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

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writing to Delta Dental, please include your name, the group's name and number, the Subscriber's Member ID number, and your daytime telephone number. V. How Payment is Made If your Dentist is a Participating Dentist, Delta Dental will base payment on the Maximum Approved Fee for Covered Services. Delta Dental will send payment directly to Participating Dentists and you will be responsible for any applicable Copayments or Deductibles. Unless otherwise prohibited by state law, you will be responsible for the Maximum Approved Fee for most commonly-performed non-covered services. For other non-covered services, you will be responsible for the Dentist's Submitted Amount. If your Dentist is a Nonparticipating Dentist, Delta Dental will base payment on the Nonparticipating Dentist Fee for Covered Services. If your Dentist is an Out-of-Country Dentist, Delta Dental will base payment on the Out-of-Country Dentist Fee for Covered Services. For Covered Services rendered by a Nonparticipating Dentist or Out-of-Country Dentist, Delta Dental will usually send payxnent to the Subscriber, and you will be responsible for making full payment to the Dentist. You will be responsible for any difference between Delta Dental's payment and the Dentist's Submitted Amount. VI. Benefit Categories Important Eligible people are entitled to ONLY those benefits listed in the Summary of Dental Plan Benefits. The following is a description of various dental benefits that can be selected for a dental program. Please be certain to review the Exclusions and Limitations section regarding the benefit information listed below. Diagnostic and Preventive Services DiaQnostic and Preventive Services Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include examinations/evaluations, prophylaxes (cleanings), space maint~iiners, and fluoride treatments. Brush Biopsy Oral brush biopsy procedure and laboratory analysis to detect oral cancer. Using this diagnostic procedure, dentists can identify and treat abnoxrnal cells that could become cancerous, or they can detect the disease in its earliest and most treatable stage. The test is quick, accurate, and involves little or no patient discomfort. Emergency Palliative Treatment Emergency treatment to temporarily relieve pain, Sealants A resinous material applied to the occlusal surface of posterior teeth to prevent decay. Radiographs Form No. 1752-NC 7 NCPPOpIus-A 01/2012 X-rays as required for routine care or as necessary for the diagnosis of a specific condition.