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

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Delta Dental Means Delta Dental of North Carolina, a North Cazolina nonprofit health service plan corporation providing dental benefits. Delta Dental is not a commercial insurance company. Delta Dental Plan An individual dental benefit plan that is a member of the Delta Dental Plans Association, the nation's largest, most experienced system of dental health plans. Delta Dental PPO qlus Premier Delta Dental's national preferred provider organization program that can reduce your out-of-pocket expenses if you receive care from one of Delta Dental's PPO Dentists. This program has back-up coverage through the Delta Dental Premier network when treatment is received from a Non-PPO Dentist. Delta Dental Premier Dentist A person licensed to practice dentistry in the state or jurisdiction in which dental services are rendered. • Delta Dental PPO Dentist (PPO Dentist) - a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in Delta Dental PPO. PPO Dentists agree to accept Delta Dental's payment and the Eligible Person's Copayment, if any, as payment in full for Covered Services. • Delta Dental Premier Dentist (Premier Dentist) - a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in Delta Dental Premier. Premier Dentists agree to accept the Maximum Approved Fee as payxnent in full for Covered Services. • Nonparticipating Dentist - a Dentist who has not signed an agreement with any Delta Dental Plan to participate in Delta Dental PPO or Delta Dental Premier. • Out-of-Country Dentist - a Dentist whose off'ice is located outside of the United States and its territories. Out-of-Country Dentists are not eligible to sign participating agreements with Delta Dental, but may participate in the Passport Dental program. PPO Denrists and Premier Dentists are sometimes collectively referred to herein as "Participating Dentists". Wherever a definition or provision of this Contract differs from another state's Delta Dental Plan and its agreement with a Participating Dentist, the agreement in that state with that Dentist shall be controlling. Premier Dentists, Nonparticipating Dentists, and Out- of-Country Dentists are sometimes collectively referred to herein as "Non-PPO Dentists". EliQible De~endent The Surrunary of Dental Plan Benefits will have specific information about your Plan's rules for dependent eligibility but, generally, your Eligible Dependents are: • Your legal spouse; • Your unmarried Children who have not yet reached the end of the calendar year of their 19th birthday; • Your unmarried Children who have reached the end of the calendar year of their 19th birthday and who are chiefly dependent on you for support and maintenance; • Any unxnarried Children for whom you or your legal spouse are financially responsible for medical, health, or dental care under the terms of a court decree or who have been named as alternate recipients under a qualified medical child support order; and • Your Children who have reached the end of the calendar year of their 19th birthday, but who were Form No. 1752-NC 3 NCPPOpIus-A 01/2012 Delta Dental's national fee-for-service dental benefits program that covers you when you go to a Non-PPO Dentist.