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

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5. Space maintainers are payable for people under age 14. 6. Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent molazs for people under age 16. The surface must be free from decay and restorations. 7. Cast restorations (including j ackets, crowns, and onlays) and associated procedures (such as core buildups and post substructures) are payable once in any five-year period per tooth. 8. Crowns or onlays are payable only for extensive loss of tooth structure due to caries (decay) and/or fracture. 9. Individual crowns over implants are payable at the prosthodontic benefit level. 10. Substructures, porcelain, porcelain substrate, and cast restorations are not payable for people under age 12. 11. An occlusal guard is payable once in a lifetime. 12. An interim partial denture is payable only for the replacement of permanent anterior teeth for people under age 17 or during the healing period for people age 17 and over. 13. Prosthodontic Services limitations: a. One complete upper and one complete lower denture are payable once in any five-year period. b. A removable partial denture, implant, or fixed bridge is payable once in any five-yeaz period unless the loss of additional teeth requires the construction of a new appliance. c. Fuced bridges and removable cast partial dentures are not payable for people under age 16. d. A reline or the complete replacement of denture base material is payable once in any two-year period per appliance. e. Implant removal is payable once per lifetime per tooth or area. f. Implant maintenance is payable once per calendar yeaz. 14. Orthodontic Services limitations: a. Orthodontic benefits are payable for people under age 19. b. If the treatment plan is ternunated before completion of the case for any reason, Delta Dental's obligation for payxnent of benefits ends on the last day of the month in which the patient was last treated. c. The Dentist may ternunate treatment, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. In those cases, Delta Dental's obligation for payment of benefits ends on the last day of the month in which the patient was last treated. d. An observation and adjustment is a benefit twice in a 12-month period. 15. Delta Dental's obligation for payment of benefits ends on the last day of coverage. However, Delta Dental will make payment for Covered Services provided on or before the last day of coverage, as long as it receives a claim for those services within one year of the date of service. Failure to submit a claim within the time required does not invalida.te or reduce any claim however, if it was not reasonably possible for the claimant to file the claim within that time, provided that the claim is submitted as soon as possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time submittal of the claim is otherwise required. 16. When services in pmgress aze interrupted and completed later by another Dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each Dentist. 17. Care ternunated due to the death of an Eligible Person will be paid to the limit of Delta Dental's liability for the services completed or in progress. 18. Optional treatment: If you select a more expensive service than is customarily provided, Delta Dental will make an allowance based on the fee for the customarily provided service. You are responsible for the difference in cost. Listed below are some examples of optional services. Remember, you are responsible for the difference in cost for any optional treatment. a. Overdentures - the Plan will pay only the applicable amount that it would pay for a conventional denture. b. Inlays, regardless of the material used - the Plan will pay only the applicable amount that Form No. 1752-NC 11 NCPPOpIus-A 01 /2012