2012-038 Human Resources - Delta Dental Claims & Administrative fees

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I. Delta Dental PPO Certificate Delta Dental of North Carolina., referred to herein as Delta Dental, issues this Certificate to you, the Subscriber. The Certificate is an easy-to-read summary of your dental benefits Plan. It reflects and is subject to the agreement between Delta Dental and your employer or organization. The benefits provided under the Plan may change if any state or federal laws change. Delta Dental agrees to provide dental benefits as described in this Certificate. All the provisions in the following pages form a part of this document as fully as if they were stated over the signature below. IN WITNESS WHEREOF, this Certificate is executed at Delta Dental's home office by an authorized o~cer. ~ • Curtis R. Ladig, CPA President and CEO Delta Dental of North Carolina II. Definitions Benefit Year Normally, the calendar year, unless your employer or organization elects a different period to serve as the Benefit Year. (See the Summary of Dental Plan Benefits for your Benefit Yeaz.) Certificate This document. Delta Dental will provide dental benefits as described in this Certificate. Any changes in this Certificate will be based on changes to the Plan. Children or Child Your natural children, stepchildren, foster children, adopted children, children by virtue of legal guardianship, or children who are residing with you during the waiting period for adoption or legal guardianship. Completion Dates Some procedures may require more than one appointment before they can be completed. Treatment is complete: • For dentures and partial dentures, on the delivery dates; • For crowns and bridgework, on the cementation dates; • For root canals and periodontal treatment, on the date of the final procedure that completes treatment. Concurrent Care Claims . Claims for benefits where an ongoing course of treatment has been agreed to by Delta Dental and/or the administrator of your Plan and the coverage for that treatment is reduced or ternunated before the treatment has been completed. A Concurrent Caze Claim may also arise if you ask the Plan to extend coverage beyond the time period or number of treatments previously agreed to. Control Plan (Delta Dental Delta Dental acts as the Control Plan for your contract. The Control Plan will provide all claims processing, service, and administration for your group. The Control Plan will be referred to as Delta Dental in this document. Copayment As provided by your Plan, the percentage of the charge, if any, that you will have to pay for Covered Services. Covered Services The unique benefits selected in your Plan. The Sux~unary of Dental Plan Benefits provided with this Certificate lists the Covered Services provided by your Plan. Deductible 'The amount.a person and/or a family must pay toward Covered Services before Delta Dental begins paying for services. The Summary of Dental Plan Benefits lists the Deductible that applies to you, if any. Form No. 1752-NC 2 NCPPOpIus-A 01l2012