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

Browse Search

Basic Services Oral Surgery Services Extractions and dental surgery, including pre-operative and post-operative care. Endodontic Services The treahnent of teeth with diseased or damaged nerves (for example, root canals). Periodontic Services The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (teeth cleaning by a specialist). Restorative Services Services to rebuild and repair natural tooth structure damaged by disease or injury. Restorative services include: • Minor restorative services, such as amalgam (silver) fillings and composite resin (white) fillings. • Major restorative services, such as crowns, used when teeth cannot be restored with another filling material. Major Services Relines and Repairs Relines and repairs to partial and complete dentures, and repairs to bridges. Prosthodontic Services Services and appliances that replace missing natural teeth (such as bridges, endosteal implants, partial dentures, and complete dentures). Orthodontic Services Services, treatment, and procedures to correct malposed teeth (such as braces). Other Benefits The Summary of Dental Plan Benefits lists any other benefits that may have been selected. VII. Exclusions and Limitations Exclusions Delta Dental will make no payment for the following services or supplies, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for the following services or supplies will be the responsibility of the Eligible Person (though the Eligible Person's payment obligation may be satisfied by insurance or some other arrangement for which he or she is eligible): 1. Services or supplies for the treatment of an occupational injury or sickness which are paid under the North Carolina Worker's Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers' compensation insurance carrier according to a final adjudication under the North Carolina Workers' Compensation Act or an order of the North Carolina Industrial Coxnmission approving a settlement agreement under the North Carolina Workers' Compensation Act. 2. Benefits or services received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act; that is, Medicaid. 3. Services or supplies, as detertnined by Delta Dental, for correction of congenital or developmental malformations, except that when a child covered from the moment of birth or placement in the adoptive home requires dental care associated with congenital defects and anomalies, congenital defects will be covered to the same extent an otherwise Covered Service is provided by the Plan. 4. Cosmetic surgery or dentistry for aesthetic reasons, as detennined by Delta Dental, except that when a Child covered from the moment of birth or placement in the adoptive home requires dental care associated with congenital defects and anomalies, congenital defects will be covered to the same extent an otherwise Covered Service is provided by the Plan 5. Services or appliances started before a person became eligible under this Plan. This exclusion Form No. 1752-NC $ NCPPOpIus-A 01/2012