERS section). You have a right to review it prior to your enrollment.
Please read the "DEFINITIONS" section. It will explain to you any words that have special or technical
meanings under your group Contract. A copy of the Contract will be furnished upon request.
Please read this summary of your dental Benefits carefully. Keep in mind that YOU means the ENROLLEES
whom Delta Dental covers. WE, US and OUR always refers to Delta Dental of California (Delta Dental).
If you have any questions about your coverage that are not answered here, please check with your
personnel office, or with Delta Dental.
DELTA DENTAL OF CALIFORNIA
100 First Street
San Francisco, CA 94105
For claims, eligibility and benefits inquiries, or additional information, call Delta Dental's Customer Service
department toll-free at: 800-765-6003 or contact us on our web site: www.deltadentalca.org
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE
CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO
YOU UPON REQUEST
This Combined Evidence of Coverage/Disclosure Form constitutes only a
summary of the dental plan. The dental Contract must be consulted to
determine the exact terms and conditions of coverage.
1
• •
TABLE OF CONTENTS
DEFINITIONS 3
WHO IS COVERED? 4
WHO ARE YOUR ELIGIBLE DEPENDENTS? 4
ENROLLING YOUR DEPENDENTS 5
COVERAGE COSTS 5
WHEN YOU ARE NO LONGER COVERED 5
CANCELING THIS PLAN 5
YOUR BENEFITS 6
LIMITATIONS 7
EXCLUSIONS/SERVICES WE DO NOT COVER 9
OTHER CHARGES 10
COVERED FEES 10
CHOICE OF DENTISTS AND PROVIDERS 10
CONTINUITY OF CARE 11
PUBLIC POLICY PARTICIPATION BY ENROLLEES 11
INTERNATIONAL DENTIST REFERRAL SERVICE 11
SAVING MONEY ON YOUR DENTAL BILLS 12
YOUR FIRST APPOINTMENT 12
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE 12
PREDETERMINATIONS 13
REIMBURSEMENT PROVISIONS 13
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST 14
SECOND OPINIONS 14
ORGAN AND TISSUE DONATION 15
GRIEVANCE PROCEDURE AND CLAIMS APPEAL 15
IF YOU HAVE ADDITIONAL COVERAGE 16
OPTIONAL CONTINUATION OF COVERAGE (COBRA) 16
NOTICE OF PRIVACY PRACTICES: CONFIDENTIALITY OF YOUR HEALTH CARE INFORMATION 19
2
• •
DEFINITIONS
Certain words that you will see in this booklet have specific meanings. These definitions should make your
dental plan easier to understand.
Benefits - those dental services available under the Contract and which are described in this booklet.
Contract - the written agreement between your employer or sponsoring group and Delta Dental to
provide dental Benefits. The Contract, together with this booklet, forms the terms and conditions of the
Benefits you are provided.
Covered Services - those dental services to which Delta Dental will apply Benefit payments, according to
the Contract.
Delta Dental PPO Dentist - a Dentist with whom Delta Dental has a written agreement to provide
services at the in-network level for Enrollees in this Delta Dental PPO Plan.
Delta Dental Dentist - a Dentist who has signed an agreement with Delta Dental or a Participating Plan,
agreeing to provide services under the terms and conditions established by Delta Dental or the
Participating Plan.
Dependent - a Primary Enrollee's Dependent who is eligible to enroll for Benefits in accordance with the
conditions of eligibility outlined in this booklet.
Effective Date - the date this plan starts.
Enrollee - A Primary Enrollee or Dependent enrolled to receive Benefits or a person who chooses to pay
for OPTIONAL CONTINUATION OF COVERAGE.
Maximum - the greatest dollar amount Delta Dental will pay for covered procedures in any calendar year
and lifetime for Orthodontic Benefits.
Participating Plan - Delta Dental and any other member of the Delta Dental Plans Association with
whom Delta Dental contracts for assistance in administering your Benefits.
Premiums - the money paid to Delta Dental each month for you and your Dependents' dental coverage.
Primary Enrollee - any group member or employee who is eligible to enroll for Benefits in accordance
with the conditions of eligibility outlined in this booklet.
Single Procedure - a dental procedure to which a separate Procedure Number has been assigned by the
American Dental Association in the current version of Common Dental Terminology (CDT).
Usual, Customary and Reasonable (UCR) -
A Usual fee is the amount which an individual dentist regularly charges and receives for a given service or
the fee actually charged, whichever is less.
A Customary fee is within the range of usual fees charged and received for a particular service by dentists
of similar training in the same geographic area.
A Reasonable fee schedule is reasonable if it is Usual and Customary. Additionally, a specific fee to a
specific patient is reasonable if it is justifiable considering special circumstances, or extraordinary
difficulty, of the case in question.
3
• •
WHO IS COVERED?
All regular employees are required to enroll and will become eligible to receive Benefits on the first day of
the month following 30 days of continuous full-time employment.
Retirees residing out of state are eligible for this plan and will received the Delta Dental PPO in-network
level of Benefits.
You are not eligible if you are not reporting to work on a regular basis and are not actively employed.
Coverage resumes on the first day of the month after you return to active employment, report to work
regularly and amounts due to Delta Dental for coverage have been paid. But, coverage can continue
without interruption if your employer continues to report you as a Primary Enrollee and amounts due Delta
Dental for your coverage continue to be paid.
Coverage is reinstated on the day employment is resumed for Enrollees that are members of the National
Guard or a military reserve unit absent from work due to active military duty. Any waiting period applied
as a result of ai Enrollee's absence from active employment due to service in the National Guard or
military reserve unit shall be waived.
Family and Medical Leave Act of 1993
You can continue your coverage if you take a leave governed by the Family and Medical Leave Act of
1993. If you do not continue your coverage during the governed leave, it will be reinstated at the same
Benefit level you received before your leave.
Uniformed Services Employment and Re-employment Rights Act of 1994
You can continue coverage for up to 24 months, if you take a leave governed by the Uniformed Services
Employment and Re-employment Rights Act of 1994. If you rrake this election, you must submit any
Premiums necessary, which may include administrative costs, to your employer. If you do not continue your
coverage during a military leave, it will be reinstated at the same Benefit level you received before your
leave.
WHO ARE YOUR ELIGIBLE DEPENDENTS?
• Your legal spouse or registered domestic partner, as defined below;
• Your unmarried dependent children until their 19th birthday;
• Your unmarried dependent children until their 23rd birthday if enrolled full-time in an accredited
school, college or university;
• An unmarried dependent child aged 19 or older who is incapable of self-support because of a physical
or mental handicap that occurred before he or she turned 19, if the child is mostly dependent on you
for support. Proof of this handicap must be given to Delta Dental or your employer within 31 days, if it
is requested. Proof will not be required more than once a year after the child has reached age 21.
"Dependent children" also means stepchildren, adopted children, children of a registered domestic partner,
children placed for adoption and foster children, provided that they are dependent upon you for support
and maintenance.
Registered domestic partners are defined as same sex partners, who are both at least 18 years of age and
opposite sex partners when one or both partners are over the age of 62 and entitled to Social Security
benefits. Registered domestic partners are required to register with the Secretary of State of the State of
California a Declaration of Domestic Partnership. A registered domestic partner is subject to the same
terms and conditions as any other Dependent enrolled under this Contract. Registered domestic partners
are eligible for continuation of coverage under COBRA.
4
• •
Dependent coverage is also extended to any child who is recognized under a Qualified Medical Child
Support Order (QMCSO).
No Dependent in the military service is eligible.
ENROLLING YOUR DEPENDENTS
A payroll deduction is required for your enrolled Dependents. Your group can only provide coverage for
your Dependents if at least half of the Primary Enrollees who have Dependents enroll all of them in this
plan.
Your Dependents must be enrolled when you first become eligible or on the first day of the month after
they become Dependents. However, Dependents who are covered under another group dental plan are not
required to enroll under this Delta Dental plan. If the other coverage ends, the Dependents may enroll
under this plan within 30 days of the loss of the other coverage. Proof of prior coverage is required.
Dependent children up to four years of age may be enrolled at the beginning of any Contract year
including the Contract year immediately following their fourth birthday. If you drop coverage for your
Dependents, you may not re-enroll them in this plan.
COVERAGE COSTS
Your employer pays Delta Dental a monthly Premium for coverage of you and your enrolled Dependents.
You do not pay for your own coverage, but a payroll deduction is made for your share of the monthly
Premium required for your Dependent's coverage. Your employer can tell you how much you must
contribute for the costs of dependent coverage.
The amount of the Premium may change at each renewal of the Contract between your employer and
Delta Dental. Premiums will not increase during the contract year unless new taxes or tax rates are
imposed upon Delta Dental for this plan or unless there is an agreement between your employer and Delta
Dental to change the Premiums.
WHEN YOU ARE NO LONGER COVERED
1. If you stop working for your employer, your dental coverage will end on the last day of the month
in which you stop working, unless you qualify for and pay for OPTIONAL CONTINUATION OF
COVERAGE. Your Dependents' coverage ends when yours does, or as soon as they are m longer
Dependents, unless they choose to pay for OPTIONAL CONTINUATION OF COVERAGE.
2. When the Contract between Delta Dental and your employer is discontinued or canceled, your
coverage ends immediately.
CANCELING THIS PLAN
Delta Dental may cancel this plan only on an anniversary date (period after the plan first takes effect or at
the end of each renewal period thereafter), or:
1. If your employer does not make payment to Delta Dental as required by the Contract;
2. If fewer than 10 people are reported eligible for three months or more;
3. If your employer does not give Delta Dental a list of who is eligible;
4. If your employer does not allow Delta Dental to inspect its records, if this is required by your group
Contract.
5
• •
If you believe that this plan has been terminated or not renewed due to your health status or
requirements for health care services (or that of your Dependents), you may request a review by the
California Director of the Department of Managed Health Care.
If the Contract is terminated for any cause, Delta Dental is not required to predetermine services beyond
the termination date or to pay for services provided after the termination date, except for Single
Procedures begun while the Contract was in effect which are otherwise Benefits under the Contract.
If this plan is canceled, you and your Dependents have no right to renewal or reinstatement of your
Benefits.
YOUR BENEFITS
Your dental plan covers several categories of Benefits, when the services are provided by a licensed
dentist, and when they are necessary and customary under the generally accepted standards of dental
practice.
Delta Dental will provide payment for these services at the percentage indicated up to a Maximum of
$2,000 for each Enrollee in each calendar year.
Payment for Orthodontic Benefits for dependent children is limited to a lifetime Maximum of $1,000.
An agreement between your employer and Delta Dental is required to change Benefits during the term of
the Contract.
The following Benefits are limited to the applicable percentages of dentist's fees or allowances specified
below. You are required to pay the balance of any such fee or allowance, known as the "patient
copayment." If the dentist discounts, waives or rebates any portion of the patient copayment to the
Enrollee, Delta Dental only provides as Benefits the applicable allowances reduced by the amount that
such fees or allowances are discounted, waived or rebated.
I. DIAGNOSTIC AND PREVENTIVE BENEFITS
100% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Diagnostic - oral exa minations (including initial examinations, periodic examinations and
emergency examinations); x-rays; diagnostic casts; examination of biopsied tissue; palliative
(emergency) treatment of dental pain; specialist consultation
Preventive - prophylaxis (cleaning); fluoride treatment; space maintainers
Note on additional Benefits during pregnancy. If you are pregnant, Delta Dental will pay for
additional services to help improve your oral health during pregnancy. The additional services each
calendar year while you are eligible in this Delta Dental plan include: one additional oral
examination and either one additional routine cleaning or one additional periodontal scaling and
root planing per quadrant. Written confirmation of your pregnancy must be provided by you or
your dentist when the claim is submitted.
II. BASIC BENEFITS
80% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Oral surgery - extractions and certain other surgical procedures, including pre- and post-operative
care
6
• •
Restorative - amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious
lesions (visible destruction of hard tooth structure resulting from the process of dental decay)
Endodontic - treatment of the tooth pulp
Periodontic - treatment of gums and bones that support the teeth
Sealants - topically applied acrylic, plastic or composite material used to seal developmental
grooves and pits in teeth for the purpose of preventing dental decay
•
Adjunctive General Services - general anesthesia; office visit for observation; office visit after
regularly scheduled hours; therapeutic drug injection; treatment of post-surgical complications
(unusual circumstances); limited occlusal adjustment
III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Crowns, Inlays, Onlays and Cast Restorations are Benefits only if they are provided to treat cavities
which cannot be restored with amalgam, silicate or direct composite (resin) restorations.
IV. PROSTHODONTIC BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Construction or repair of fixed bridges, partial dentures and complete dentures are Benefits if
provided to replace missing, natural teeth.
Implant surgical placement and removal and for implant supported prosthetics, including implant
repair and re-cementation.
V. ORTHODONTIC BENEFITS
50% if provided by a Delta Dental PPO Dentist
50% if provided by other dentists
Procedures using appliances or surgery to straighten or realign teeth, which otherwise would not
function properly.
LIMITATIONS
1. Only the first two oral examinations, including office visits for observation and specialist
consultations, or combination thereof, in a calendar year are Benefits while you are eligible under
any Delta Dental plan. See Note on additional Benefits during pregnancy.
2. Full-mouth x-rays are Benefits once in a five-year period while you are eligible under any Delta
Dental plan.
3. Bitewing x-rays are provided on request by the dentist, but no more than twice in any calendar
year for children to age 18 or once in any calendar year for adults age 18 and over, while you are
eligible under any Delta Dental plan.
4. Diagnostic casts are a Benefit only when made in connection with subsequent orthodontic
treatment covered under this plan.
7
• •
5, We pay for two cleanings or a dental procedure that includes a cleaning each calendar year under
any Delta Dental plan. If you are pregnant during this time, we may pay for an additional cleaning.
See Note on additional Benefits during pregnancy.
Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and periodontal
prophylaxes are covered as a Basic Benefit.
6. Fluoride treatments are covered twice each calendar year under any Delta Dental plan.
7. Periodontal scaling and root planing is a Benefit once for each quadrant each 24-month period. See
note on additional Benefits during pregnancy.
8. Sealant Benefits include the application of sealants only to permanent first molars through age
eight and second molars through age 15 if they are without caries (decay) or restorations on the
occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any
tooth within two years of its application.
9. Direct composite (resin) restorations are Benefits on anterior teeth and the facial surface of
bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta
Dental's payment is limited to the cost of the equivalent amalgam restorations.
10. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five
years, while you are a patient under any Delta Dental plan, unless Delta Dental determines that
replacement is required because the restoration is unsatisfactory as a result of poor quality of care,
or because the tooth involved has experience extensive loss or changes to tooth structure or
supporting tissues since the replacement of the restoration.
11. Prosthodontic appliances and implants are Benefits only once every five years, while you are
eligible under any Delta Dental plan, unless Delta Dental determines that there has been such an
extensive loss of remaining teeth or a change in supporting tissues that the existing appliance
cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta
Dental plan will be made if it is unsatisfactory and cannot be made satisfactory.
Delta Dental will replace an implant, a prosthodontic appliance or an implant supported prosthesis
you received under another dental plan if we determine it is unsatisfactory and cannot be made
satisfactory.
We will pay for the removal of an implant once for each tooth during the Enrollee's lifetime.
12 Delta Dental will pay the applicable percentage ff the dentist's fee for a standard partial or
complete denture. A standard partial or complete denture is defined as a removable prosthetic
appliance provided to replace missing natural, permanent teeth that are made from accepted
materials and by conventional methods.
13. If you select a more expensive plan of treatment than is customarily provided, or specialized
techniques, an allowance will be made for the least expensive, professionally acceptable,
alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee for the
customary or standard treatment and you are responsible for the remainder of the dentist's fee.
For example: a crown where an amalgam filling would restore the tooth; or a precision denture
where a standard denture would suffice.
14. Orthodontic coverage is limited to eligible dependent children.
15. If orthodontic treatment is begun before you become eligible for coverage, Delta Dental's payments
will begin with the first payment due to the dentist following your eligibility date.
8
• •
16. Delta Dental's orthodontics payments will stop when the first payment is due to the dentist
following either a loss of eligibility, or if treatment is ended for any reason before it is completed.
17. X-rays and extractions that might be necessary for orthodontic treatment are not covered by
Orthodontic Benefits, but may be covered under Diagnostic and Preventive or Basic Benefits.
18. Delta Dental will pay the applicable percentage of the Dentist's fee for a standard orthodontic
treatment plan involving surgical and/or non-surgical procedures. If you select specialized
orthodontic appliances or procedures chosen for aesthetic considerations an allowance will be made
for the cost of a standard orthodontic treatment plan and you are responsible for the remainder of
the Dentist's fee.
EXCLUSIONS/SERVICES WE DO NOT COVER
Delta Dental covers a wide variety of dental care expenses, but there are some services for which we do
not provide Benefits. It is important for you to know what these services are before you visit your dentist.
Delta Dental does not provide benefits for:
1. Services for injuries or conditions that are covered under Workers' Compensation or Employer's
Liability Laws.
2. Services that are provided to the Enrollee by any Federal or State Governmental Agency or are
provided without cost to the Enrollee by any municipality, county or other political subdivision,
except Medi-Cal benefits.
3. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental
defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and
teeth that are discolored or lacking enamel.
4. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for
rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for
stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting.
5. Any Single Procedure, bridge, denture or other prosthodontic service that was started before the
Enrollee was covered by this plan.
6. Prescribed drugs, or applied therapeutic drugs, premedication or analgesia.
7. Experimental procedures.
8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by
the Dentist for treatment in any such facility.
9. Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures.
10. Grafting tissues from outside the mouth to tissues inside the mouth ("extraoral grafts").
11. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw)
joints or associated muscles, nerves or tissues.
12. Replacement of existing restoration for any purpose other than active tooth decay.
13. Intravenous sedation, occlusal guards and complete occlusal adjustment.
14. Charges for replacement or repair of an orthodontic appliance paid in part or in full by this plan.
9
OTHER CHARGES
Delta Dental's co-payment for your Benefits is shown in this Evidence of Coverage under the caption titled
"YOUR BENEFITS." If dental services are provided by a Delta Dental Dentist or a Delta Dental PPO Dentist,
you are responsible for your co-payment only. If the dental services you receive are provided by a dentist
who is not a Delta Dental Dentist or Delta Dental PPO Dentist, you are responsible for the difference
between the amount Delta Dental pays and the amount charged by the non-Delta Dental dentist.
COVERED FEES
It is to your advantage to select a dentist who is a Delta Dental Dentist, since a lower percentage of the
dentist's fees may be covered by this plan if you select a dentist who is not a Delta Dental Dentist.
A list of Delta Dental Dentists (see DEFINITIONS) is available in a directory at your group benefits office,
or by calling 800-765-6003.
Payment to a Delta Dental PPO Dentist will be based on the applicable percentage of the lesser of the Fee
Actually Charged, the dentist's accepted Usual, Customary and Reasonable Fee on file with Delta Dental,
or a fee which the dentist has contractually agreed upon with Delta Dental to accept for treating enrollees
under this plan.
Payment to a Delta Dental Dentist will be based on the applicable percentage of the lesser of the Fee
Actually Charged, or the accepted fee that the dentist has on file with Delta Dental.
Payment for services by a California dentist, or an out-of-state dentist, who is not a Delta Dental Dentist
will be based on the applicable percentage of the lesser of the Fee Actually Charged, or the fee that
satisfies the majority of Delta Dental Dentists.
Payment for services by a dentist located outside the United States will be based on the applicable
percentage of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental
dentists.
CHOICE OF DENTISTS AND PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT
GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Nearly 27,000 dentists in active practice in California are Delta Dental Dentists. About 16,000 of these
Delta Dental Dentists are also Delta Dental PPO Dentists. You are free to choose any dentist for treatment,
but it is to your advantage to choose a Delta Dental Dentist. This is because his or her fees are approved
in advance by Delta Dental. Delta Dental Dentists have treatment forms on hand and will complete and
submit the forms to Delta Dental free of charge.
If you choose a Delta Dental PPO Dentist, you will receive all of the advantages of going to a Delta Dental
Dentist, and you may have a higher level of Benefits for certain services.
If you go to a non-Delta Dental Dentist, Delta Dental cannot assure you what percentage of the charged
fee may be covered. Claims for services from non-Delta Dental Dentists may be submitted to Delta Dental
at P.O. Box 997330, Sacramento, CA 95899-7330.
Dentists located outside the United States are not Delta Dental Dentists. Claims submitted by out-of-
country dentists are translated by Delta Dental staff and the currency is converted to U.S. dollars. Claims
submitted by out-of-country dentists for patients residing in California are referred to Delta Dental's
Quality Review department for processing. Delta Dental may require a clinical examination to determine
the quality of the services provided, and Delta Dental may decline to reimburse you for Benefits if the
services are found to be unsatisfactory.
10
• •
A list of Delta Dental PPO Dentists and Delta Dental Dentists can be obtained by calling 800-765-6003.
This list will identify those dentists who can provide care for individuals who have mobility impairments or
have special health care needs. You can obtain specific information about Delta Dental PPO Dentists and
Delta Dental Dentists by using our web site - www.deltadentalca.orq or calling the Delta Dental Customer
Service department at the number listed on page 1. A printed list of the Delta Dental PPO Dentists and
Delta Dental Dentists in your area is also available by calling 800-765-6003.
Services from dental school clinics may be provided by students of dentistry or instructors who are not
licensed by the state of California.
Delta Dental shares the public and professional concern about the possible spread of HIV and other
infectious diseases in the dental office. However, Delta Dental cannot ensure your dentist's use of
precautions against the spread of such diseases, or compel your dentist to be tested for HIV or to disclose
test results to Delta Dental, or to you. Delta Dental informs its panel dentists about the need for clinical
precautions as recommended by recognized health authorities on this issue. If you should have questions
about your dentist's health status or use of recommended clinical precautions, you should discuss them
with your dentist.
CONTINUITY OF CARE
Current Enrollees:
Current Enrollees Tray have the right to the benefit of completion of care with their terminated Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of
your terminated Delta Dental Dentist. We are not required to continue your care with that dentist if you
are not eligible under our policy or if we cannot reach agreement with your terminated Delta Dental
Dentist on the terms regarding your care in accordance with California law.
New Enrollees:
A new Enrollee may have the right to the qualified benefit of completion of care with their non-Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental's Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental's Continuity of Care Policy. You must make a specific request to continue under the care of
your current provider. We are not required to continue your care with that dentist if you are not eligible
under our policy or if we cannot reach agreement with your non-Delta Dental Dentist on the terms
regarding your care in accordance with California law. This policy does not apply to new enrollees of an
individual subscriber contract.
PUBLIC POLICY PARTICIPATION BY ENROLLEES
Delta Dental's Board of Directors includes Enrollees who participate in establishing Delta Dental's public
policy regarding Enrollees through periodic review of Delta Dental's Quality Assessment program reports
and communications from Enrollees. Enrollees may submit any suggestions regarding Delta Dental's public
policy in writing to: Delta Dental of California, Customer Service Department, P. O. Box 997330,
Sacramento, CA 95899-7330.
INTERNATIONAL DENTIST REFERRAL SERVICE
You can receive your covered dental care when you are outside of the United States through a partnership
between Delta Dental and International SOS Assistance, Inc. I-SOS provides referrals to 3,200 dentist or
dental clinics in nearly 200 countries worldwide. English-speaking operators are available around the
clock to help you find a dentist. For more information, check our web site at www.deltadentalca.org or
call (800) 523-6586 from the US. Once you leave the US, you can call I-SOS at (215) 942-8226—collect.
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When you see an I-SOS dentist, you must pay for your treatment at the time of service and get a detailed
receipt from the dentist. In addition to providing the dentist's name and address (including country), this
receipt should describe the services performed by the dentist and indicate the tooth or teeth that were
treated. It should also indicate whether the dentist's charges were billed in U.S. dollars or another
currency.
Once we receive your claim, we will reimburse you subject to the terms and conditions of your Delta
Dental coverage. Reimbursement is based on the out-of-network benefit provided through your group
plan. As with any dental plan, this reimbursement may not cover the entire cost of the treatment
rendered.
•
SAVING MONEY ON YOUR DENTAL BILLS
You can keep your dental expenses down by practicing the following:
1. Compare the fees of different dentists;
2. Use a Delta Dental Dentist;
3. Have your dentist obtain predetermination from Delta Dental for any treatment over $300;
4. Visit your dentist regularly for checkups;
5. Follow your dentist's advice about regular brushing and flossing;
6. Avoid putting off treatment until you have a major problem; and
7. Learn the facts about overbilling. Under this plan, you must pay the dentist your copayment share
(see YOUR BENEFITS). You may hear of some dentists who offer to accept insurance payments as
"full payment." You should know that these dentists may do so by overcharging your plan and
may do more work than you need, thereby increasing plan costs. You can help keep your dental
Benefits intact by avoiding such schemes.
YOUR FIRST APPOINTMENT
During your first appointment, be sure to give your dentist the following information:
1. Your Delta Dental group number (on the front of this booklet);
2. The employer's name;
3. Primary Enrollee's ID number (which must also be used by Dependents);
4. Primary Enrollee's date of birth;
5. Any other dental coverage you may have.
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE
If you or a family member has special needs, you should ask your dentist about accessibility to their office
or clinic at the time you call for an appointment. Your dentist will be able to tell you if their office is
accessible taking into consideration the specific requirements of your needs.
Routine or urgent care may be obtained from any licensed dentist during their normal office hours. Delta
Dental does not require prior authorization before seeking treatment for urgent or after-hours care. You
may plan in advance, for treatment for urgent, emergency or after-hours care by asking your dentist how
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you can contact the dentist in the event you or a family member may need urgent care treatment or
treatment after normal business hours. Many dentists have made prior arrangements with other dentists
to provide care to you if treatment is immediately or urgently needed. You may also call the local dental
society that is listed in your local telephone directory if your dentist is not available to refer you to another
dentist for urgent, emergency or after-hours care.
PREDETERMINATIONS
After an examination, your dentist will talk to you about treatment you may need. The cost of treatment
is something you may want to consider. If the service is extensive and involves crowns or bridges, or if
the service will cost more than $300, we encourage you to ask your dentist to request a predetermination.
A predetermination does not guarantee payment. It is an estimate of the amount Delta Dental
will pay if you are eligible and meet all the requirements of your plan at the time the treatment
you have planned is completed.
In order to receive predetermination, your dentist must send a claim form to us listing the proposed
treatment. Delta Dental will send your dentist a Notice of Predetermination that estimates how much you
will have to pay. After you review the estimate with your dentist and decide to go ahead with the
treatment plan, your dentist returns the statement to us for payment when treatment has been
completed.
Computations are estimates only and are based on what would be payable on the date the Notice of
Predetermination is issued if the patient is eligible. Payment will depend on the patient's eligibility and the
remaining annual Maximum when completed services are submitted to Delta Dental.
Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you
have any concerns about the predetermination, let us know before treatment begins so your questions can
be answered before you incur any charges.
REIMBURSEMENT PROVISIONS
A Delta Dentist will file the claim for you. You do not have to file a claim or pay Delta Dental's co-payment
for covered services if provided by a Delta Dental Dentist. Delta Dental of California's agreement with our
Delta Dental Dentists makes sure that you will not be responsible to the dentist for any money we owe.
If the covered service is provided by a dentist who is not a Delta Dental Dentist, you are responsible for
filing the claims and paying your dentist. Claims should be filed with Delta Dental of California at P. O. Box
997330, Sacramento, CA 95899-7330 and Delta Dental will reimburse you. However, if for any reason we
fail to pay a dentist who is not a Delta Dental Dentist, you may be liable for that portion of the cost.
Payments made to you are not assignable (in other words, we will not grant requests to pay non-Delta
Dental Dentists directly).
Payment for claims exceeding $500 for services provided by dentists located outside the United States
may, at Delta Dental's option, be conditioned upon a clinical evaluation at Delta Dental's request (see
Second Opinions). Delta Dental will not pay Benefits for such services if they are found to be
unsatisfactory.
Delta Dental does not pay Delta Dental Dentists any incentive as an inducement to deny, reduce, limit or
delay any appropriate service. If you wish to know more about the method of reimbursement to Delta
Dental Dentists, you may call Delta Dental's Customer Service department for more information.
Payment for any Single Procedure that is a Covered Service will only be made upon completion of that
procedure. Delta Dental does not make or prorate payments for treatment in progress or incomplete
procedures. The date the procedure is completed governs the calculation of any Deductible (and
determines when a charge is made against any Maximum) under your plan.
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If there is a difference between what your dentist is charging you and what Delta Dental says your portion
should be, or if you are not satisfied with the dental work you have received, contact Delta Dental's
Customer Service department. We may be able to help you resolve the situation.
Delta Dental may deny payment of a claim for services submitted more than 12 months after the date the
services were provided. If a claim is denied due to a Delta Dental Dentist's failure to make a timely
submission, you shall not be liable to that dentist for the amount which would have been payable by Delta
Dental (unless you failed to advise the dentist of your eligibility at the time of treatment).
The process Delta Dental uses to determine or deny payment for services is distributed to all Delta Dental
Dentists. It describes in detail the dental procedures covered as Benefits, the conditions under which
coverage is provided, and the limitations and exclusions applicable to the plan. Claims are reviewed for
eligibility and are paid according to these processing policies. Those claims which require additional review
are evaluated by Delta Dental's dentist consultants. If any claims are not covered, or if limitations or
exclusions apply to services you have received from a Delta Dental Dentist, you will be notified by an
adjustment notice on the Notice of Payment or Action. You may contact Delta Dental's Customer Service
department for more information regarding Delta Dental's processing policies.
Delta Dental uses a method called "first-in/first-out" to begin processing your claims. The date we receive
your claim determines the order in which processing begins. For example, if you receive dental services in
January and February, but we receive the February claim first, processing begins on the February claim
first.
Incomplete or missing data can affect the date the claim is paid. If all information necessary to complete
claim processing has not been provided, payment could be delayed until any missing or incomplete data is
received by Delta Dental.
The order in which your claims are processed and paid by Delta Dental may also impact your annual
maximum. For example, if a claim with a later date of service is paid and your annual maximum for the
year has been reached then a claim with an earlier date of service in the same calendar year will not be
paid.
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST
If you have questions about the services you receive from a Delta Dental Dentist, we recommend that you
first discuss the matter with your dentist. If you continue to have concerns, call our Quality Review
department at 800-765-6003. If appropriate, Delta Dental can arrange for you to be examined by one of
our consulting dentists in your area. If the consultant recommends the work be replaced or corrected,
Delta Dental will intervene with the original dentist to either have the services replaced or corrected at no
additional cost to you or obtain a refund. In the latter case, you are free to choose another dentist to
receive your full Benefit.
SECOND OPINIONS
Delta Dental obtains second opinions through Regional Consultant members of its Quality Review
Committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate
treatment that is proposed or has been provided.
Delta Dental will authorize such an examination prior to treatment when necessary to make a Benefits
determination in response to a request for a Predetermination of treatment cost by a dentist. Delta Dental
will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of
care provided. Delta Dental will notify the Enrollee and the treating dentist when a second opinion is
necessary and appropriate, and direct the Enrollee to the Regional Consultant selected by Delta Dental to
perform the clinical examination. When Delta Dental authorizes a second opinion through a Regional
Consultant, Delta Dental will pay for all charges.
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Enrollees may otherwise obtain second opinions about treatment from any dentist they choose, and claims
for the examination may be submitted to Delta Dental for payment. Delta Dental will pay such claims in
accordance with the Benefits of the plan.
This is only a summary of Delta Dental's policy on second opinions. A copy of Delta Dental's
formal policy is available from Delta Dental's Customer Service department upon request.
ORGAN AND TISSUE DONATION
Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of
transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants
far exceeds availability. If you are interested in organ donation, please speak to your physician. Organ
donation begins at the hospital when a patient is pronounced brain dead and identified as a potential
organ donor. An organ procurement organization will become involved to coordinate the activities.
GRIEVANCE PROCEDURE AND CLAIMS APPEAL
If you have any questions about the services received from a Delta Dental Dentist, we recommend that
you first discuss the matter with your Dentist. If you continue to have concerns, you may call or write us.
We will provide notifications if any dental services or claims are denied, in whole or part, stating the
specific reason or reasons for denial. Any questions of ineligibility should first be handled directly between
you and your group. If you have any question or complaint regarding the denial of dental services or
claims, the policies, procedures and operations of Delta Dental, or the quality of dental services performed
by a Delta Dental Dentist, you may call us toll-free at 800-765-6003, contact us on our web site:
www.deltadentalca.org or write us at P. O. Box 997330, Sacramento, CA 95899-7330, Attention:
Customer Service Department.
If your claim has been denied or modified, you may file a request for review (a grievance) with us within
180 days after receipt of the denial or modification. If in writing, the correspondence must include your
group name and number, the Primary Enrollee's name and ID number, the inquirer's telephone number
and any additional information that would support the claim for benefits. Your correspondence should also
include a copy of the treatment form, Notice of Payment and any other relevant information. Upon request
and free of charge, we will provide the Enrollee with copies of any pertinent documents that are relevant
to the claim, a copy of any internal rule, guideline, protocol, and/or explanation of the scientific or clinical
judgment if relied upon in denying or modifying the claim.
Our review will take into account all information, regardless of whether such information was submitted or
considered initially. Certain cases may be referred to one of our regional consultants, to a review
committee of the dental society or to the state dental association for evaluation. Our review shall be
conducted by a person who is neither the individual who made the original claim denial, nor the
subordinate of such individual, and we will not give deference to the initial decision. If the review of a
claim denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a
clinical judgment in applying the terms of the contract terms, we shall consult with a dentist who has
appropriate training and experience. The identity of such dental consultant is available upon request.
We will provide the Enrollee a written acknowledgement within five calendar days of receipt of the request
for review. We will make a written decision within 30 calendar days of receipt of the request for review.
We will respond, within three calendar days of receipt, to complaints involving severe pain and imminent
and serious threat to a patient's health. You may file a complaint with the Department of Managed Health
Care after you have completed Delta Dental's grievance procedure or after you have been involved in
Delta Dental's grievance procedure for 30 calendar days. You may file a complaint with the Department
immediately in an emergency situation, which is one involving severe pain and/or imminent and serious
threat to the Enrollee's health.
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The California Department of Managed Health Care is responsible for regulating health care service plans.
If you have a grievance against Delta Dental, your health plan, you should first telephone Delta Dental at
800-765-6003 and use Delta Dental's grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.
If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has remained unresolved for more than 30 calendar
days, you may call the department for assistance. You may also be eligible for an Independent Medical
Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical
decisions made by a health plan related to the medical necessity of a proposed service or treatment,
coverage decisions for treatments that are experimental or investigational in nature and payment disputes
for emergency or urgent medical services. The department also has a toll-free telephone number (888-
HMO-2219) and a TDD line (877-688-9891) for the hearing and speech impaired. The department's
Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms
and instructions online.
IMR is generally not applicable to a dental plan, unless that dental plan covers services related to the
practice of medicine or offered pursuant to a contract with a health plan providing medical, surgical or
hospital services.
If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the
Enrollee may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for
further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may
also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is:
U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue,
N.W. Washington, D.C. 20210.
IF YOU HAVE ADDITIONAL COVERAGE
It is to your advantage to let your dentist and Delta Dental know if you have dental coverage in addition
to this Delta Dental plan. Most dental carriers cooperate with one another to avoid duplicate payments,
but still allow you to make use of both plans - sometimes paying 100% of your dental bill. For example,
you might have some fillings that cost $100. If the primary carrier usually pays 80% for these services, it
would pay $80. The secondary carrier might usually pay 50% for this service. In this case, since
payment is not to exceed the entire fee charged, the secondary carrier pays the remaining $20 only.
Since this method pays 100% of the bill, you have no out-of-pocket expense.
Be sure to advise your dentist of all plans under which you have dental coverage and have him or her
complete the dual coverage portion of the claim form, so that you will receive all benefits to which you are
entitled. For further information, contact the Delta Dental Customer Service department at the number in
the USING THIS BOOKLET section.
OPTIONAL CONTINUATION OF COVERAGE (COBRA)
Please examine your options carefully before declining this coverage. You should be aware
that companies selling individual health insurance typically require a review of your medical
history that could result in a higher premium or you could be denied coverage entirely.
The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers
having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal-COBRA, •
pertaining to employers with two to 19 employees), both require that continued health care coverage be
made available to "Qualified Beneficiaries" who lose health care coverage under the group plan as a result
of a "Qualifying Event." You may be entitled to continue coverage under this plan, at your expense, if
certain conditions are met. The period of continued coverage depends on the Qualifying Event and
whether you are covered under federal COBRA or Cal-COBRA.
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DEFINITIONS
•
The meaning of key terms used in this section are shown below and apply to both federal and Cal-COBRA.
Qualified Beneficiary means:
1. You and/or your Dependents who are enrolled in the Delta Dental plan on the day before the
Qualifying Event, or
2. A child who is born to or placed for adoption with you during the period of continued coverage,
provided such child is enrolled within 30 days of birth or placement for adoption.
Qualifying Event means any of the following events which, except for the election of this continued
coverage, would result in a loss of coverage under the dental plan:
Event 1. The termination of employment (other than termination for gross misconduct) or the
reduction in work hours, by your employer;
Event 2. Your death;
Event 3. Your divorce or legal separation from your spouse;
Event 4. Your Dependents' loss of dependent status under the plan; and
Event 5. As to your Dependents only, your entitlement to Medicare.
You means the Primary Enrollee.
PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying
Event 1 occurs.
This 18-month period can be extended for a total of 29 months, provided:
1. A determination is made under Title II or Title XVI of the Social Security Act that an individual is
disabled on the date of the Qualifying Event or becomes disabled at any time during the first 60
days of continued coverage; and
•
2. Notice of the determination is given to the employer during the initial 18 months of continued
coverage and within 60 days of the date of termination.
This period of coverage will end on the first day of the month that begins more than 30 days after the
date of the final determination that the disabled individual is no longer disabled. You must notify your
employer or Delta Dental within 30 days of any such determination.
If, during the 18-month continuation period resulting from Qualifying Event 1, your Dependents, who are
Qualified Beneficiaries, experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for
up to a total of 36 months (inclusive of the period continued under Qualifying Event 1).
Your Dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the
occurrence of Qualifying Events 2, 3, 4 or 5.
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When an employer has filed for bankruptcy under Title II, United States Code, Benefits may be
substantially reduced or eliminated for retired employees and their Dependents, or the surviving spouse of
a deceased retired employee. If this Benefit reduction or elimination occurs within one year before or one
year after filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost
coverage because of this Qualifying Event, he or she may choose to continue coverage until his or her
death. The Primary Enrollee's Dependents who have lost coverage because of this Qualifying Event may
choose to continue coverage for up to 36 months following the Primary Enrollee's death.
PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (groups of 2 - 19)
In the case of Cal-COBRA, Delta Dental will act as the administrator. Notification and Premium payments
should be made directly to Delta Dental. Notifications and payments should be delivered by first-class
mail, certified mail or other reliable means of delivery.
Individuals who are eligible for coverage under the federal COBRA law are not eligible for coverage under
Cal-COBRA. The employer must notify Delta Dental in writing within 30 days of the date when the
employer becomes subject to COBRA.
Qualified Beneficiaries may continue coverage for 36 months following the month in which Qualifying
Events 1, 2, 3, 4 or 5 occur.
If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary is
determined under Title II or Title XVI of the Social Security Act to be disabled on the date of the Qualifying
Event or became disabled at any time during the first 60 days of continuation coverage, and notice of the
determination is given to the employer during the initial period of continuation coverage and within 60
days of the date of the social security determination letter, the Qualified Beneficiary may continue
coverage for a total of 36 months following the month in which Qualifying Event 1 occurs.
This period of coverage will end on the first of the month that begins more than 30 days after the date of
the final determination that the disabled individual is no longer disabled. The Qualified Beneficiary must
notify the employer or administrator within 30 days of any such determination.
If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary
experiences Qualifying Events 2, 3, 4 or 5, he or she must notify the employer within 60 days of the
second Qualifying Event and has a total of 36 months continuation coverage after the date of the first
Qualifying Event.
Delta Dental shall notify the Primary Enrollee of the date his or her continued coverage will terminate. This
termination notification will be sent during the 180-day period prior to the end of coverage.
ELECTION OF CONTINUED COVERAGE
A Qualified Beneficiary will have 60 days from a Qualifying Event to give Delta Dental written notice of the
election to continue coverage.
Upon written notice, Delta Dental will provide a Qualified Beneficiary with the necessary Benefits
information, monthly Premium charge, enrollment forms and instructions to allow election of continued
coverage. Failure to provide this written notice of election to Delta Dental within 60 days will result in the
loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the initial
Premium to Delta Dental, which includes the Premium for each month since the loss of coverage. Failure
to pay the required Premium within the 45 days will result in the loss of the right to continue coverage,
and any Premiums received after that will be returned to the Qualified Beneficiary.
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CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to active employees and
their Dependents who are still enrolled in the dental plan. If the employer changes the coverage for active
employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes
made.
TERMINATION OF CONTINUED COVERAGE
A Qualified Beneficiary's coverage will terminate at the end of the month in which any of the following
events first occur:
1. The allowable number of consecutive months of continued coverage is reached;
2. Failure to pay the required Premiums in a timely manner;
3. The employer ceases to provide any group dental plan to its employees;
4. The individual first obtains coverage for dental Benefits, after the date of the election of continued
coverage, under another group health plan (as an employee or Dependent) which does not contain
or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if
that pre-existing condition is covered under this plan; or
5. Entitlement to Medicare.
Once continued coverage ends, it cannot be reinstated.
TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the time that the
continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary either
30 days prior to the termination or when all Enrollees are notified, whichever is later, of the ability to elect
continuation of coverage under the employer's subsequent dental plan, if any. The continuation coverage
will be provided only for the balance of the period that a Qualified Beneficiary would have remained
covered under the Delta Dental plan had such plan with the former employer not terminated. The
employer shall notify the successor plan in writing of the Qualified Beneficiaries receiving continuation
coverage so they may be notified of how to continue coverage. The continuation coverage will terminate if
a Qualified Beneficiary fails to comply with the requirements pertaining to enrollment in and payment of
Premiums to the new group benefit plan.
OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment
period, if the employer has contracted with another plan to provide coverage to its active employees. The
continuation coverage under the other plan will be provided only for the balance of the period that a
Qualified Beneficiary would have remained under the Delta Dental plan.
NOTICE OF PRIVACY PRACTICES: CONFIDENTIALITY OF YOUR HEALTH CARE
INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
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This notice is required by law to tell you how Delta Dental of California and its affiliates ("Delta Dental")
protect the confidentiality of your health care information in our possession. Protected Health Information
(PHI) is defined as any individually identifiable information regarding a patient's healthcare history;
mental or physical condition; or treatment. Some examples of PHI include your name, address, telephone
and/or fax number, electronic mail address, social security number or other identification number, date of
birth, date of treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives,
uses and discloses your PHI to administer your benefit plan or as permitted or required by law. Any other
disclosure of your PHI without your authorization is prohibited.
We must follow the privacy practices that are described in this notice, but also comply with any stricter
requirements under federal or state law that may apply to our administration of your benefits. However,
we may change this notice-and make the new notice effective for all of your PHI that we maintain. If we
make any substantive changes to our privacy practices, we will promptly change this notice and
redistribute to you within 60 days of the change to our practices. You may also request a copy of this
notice anytime by contacting the address or phone number at the end of this notice. You should receive a
copy of this notice at the time of enrollment in a Delta Dental program, and we will notify you of how you
can receive a copy of this notice every three years.
Permitted Uses and Disclosures of Your PHI
We are permitted to use or disclose your PHI without your prior authorization for the following purposes.
These permitted uses and/or disclosures include disclosures to you, uses and/or disclosures for purposes
of health care treatment, payment of claims, billing of premiums, and other health care operations. If your
benefit plan is sponsored by your employer or another party, we may provide PHI to your employer or
that sponsor for purposes of administering your benefits. We may disclose PHI to third parties that
perform services for Delta Dental in the administration of your benefits. These parties are required by law
to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an
affiliate that performs services for Delta Dental in the administration of your benefits. These affiliates have
implemented privacy policies and procedures and comply with applicable federal and state law.
We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to notify or
assist in notifying a family member, another person, or a personal representative of your condition, to
assist in disaster relief efforts, and to report victims of abuse, neglect, or domestic violence. Other
permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial,
administrative, or other law enforcement purposes, information about decedents to coroners, medical
examiners and funeral directors, for research purposes, for organ donation purposes, to avert a serious
threat to health or safety, for specialized government functions such as military and veterans activities, for
workers compensation purposes, and for use in creating summary information that can no longer be
traced to you. Additionally, with certain restrictions, we are permitted to use and/or disclose your PHI for
underwriting. We are also permitted to incidentally use and/or disclose your PHI during the course of a
permitted use and/or disclosure, but we must attempt to keep incidental uses and/or disclosures to a
minimum. We use administrative, technical, and physical safeguards to maintain the privacy of your PHI,
and we must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish
the purpose of the use and/or disclosure.
Examples of Uses and Disclosures of Your PHI for Treatment, Payment or Healthcare
Operations
Such activities may include but are not limited to: processing your claims, collecting enrollment
information and premiums, reviewing the quality of health care you receive, providing customer service,
resolving your grievances, and sharing payment information with other insurers. Additional examples
• include the following.
• Uses and/or disclosures of PHI in facilitating treatment.
For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested
by your provider.
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• Uses and/or disclosures of PHI for payment.
For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor.
• Uses and/or disclosures of PHI for health care operations.
For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our
network of providers.
Disclosures Without an Authorization
We are required to disclose your PHI to you or your authorized personal representative (with certain
exceptions), when required by the U. S. Secretary of Health and Human Services to investigate or
determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your
PHI without your prior authorization in response to the following:
• Court order;
• Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its
lawful authority;
• Subpoena in a civil action;
• Investigative subpoena of a government board, commission, or agency;
• Subpoena in an arbitration;
• Law enforcement search warrant; or
• Coroner's request during investigations
Disclosures Delta Dental Makes With Your Authorization
Delta Dental will not use or disclose your PHI without your prior authorization if the law requires your
authorization. You can later revoke that authorization in writing to stop any future use and disclosure. The
authorization will be obtained from you by Delta Dental or by a person requesting your PHI from Delta
Dental.
Your Rights Regarding PHI
You have the right to request an inspection of and obtain a copy of your PHI. You may access
your PHI by contacting the appropriate Delta Dental office. You must include (1) your name, address,
telephone number and identification number and (2) the PHI you are requesting. Delta Dental may charge
a reasonable fee for providing you copies of your PHI. Delta Dental will only maintain that PHI that we
obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or X-rays, is
returned by Delta Dental to the dentist after we have completed our review of that information. You may
need to contact your health care provider to obtain PHI that Delta Dental does not possess.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or
state law. In some circumstances, you may have a right to have this decision reviewed. Please contact the
privacy office as noted below if you have questions about access to your PHI.
You have the right to request a restriction of your PHI. You have the right to ask that we limit how
we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we
accept your request, we will put any limits in writing and abide by them except in emergency situations.
You may not limit the uses and disclosures that we are legally required or allowed to make.
You have the right to correct or update your PHI. This means that you may request an amendment
of PHI about you for as long as we maintain this information. In certain cases we may deny your request
for an amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy
of any such rebuttal.
21
If your PHI was sent to us by another, we may refer you to that person to amend your PHI. For example,
we may refer you to your dentist to amend your treatment chart or to your employer, if applicable, to
amend your enrollment information. Please contact the privacy office as noted below if you have questions
about amending your PHI.
You have the right to request or receive confidential communications from us by alternative
means or at a different address. We will agree to a reasonable request if you tell us that disclosure of
your PHI could endanger you. You may be required to provide us with a statement of possible danger, a
different address, another method of contact or information as to how payment will be handled. Please
make this request in writing to the privacy office as noted below.
You have the right to receive an accounting of certain disclosures we have made, if any, of your
PHI. This right does not apply to disclosures for purposes of treatment, payment, or health care
operations or for information we disclosed after we received a valid authorization from you. Additionally,
we do not need to account for disclosures made to you, to family members or friends involved in your
care, or for notification purposes. We do not need to account for disclosures made for national security
reasons or certain law enforcement purposes, disclosures made as part of a limited data set, incidental
disclosures, or disclosures made prior to April 14, 2003. Please contact the privacy office as noted below if
you would like to receive an accounting of disclosures or if you have questions about this right.
You have the right to get this notice by e-mail. You have the right to get a copy of this notice by e-
mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy
of this notice.
•
Complaints
You may complain to us or to the U. S. Secretary of Health and Human Services if you believe that Delta
Dental has violated your privacy rights. You may file a complaint with us by notifying the privacy office as
noted below. We will not retaliate against you for filing a complaint.
Contacts
Delta Dental of California offers and administers fee-for-service dental programs for groups headquartered
in the state of California.
You may contact the Privacy Department at the address and telephone number listed below for further
information about the complaint process or any of the information contained in this notice.
Delta Dental Subscriber Services
P.O. Box 997330
Sacramento, CA 95899-7330
(877) 335-8273
This notice is effective on and after July 1, 2006.
11-07 VT
22
• •
AMENDMENT NO. 5 TO AGREEMENT
RENEWAL
GROUP #7809
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and DELTA
DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January 1, 2010, as
follows:
Paragraph 1.4 is amended to read:
1.4 "Contract Term" means the period beginning on January 1, 2010, and ending on December 31,
2010 and each subsequent yearly period during which this Contract remains in effect.
Sub - paragraph 1 of Paragraph 3.1 is amended to read:
3.1 Within 10 days after receipt of Delta Dental's invoice, the Contractholder agrees to pay the
following monthly Premiums to Delta Dental, at the address shown on the first page of this
Contract, for all of the Contractholder's Primary Enrollees and their Dependents who are
Enrollees as set forth in Article 2 of this Contract:
$49.03 for each Primary Enrollee without Dependents;
$91.83 for each Primary Enrollee with one enrolled Dependent; and
$136.44 for each Primary Enrollee with two or more enrolled Dependents.
Paragraph 8.7 is hereby deleted.
URF #933629 1
CITY OF SEAL BEACH
DELTA DENTAL GROUP #7809
Date Amendment Signed: &'i i
By: GLZt 4 /<'- cc,A
Cl Signature
/OA N e Y &A- 1.5
Printed Name
,1/?-,o4 & 7''2 7 / -, ),4 - Y5 %
Title
DATE: October 26, 2009
DELTA DENTAL OF CALIFORNIA
111#1144
Belinda Martinez
Senior Vice President
Sales /Marketing
Kenneth E. Bernardi
Vice President
Underwriting & Actuarial
URF #933629 2
• •
CITY OF SEAL BEACH
DELTA DENTAL GROUP #7809
Date Amendment Signed: i2_C-1-1 X11 a o / o
By: // "Lc `
CJ Signature
N f N e / /C_i4 LS nt-Al
Printed Name
, 134-&-& m ax7> n-.-/4 L YS %
Title
DATE: October 26, 2009
DELTA DENTAL-OF CALIFORNIA
A
Belinda Martinez
Senior Vice President
Sales/Marketing
47,
Kenneth E. Bernardi
Vice President
Underwriting & Actuarial
URF#933629 2
. .
AMENDMENT NO. 6 TO AGREEMENT
RENEWAL
GROUP #7809
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and DELTA
DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January 1, 2011, as
follows:
Paragraph 1.4 is amended to read:
1.4 "Contract Term" means the period beginning on January 1, 2011, and ending on December 31,
2011 and each subsequent yearly period during which this Contract remains in effect.
Sub - paragraph 2 of Paragraph 3.1 is amended to read:
$51.37 for each Primary Enrollee with no enrolled Dependents;
$96.22 for each Primary Enrollee with one enrolled Dependent; and
$142.96 for each Primary Enrollee with two or more enrolled Dependents.
Sub - paragraph 7 of paragraph 4.3, Adjunctive General Services, is amended to include:
I.V. Sedation
Paragraphs 4.7 (b) is amended to read:
(b) Delta Dental pays for full -mouth x -rays only after five years have elapsed since any
prior set of full -mouth x -rays was provided under any Delta Dental plan.
Delta Dental pays for a panoramic x -ray provided as an individual service only after
five years have elapsed since any prior panoramic x -ray was provided under any Delta
Dental plan.
Paragraph 4.8 (i) is amended to read:
(i) Charges for anesthesia, other than general anesthesia or I.V. sedation administered by
a licensed Dentist in connection with covered Oral Surgery services and select
Endodontic and Periodontic procedures.
Paragraph 4.8 (n) is amended to read:
(n) Occlusal guards and complete occlusal adjustment.
Appendix B, CODE ON DENTAL PROCEDURES AND NOMENCLATURE, attached hereto, is hereby
amended.
#1163635
i
• •
CITY OF SEAL BEACH
DELTA DENTAL GROUP #7809
Date Amendment Signed: 424ff) 1/) )-12/7
By: / Za
Signature
/VA-Aid-7 'C 6-9 r77J
Printed Name
/'2-t u4-6-6/4'LL7U% /1-A JA-c-75-
Title
DATE: March 30, 2011
DELTA DENTAL OF CALIFORNIA
Belinda Martinez
Senior Vice President
Sales/Marketing
r
((el'
Kevin Jackson
Group Vice President
Underwriting & Actuarial
#1163635
1�
APPENDIX B
CODE ON DENTAL PROCEDURES AND NOMENCLATURE
NOTE: All the listed procedures may not be benefits under the terms of your contract. Refer to your
contract for your specific benefits.
DO100 - D0999 DIAGNOSTIC
• Clinical oral evaluations
D0120 Periodic oral evaluation - established patient
D0140 Limited oral evaluation — problem focused
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150 Comprehensive oral evaluation — new or established patient
D0160 Detailed and extensive oral evaluation — problem focused, by report
D0170 Re-evaluation — limited, problem focused (established patient; not post-operative visit)
D0180 Comprehensive periodontal evaluation — new or established patient
Radiographs/diagnostic imaging (including interpretation)
D0210 Intraoral — complete series (including bitewings)
D0220 Intraoral — periapical first film
D0230 Intraoral — periapical each additional film
D0240 Intraoral — occlusal film
D0250 Extraoral — first film
00260 Extraoral — each additional film
D0270 Bitewing — single film
D0272 Bitewings — two films
00273 Bitewings - three films
00274 Bitewings — four films
D0277 Vertical bitewings — 7 to 8 films
D0290 Posterior — anterior or lateral skull and facial bone survey film
00310 Sialography
D0320 Temporomandibular joint arthrogram, including injection
D0321 Other temporomandibular joint films, by report
D0322 Tomographic survey
D0330 Panoramic film
D0340 Cephalometric film
00350 Oral/facial photographic images
00360 Cone beam ct - craniofacial data capture
D0362 Cone beam - two-dimensional image reconstruction using existing data, includes
multiple images
D0363 Cone beam - three-dimensional image reconstruction using existing data, includes
multiple images
Tests and examinations
D0415 Collection of microorganisms for culture and sensitivity
D0416 Viral culture
D0421 Genetic test for susceptibility to oral diseases
D0425 Caries susceptibility tests
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including
premalignant and malignant lesions, not to include cytology or biopsy procedures
D0460 Pulp vitality tests
D0470 Diagnostic casts
CDT2011 (Eff. 01-01-11)
Oral pathology laboratory
D0472 Accession of tissue, gross examination, preparation and transmission of written report
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of
written report
D0474 Accession of tissue, gross and microscopic examination; including assessment of surgical
margins for presence of disease, preparation and transmission of written report
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
D0479 Tissue in-situ hybridization, including interpretation
00480 Accession of exfoliative cytologic smears, microscopic examination, preparation and
transmission of written report
D0481 Electron microscopy - diagnostic
D0482 Direct immunofluorescence
D0483 Indirect immunofluorescence
D0484 Consultation on slides prepared elsewhere
00485 Consultation, including preparation of slides from biopsy material supplied by referring
source
D0486 Accession of brush biopsy sample, microscopic examination, preparation and transmission of
written report
D0502 Other oral pathology procedures, by report
D0999 Unspecified diagnostic procedure, by report
D1000 - D1999 PREVENTIVE
Dental prophylaxis
D1110 Prophylaxis — adult
D1120 Prophylaxis — child through age 13
Topical fluoride treatment (office procedure)
D1203 Topical application of fluoride (prophylaxis not included) — child through age 13
D1204 Topical application of fluoride (prophylaxis not included) — adult
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
Other preventive services
D1310 Nutritional counseling for control of dental disease
D1320 Tobacco counseling for the control and prevention of oral disease
D1330 Oral hygiene instructions
D1351 Sealant — per tooth
D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth
Space maintenance (passive appliances)
D1510 Space maintainer — fixed — unilateral
D1515 Space maintainer — fixed — bilateral
D1520 Space maintainer — removable — unilateral
D1525 Space maintainer — removable — bilateral
D1550 Recementation of space maintainer
D1555 Removal of fixed space maintainer
D2000 - D2999 RESTORATIVE
Amalgam restorations (including polishing)
D2140 Amalgam — one surface, primary or permanent
D2150 Amalgam — two surfaces, primary or permanent
D2160 Amalgam — three surfaces, primary or permanent
D2161 Amalgam — four or more surfaces, primary or permanent
•
CDT2011 (Eff. 01-01-11)
Resin-based composite restorations-direct
D2330 Resin-based composite — one surface, anterior
D2331 Resin-based composite — two surfaces, anterior
D2332 Resin-based composite — three surfaces, anterior
D2335 Resin-based composite — four or more surfaces or involving incisal angle (anterior)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite — one surface, posterior
D2392 Resin-based composite — two surfaces, posterior
D2393 Resin-based composite — three surfaces, posterior
D2394 Resin-based composite — four or more surfaces, posterior
Gold foil restorations
D2410 Gold foil — one surface
D2420 Gold foil — two surfaces
D2430 Gold foil — three surfaces
Inlay/onlay restorations
D2510 Inlay — metallic — one surface
D2520 Inlay — metallic — two surfaces
D2530 Inlay — metallic — three or more surfaces
D2542 Onlay — metallic — two surfaces
D2543 Onlay — metallic — three surfaces
D2544 Onlay — metallic — four or more surfaces
D2610 Inlay — porcelain/ceramic — one surface
D2620 Inlay — porcelain/ceramic — two surfaces
D2630 Inlay — porcelain/ceramic — three or more surfaces
D2642 Onlay — porcelain/ceramic — two surfaces
D2643 Onlay — porcelain/ceramic — three surfaces
D2644 Onlay — porcelain/ceramic — four or more surfaces
D2650 Inlay — resin-based composite — one surface
D2651 Inlay — resin-based composite — two surfaces
D2652 Inlay — resin-based composite — three or more surfaces
D2662 Onlay — resin-based composite — two surfaces
D2663 Onlay — resin-based composite — three surfaces
D2664 Onlay — resin-based composite — four or more surfaces
Crowns — single restorations only
D2710 Crown — resin-based composite (indirect)
D2712 Crown — 3/4 resin-based composite (indirect)
D2720 Crown — resin with high noble metal
D2721 Crown — resin with predominantly base metal
D2722 Crown — resin with noble metal
D2740 Crown — porcelain/ceramic substrate
D2750 Crown — porcelain fused to high noble metal
D2751 Crown — porcelain fused to predominantly base metal
D2752 Crown — porcelain fused to noble metal •
D2780 Crown — 3/4 cast high noble metal
D2781 Crown — 3/4 cast predominantly base metal
D2782 Crown — 3/4 cast noble metal
D2783 Crown — 3/4 porcelain/ceramic
D2790 Crown — full cast high noble metal
D2791 Crown — full cast predominantly base metal
D2792 Crown — full cast noble metal
D2794 Crown — titanium
D2799 Provisional crown
CDT2011 (Eff. 01-01-n)
Other restorative services
D2910 Recement inlay, onlay, or partial coverage restoration
D2915 Recement cast or prefabricated post and core
D2920 Recement crown
D2930 Prefabricated stainless steel crown — primary tooth
D2931 Prefabricated stainless steel crown — permanent tooth
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown with resin window
D2934 Prefabricated esthetic coated stainless steel crown — primary tooth
D2940 Sedative filling
D2950 Core buildup, including any pins
D2951 Pin retention — per tooth, in addition to restoration
D2952 Post and core in addition to crown, indirectly fabricated
D2953 Each additional indirectly fabricated post — same tooth
D2954 Prefabricated post and core in addition to crown
D2955 Post removal (not in conjunction with endodontic therapy)
D2957 Each additional prefabricated post — same tooth
D2960 Labial veneer (resin laminate) — chairside
D2961 Labial veneer (resin laminate) — laboratory
D2962 Labial veneer (porcelain laminate) — laboratory
D2970 Temporary crown (fractured tooth)
D2971 Additional procedures to construct new crown under existing partial denture framework
D2975 Coping
D2980 Crown repair, by report •
D2999 Unspecified restorative procedure, by report
D3000 - D3999 ENDODONTICS
Pulp capping
D3110 Pulp cap — direct (excluding final restoration)
D3120 Pulp cap — indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to the
dentinocemental junction and application of medicament
D3221 Pulpal debridement, primary and permanent teeth
D3222 Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development
D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration)
D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration)
Endodontic therapy on primary teeth (including treatment plan, clinical procedures and follow-
up tare)
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration)
D3330 Endodontic therapy, molar tooth (excluding final restoration)
D3331 Treatment of root canal obstruction; non-surgical access
D3332 Incomplete endodontic therapy; inoperable; unrestorable or fractured tooth
D3333 Internal root repair of perforation defects
Endodontic retreatment
D3346 Retreatment of previous root canal therapy — anterior
D3347 Retreatment of previous root canal therapy — bicuspid
D3348 Retreatment of previous root canal therapy — molar
CDT2011 (Eff. 01-01-11)
Apexification/recalcification procedures
D3351 Apexification/recalcification/pupal regeneration — initial visit (apical closure/calcific repair of
perforations, root resorption, pulp space disinfection, etc.)
D3352 Apexification/recalcification/pulpal regeneration — interim medication replacement (apical
closure/calcific repair of perforations, root resorption, pulpal space disinfection, etc.)
D3353 Apexification/recalcification — final visit (includes completed root canal therapy — apical
closure/calcific repair of perforations, root resorption, etc.)
Apicoectomy/periradicular services
D3410 Apicoectomy/periradicular surgery — anterior
D3421 Apicoectomy/periradicular surgery — bicuspid (first root)
D3425 Apicoectomy/periradicular surgery — molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling — per root
D3450 Root amputation — per root
D3460 Endodontic endosseous implant
D3470 Intentional reimplantation (including necessary splinting)
Other endodontic procedures
D3910 Surgical procedure for isolation of tooth with rubber dam
D3920 Hemisection (including any root removal), not including root canal therapy
D3950 Canal preparation and fitting of preformed dowel or post
D3999 Unspecified endodontic procedure, by report
D4000 — D4999 PERIODONTICS
Surgical services (including usual post-operative care)
D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per
quadrant
D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per
quadrant
D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant
D4231 Anatomical crown exposure - one to three teeth per quadrant
D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or bounded
teeth spaces per quadrant
D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or bounded
teeth spaces per quadrant
D4245 Apically positioned flap
•
D4249 Clinical crown lengthening — hard tissue
D4260 Osseous surgery (including flap entry and closure) — four or more contiguous teeth or
bounded teeth spaces per quadrant •
D4261 Osseous surgery (including flap entry and closure) — one to three contiguous teeth or
bounded teeth spaces per quadrant
D4263 Bone replacement graft — first site in quadrant
D4264 Bone replacement graft — each additional site in quadrant
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration — resorbable barrier, per site
D4267 Guided tissue regeneration — nonresorbable barrier, per site (includes membrane removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area)
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
CDT2011 (Eff. 01-01-11)
Non-surgical periodontal service
D4320 Provisional splinting — intracoronal
D4321 Provisional splinting — extracoronal
D4341 Periodontal scaling and root planing — four or more teeth per quadrant
D4342 Periodontal scaling and root planing, — one to three teeth, per quadrant
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased
crevicular tissue, per tooth, by report
Other periodontal services
D4910 Periodontal maintenance
D4920 Unscheduled dressing change (by someone other than treating dentist)
D4999 Unspecified periodontal procedure, by report
D5000 — D5899 PROSTHODONTICS (REMOVABLE)
Complete dentures (including routine post-delivery care)
D5110 Complete denture — maxillary
D5120 Complete denture — mandibular
D5130 Immediate denture — maxillary
05140 Immediate denture — mandibular
Partial dentures (including routine post-delivery care)
D5211 Maxillary partial denture — resin base (including any conventional clasps, rests and teeth)
D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and teeth)
D5213 Maxillary partial denture — cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth)
D5214 Mandibular partial denture — cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth)
D5225 Maxillary partial denture — flexible base (including any clasps, rests and teeth)
D5226 Mandibular partial denture — flexible base (including any clasps, rests and teeth)
D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth)
Adjustments to dentures
D5410 Adjust complete denture — maxillary
D5411 Adjust complete denture — mandibular
D5421 Adjust partial denture — maxillary
D5422 Adjust partial denture — mandibular
Repairs to complete dentures
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth — complete denture (each tooth)
Repairs to partial dentures
D5610 Repair resin denture base
D5620 Repair cast framework
D5630 Repair or replace broken clasp
D5640 Replace broken teeth — per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
Denture rebase procedures
D5710 Rebase complete maxillary denture
D5711 Rebase complete mandibular denture
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
CDT2011 (Eff. 01-01-11)
•
Denture reline procedures
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline maxillary partial denture (laboratory)
D5761 Reline mandibular partial denture (laboratory)
Interim prosthesis
D5810 Interim complete denture (maxillary)
05811 Interim complete denture (mandibular)
D5820 Interim partial denture (maxillary)
D5821 Interim partial denture (mandibular)
Other removable prosthetic services
D5850 Tissue conditioning — maxillary
D5851 Tissue conditioning — mandibular
D5860 Overdenture — complete, by report
D5861 Overdenture — partial, by report
D5862 Precision attachment, by report
D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female
component)
D5875 Modification of removable prosthesis following implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
D5900 — D5999 MAXILLOFACIAL PROSTHETICS
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis, replacement
D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical
D5932 Obturator prosthesis, definitive
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with guide flange
D5935 Mandibular resection prosthesis without guide flange
D5936 Obturator prosthesis, interim
D5937 Trismus appliance (not for TMD treatment)
D5951 Feeding aid
D5952 Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult
D5954 Palatal augmentation prosthesis
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim
CDT2011 (Eff. 01-01-11)
D5959 Palatal lift prosthesis, modification
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier
D5987 Commissure splint
D5988 Surgical splint
D5999 Unspecified maxillofacial prosthesis, by report
D6000 – D6199 IMPLANT SERVICES
D6010 Surgical placement of implant body: endosteal implant
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
Implant supported prosthetics
D6053 Implant/abutment supported removable denture for completely edentulous arch
D6054 Implant/abutment supported removable denture for partially edentulous arch
D6055 Dental implant supported connecting bar
D6056 Prefabricated abutment — includes placement
D6057 Custom abutment — includes placement
D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble
metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)
06068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or
high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
D6078 Implant/abutment supported fixed denture for completely edentulous arch
D6079 Implant/abutment supported fixed denture for partially edentulous arch
Other implant services
D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis
and abutments and reinsertion of prosthesis
D6090 Repair implant supported prosthesis, by report
D6091 Replacement of semi-precision or precision attachment (male or female component) of
implant/abutment supported prosthesis, per attachment
D6092 Recement implant/abutment supported crown
D6094 Abutment supported crown — (titanium)
CDT2011 (Eff. 01-01-11)
D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6190 Radiographic/surgical implant index, by Report
D6093 Recement implant/abutment supported fixed partial denture
D6194 Abutment supported retainer crown for FPD — (titanium)
D6199 Unspecified implant procedure, by report
D6200 m D6999 PROSTHODONTICS, FIXED
(Each retainer and each pontic constitutes a unit in a fixed partial denture)
Fixed partial denture pontics
D6205 Pontic — indirect resin based composite
D6210 Pontic — cast high noble metal
D6211 Pontic — cast predominantly base metal
D6212 Pontic — cast noble metal
D6214 Pontic — titanium
D6240 Pontic — porcelain fused to high noble metal
D6241 Pontic — porcelain fused to predominantly base metal
D6242 Pontic — porcelain fused to noble metal
D6245 Pontic — porcelain/ceramic
D6250 Pontic — resin with high noble metal
D6251 Pontic — resin with predominantly base metal
D6252 Pontic — resin with noble metal
D6253 Provisional pontic
Fixed partial denture retainers — inlays/ onlays
D6545 Retainer — cast metal for resin bonded fixed prosthesis
D6548 Retainer — porcelain/ceramic for resin bonded fixed prosthesis
D6600 Inlay — porcelain/ceramic, two surfaces
D6601 Inlay — porcelain/ceramic, three or more surfaces
D6602 Inlay — cast high metal, two surfaces
D6603 Inlay — cast high.metal, three or more surfaces
D6604 Inlay — cast predominantly base metal, two surfaces
06605 Inlay — cast predominantly base metal, three or more surfaces
D6606 Inlay — cast noble metal, two surfaces
D6607 Inlay — cast noble metal, three or more surfaces
D6608 Onlay — porcelain/ceramic, two surfaces
D6609 Onlay — porcelain/ceramic, three or more surfaces
D6610 Onlay — cast high noble metal, two surfaces
D6611 Onlay — cast high noble metal, three or more surfaces
D6612 Onlay — cast predominantly base metal, two surfaces
D6613 Onlay — cast predominantly base metal, three or more surfaces
D6614 Onlay — cast noble metal, two surfaces
D6615 Onlay — cast noble metal, three or more surfaces
D6624 Inlay — titanium
D6634 Onlay — titanium
Fixed partial denture retainers — crowns
D6710 Crown — indirect resin based composite
D6720 Crown — resin with high noble metal
D6721 Crown — resin with predominantly base metal
D6722 Crown — resin with noble metal
D6740 Crown — porcelain/ceramic
D6750 Crown — porcelain fused to high noble metal
D6751 Crown — porcelain fused to predominantly base metal
D6752 Crown — porcelain fused to noble metal
06780 Crown — 3/4 cast high noble metal
CDT2011 (Eff. 01-01-11)
D6781 Crown — 3/4 cast predominantly base metal
D6782 Crown — 3/4 cast noble metal
D6783 Crown — 3/4 porcelain/ceramic
D6790 Crown — full cast high noble metal
D6791 Crown — full cast predominantly base metal
D6792 Crown — full cast noble metal
D6793 Provisional retainer crown
D6794 Crown — titanium
Other fixed partial denture services
D6920 Connector bar
D6930 Recement fixed partial denture
D6940 Stress breaker
D6950 Precision attachment
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated
D6972 Prefabricated post and core in addition to fixed partial denture retainer
D6973 Core buildup for retainer, including any pins
D6975 Coping — metal
D6976 Each additional indirectly fabricated post — same tooth
D6977 Each additional prefabricated post — same tooth
D6980 Fixed partial denture repair, by report
D6985 Pediatric partial denture, fixed
D6999 Unspecified, fixed prosthodontic procedure, by report
D7000 — D7999 ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7111 Extraction, coronal remnants — deciduous tooth
07140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative
care)
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated
D7220 Removal of impacted tooth — soft tissue
D7230 Removal of impacted tooth — partially bony
D7240 Removal of impacted tooth — completely bony
D7241 Removal of impacted tooth — completely bony, with unusual surgical complications
D7250 Surgical removal of residual tooth roots (cutting procedure)
Other surgical procedures
D7260 Oroantral fistual closure
D7261 Primary closure of a sinus perforation
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or
stabilization)
D7280 Surgical access of an unerupted tooth
D7282 Mobilization of erupted or malpositioned tooth to aid eruption
D7283 Placement of device to facilitate eruption of impacted tooth
D7285 Biopsy of oral tissue — hard (bone, tooth)
D7286 Biopsy of oral tissue — soft
D7287 Exfoliative cytological sample collection
D7288 Brush biopsy — transepithelial sample collection
07290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report
D7292 Surgical placement: temporary anchorage device [screw retained plate] requiring
surgical flap
CDT2011 (Eff. 01-01-11)
D7293 Surgical placement: temporary anchorage device requiring surgical flap
D7294 Surgical placement: temporary anchorage device without surgical flap
Alveoloplasty — surgical preparation of ridge fordentures •
D7310 Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces, per
quadrant
D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces, per
quadrant
D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth spaces, per
quadrant
D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per
quadrant
Vestibuloplasty
D7340 Vestibuloplasty — ridge extension (secondary epithelialization)
D7350 Vestibuloplasty — ridge extension (including soft tissue grafts, muscle reattachment,
revision of soft tissue attachment and management of hypertrophied and hyperplastic
tissue)
Surgical excision of of soft tissue lesions
D7410 Excision of benign lesion up to 1.25 cm
D7411 Excision of benign lesion greater than 1.25 cm
D7412 Excision of benign lesion, complicated
D7413 Excision of malignant lesion up to 1.25 cm
D7414 Excision of malignant lesion greater than 1.25 cm
D7415 Excision of malignant lesion complicated
D7465 Destruction of lesion(s) by physical or chemical method, by report
Surgical excision of intra-osseous lesions
D7440 Excision of malignant tumor — lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm
D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm
D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm
D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm
D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm
Excision of bone tissue
D7471 Removal of lateral exostosis (maxilla or mandible)
D7472 Removal of torus palatinus
D7473 Removal of torus manibularis
D7485 Surgical reduction of osseous tuberosity
D7490 Radical resection of maxilla or mandible
Surgical incision
D7510 Incision and drainage of abscess — intraoral soft tissue
D7511 Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of
multiple fascial spaces)
D7520 Incision and drainage of abscess — extraoral soft tissue
D7521 Incision and drainage of abscess — extraoral soft tissue — complicated (includes drainage of
multiple fascial spaces)
D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
CDT2011 (Eff. 01-01-11)
Treatment of fractures — simple
D7610 Maxilla — open reduction (teeth immobilized, if present)
D7620 Maxilla — closed reduction (teeth immobilized, if present)
D7630 Mandible — open reduction (teeth immobilized, if present)
D7640 Mandible — closed reduction (teeth immobilized, if present)
D7650 Malar and/or zygomatic arch — open reduction
D7660 Malar and/or zygomatic arch — closed reduction
D7670 Alveolus — closed reduction, may include stabilization of teeth
D7671 Alveolus — open reduction, may include stabilization of teeth
D7680 Facial bones — complicated reduction with fixation and multiple surgical approaches
Treatment of fractures — compound
07710 Maxilla — open reduction
D7720 Maxilla — closed reduction
D7730 Mandible — open reduction
D7740 Mandible — closed reduction
D7750 Malar and/or zygomatic arch — open reduction
07760 Malar and/or zygomatic arch — closed reduction
D7770 Alveolus — open reduction splinting stabilization of teeth
D7771 Alveolus — closed reduction stabilization of teeth
D7780 Facial bones — complicated reduction with fixation and multiple surgical approaches
Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with/without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non-arthroscopic lysis and lavage
D7872 Arthroscopy — diagnosis, with or without biopsy
D7873 Arthroscopy — surgical: lavage and lysis of adhesions
D7874 Arthroscopy — surgical: disc repositioning and stabilization
D7875 Arthroscopy — surgical: synovectomy
D7876 Arthroscopy — surgical: discectomy
D7877 Arthroscopy — surgical: debridement
D7880 Occlusal orthotic device, by report
D7899 Unspecified TMD therapy, by report
Repair of traumatic wounds
D7910 Suture of recent small wounds up to 5 cm
Complicated suturing (reconstruction requiring delicate handling of tissues and wide
undermining for meticulous closure)
D7911 Complicated suture — up to 5 cm
D7912 Complicated suture — greater than 5 cm
Other repair procedures
D7920 Skin graft (identify defect covered, location and type of graft)
D7940 Osteoplasty — for orthognathic deformities
•
CDT2011 (Eff. 01-01-11)
D7941 Osteotomy — mandibular rami
D7943 Osteotomy — mandibular rami with bone graft; includes obtaining the graft
D7944 Osteotomy — segmented or subapical
D7945 Osteotomy — body of mandible
D7946 LeFort I (maxilla — total)
D7947 LeFort I (maxilla — segmented) •
D7948 LeFort II or LeFort III (osteoplasty of
facial bones for rnidface hypoplasia or retrusion) — without bone graft
D7949 LeFort II or LeFort III — with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or
nonautogenous, by report
D7951 Sinus augmentation with bone or bone substitutes
D7953 Bone replacement graft for ridge preservation — per site
D7955 Repair of maxillofacial soft and/or hard tissue defect
D7960 Frenulectomy - also known as frenectomy or frenotomy — separate procedure not incidental
to another procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue — per arch
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous tuberosity
D7980 Sialolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft — mandible or facial bones, by report
D7996 Implant — mandible for augmentation purposes (excluding alveolar ridge), by report
D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar
D7998 Intraoral placement of a fixation device not in conjunction with a fracture
D7999 Unspecified oral surgery procedure, by report
D8000 - D8999 ORTHODONTICS
Limited orthodontic treatment
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
Interceptive orthodontic treatment
D8050 Interceptive orthodontic treatment of the primary dentition
08060 Interceptive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
Minor treatment to control harmful habits
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
Other orthodontic services
D8660_ Pre-orthodontic treatment visit
D8670 Periodic orthodontic treatment visit (as part of contract)
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer[s])
CDT2011 (Eff. 01-01-11)
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
D8692 Replacement of lost or broken retainer
D8693 Rebonding or recementing; and/or repaid, as required, of fixed retainers
D8999 Unspecified orthodontic procedure, by report
D9O0O — D9999 ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
D9110 Palliative (emergency) treatment of dental pain — minor procedure
D9120 Fixed partial denture sectioning
Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia
D9220 Deep sedation/general anesthesia — first 30 minutes
D9221 Deep sedation/general anesthesia — each additional 15 minutes
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide
D9241 Intravenous conscious sedation/ analgesia — first 30 minutes
D9242 Intravenous conscious sedation/ analgesia — each additional 15 minutes
D9248 Non-intravenous conscious sedation
Professional consultation
D9310 Consultation (diagnostic service provided by dentist or physician other than requesting
dentist or physician
Professional visits
D9410 House/extended care facility call
D9420 Hospital call
D9430 Office visit for observation (during regularly scheduled hours) — no other services
performed
D9440 Office visit — after regularly scheduled hours
D9450 Case presentation, detailed and extensive treatment planning
Drugs
D9610 Therapeutic parenteral drug, single administration
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
D9630 Other drugs and/or medicaments, by report
Miscellaneous services
•
D9910 Application of desensitizing medicament
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post-surgical) — unusual circumstances, by report
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9942 Repair and/or reline of occlusal guard
D9950 Occlusion analysis — mounted case
D9951 Occlusal adjustment — limited
D9952 Occlusal adjustment — complete
D9970 Enamel microabrasion
D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections
CDT2011 (Eff. 01-01-11)
D9972 External bleaching — per arch
D9973 External bleaching — per tooth
D9974 Internal bleaching — per tooth
D9999 Unspecified adjunctive procedure, by report
•
Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental
Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the copyright of
the American Dental Association, and have been accepted as the standard for data transmission purposes
under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental's
administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the
then-current version of CDT whether or not a revised Appendix B is provided.
•
cDT2n11 (Eff. 01-01-11)
• •
CITY OF SEAL BEACH
DELTA DENTAL GROUP #7809
Date Amendment Signed: 47,1.;11 /1 / d-°//
By: 1L6441 4-6 "
Signature
/V,' - j loft -S !--)
Printed Name
144 A M t &_7U i /17UA -t- r5 T
Title
DATE: March 30, 2011
DELTA DENTAL OF CALIFORNIA
Belinda Martinez
Senior Vice President
Sales /Marketing
'
Kevin Jackson
Group Vice President
Underwriting & Actuarial
#1163635
AMENDMENT NO. 7 TO AGREEMENT
RENEWAL
GROUP #07809
AGREEMENT dated January 1, 2005, as amended, between CITY OF SEAL BEACH and DELTA
DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January 1, 2012, as
follows:
Paragraph 1.4 is amended to read:
1.4 "Contract Term" means the period beginning on January 1, 2012, and ending on December 31,
2012 and each subsequent yearly period during which this Contract remains in effect.
CITY OF SEAL BEACH
DELTA DENTAL GROUP #07809
Date Amendment Signed: ? a 42t el-0/.2-
By: “F---
Signature
N4NGY 444- ��
Printed Name
14-70 j---xteO A-c. VsT-
Title
DATE: February 15, 2012
DELTA DENTAL OF CALIFORNIA
,---- -404- /ot `41.1
Belinda Martinez
Senior Vice President
Sales/Marketing
C
2
•
Kevin Jackson
Group Vice President
Underwriting & Actuarial