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

Browse Search

37. Precision attachments and stress breakers. 38. Specialized implant surgical techniques, including a radiographic/surgical implant index. 39. Appliances, restorations, or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ). 40. Diagnostic photographs, diagnostic casts (study models), and cephalometric films, unless done for orthodontics. 41. Myofunctional therapy. 42. Mounted case analyses. Delta Dental will make no payment for the following services or supplies. Participating Dentists may not charge Eligible Persons for these services or supplies. All charges from Nonparticipating Dentists for the foilowing services or supplies will be the responsibility of the Eligible Person: 1. The completion of forms or submission of claims. 2. Consultations, when performed in conjunction with examixiations/evaluations. 3. Local anesthesia. 4. Acid etching, cement bases, cavity liners, and bases or temporary fillings. 5. Infection control. 6. Temporary crowns. 7. Gingivectomy as an aid to the placement of a restoration. 8. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces. 9. Diagnostic casts, when performed in conjunction with restorative or prosthodontic procedures. 10. Palliative treatment, when any other service is provided on the same date except X-rays and tests necessary to diagnose the emergency condition. 11. Post-operative X-rays, when done following any completed service or procedure. 12. Periodontal charting. 13. Pins and/or preformed posts, when done with core buildups for crowns, onlays, or inlays. 14. A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with pulpal debridement for the relief of acute pain before conventional root canal therapy or another endodontic procedure. The opening and draina.ge of a tooth or palliative treatment, when done by the same Dentist or dental office on the same day as completed root canal treatrnent. 15. A pulpotomy on a permanent tooth, except on a tooth with an open apex. 16. A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed. 17. Retreatment of a root canal by the same Dentist or dental office within two years of the original root canal treatment. 18. A prophylaxis or full mouth debridement, when done on the same day as periodontal maintenance or scaling and root planing. 19. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard. 20. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture. 21. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture. Limitations The Benefits for the following services or supplies are limited as follows, unless otherwise specified in the Summary of Dental Plan Benefits. All charges for services or supplies that exceed these limitations will be the responsibility of the Eligible Person. All time limitations are measured from the last date of service in any Delta Dental Plan record or, at the request of your group, any dental plan record: 1. Bitewing X-rays are payable once per calendar year. Full mouth X-rays (which include bitewing X- rays) aze payable once in any five-year period. A panographic X-ray (including bitewings) is considered a full mouth X-ray. 2. Any combination of prophyla~ces (teeth cleanings) and periodontal maintenance procedures are payable twice per calendar year. 3. Oral exaininations/evaluations are only payable twice per calendar year, regardless of the Dentist's specialty. 4. Preventive fluoride treatments are payable twice per calendar year for people under age 19. Form No. 1752-NC 1 Q NCPPOpIus-A 01/2012