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

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PPO Dentists 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". M. Eligible Dependent means (a) the Subscriber's legal spouse and (b) any other dependents who meet the criteria for eligibility set forth in E~chibits A and/or B. If dependent coverage has been selected, it will be indicated in Exhibit A. N. Eligible Person means any Subscriber or Eligible Dependent under this Contract. O. Maximum Approved Fee means a system used by Delta Dental to detemrine 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£ 1. The Submitted Amount. 2. 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. 3. The xnaximum fee that the local Delta Dental Plan approves for a given procedure in a given region and/or specialty, under normal circumstances, based upon applicable Delta Dental PPO or Delta Dental Premier 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 all cases, Delta Dental will make the final determination regarding the Ma~cimum Approved Fee for a Covered Service. P. Maximum Payment means the maximum dollaz amount Delta Dental will pay in any Benefit Year or lifetime for Covered Services. The Maximum Payment is specified in Exhibit A and Exhibit B. Q. Nonparticipating Dentist Fee means the ma~cimum fee that Delta Dental will pay per procedure for services rendered by a Nonparticipating Dentist. R. Out-of-Country Dentist Fee means the maximum fee that Delta Dental will pay per procedure for services rendered by an Out-of- Country Dentist. S. Plan means the dental coverage established for Eligible Persons pursuant to this Contract. T. Post Service Claims means claims for benefits that are not conditioned on the Eligible Person seeking advance approval, certification, or authorization to receive the full amount of any covered benefit. In other words, Post Service Claims arise when the Eligible Person receives the dental service or treatment before the claim is filed for the benefit payment. Revised 09/2011