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

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at that time (and continue to be), totally and permanently disabled by a physical or mental condition and who are chiefly dependent upon you for support and maintenance. If Delta Dental asks you to do so, you must submit medical reports conf"urning your Child's initial disability within 31 days of the end of the calendar year of that Child's 19~ birthday. Thereafter, Delta Dental may request proof of your Child's continuing disability, but no more frequently than annually. Eliqible Person Any Subscriber or Eligible Dependent with coverage under the Plan. Maximum Approved Fee A system used by Delta Dental to determine the approved fee for a given procedure for a given Participating Dentist. A fee meets Maximum Approved Fee requirements if it is the lowest o£ • The Submitted Amount. • The lowest fee regularly charged, offered, or received by an individual Dentist for a dental service or supply, irrespective of the Dentist's contractual agreement with another dental benefits organization: • The maximum fee that the local Delta Dental Plan approves for a given procedure in a given region and/or specialty, under noxmal circumstances based upon applicable Participating Dentist schedules and intemal procedures. Delta Dental may also approve a fee under unusual circumstances. Participating Dentists are not allowed to charge Delta Dental patients more than the Maximum Approved Fee for a Covered Service. In a11 cases, Delta Dental will ma.ke the final detemunation regarding the Maximum Approved Fee for a Covered Service. Maximum Pavment The maximum dollaz amount Delta Dental will pay in any benefit year or lifetime for covered dental services. (See the Summary of Dental Plan Benefits.) Nonparticipating Dentist Fee The maximum fee that Delta Dental will pay per procedure for services rendered by a Nonparticipating Dentist. Out-of-Countrv Dentist Fee The maximum fee that Delta Dental will pay per procedure for services rendered by an Out-of-Country Dentist. Plan The azrangement for the provision of dental benefits to Eligible Persons established by the contract between Delta Dental and your employer or organization. Post-Service Claims Claims for benefits that are not conditioned on your seeking advance approval, certification, or authorization to receive the full amount of any covered benefit. In other words, Post-Service Claims arise when you receive the dental service or treatment before you file a claim for the benefit payment. PPO Dentist Schedule The maximum fee allowed per procedure for services rendered by a PPO Dentist as deternuned by that Dentist's local Delta Dental Plan. Premier Dentist Schedule The maximum fee allowed per procedure for services rendered by a Premier Dentist as deternuned by that Dentist's local Delta Dental Plan. Predetermination Predetermination is a voluntary, optional procedure where Delta Dental issues a written estimate of Benefits which may be available under your Plan for your proposed dental treatment. Your Dentist submits the proposed dental treatment to Delta Dental in advance of providing the treatment. Predetermination is provided for informational purposes only and is not required before you receive any dental care. It is not a prerequisite or condition for approval of future dental benefits payment. You will receive the same Benefits under your Plan whether or not a Predeterminafion is requested. The Benefits estimate provided on a Predeternunation notice is based on Benefits available on the date the notice is issued. It is not a guarantee of future Benefits or payment. Availability of Benefits at the time your treatment is completed depends on several factors such as, but not limited to, your continued eligibility for Benefits, your Form No. 1752-NC 4, NCPPOpIus-A 01 /2012