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

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it would pay for an amalgam or composite resin restoration. c. All-porcelain/ceramic bridges - the Plan will pay only the applicable amount that it would pay for a conventional fixed bridge. d. Implanbabutment supported complete or partial dentures - the Plan will pay only the applicable amount that it would pay for a conventional denture. 19. Maximuxn Payment: a. The maximum benefit payable in any one benefit year will be limited to the Maximum Payment specified in the Sumrnary of Dental Plan Benefits. b: Delta Dental's payment for Orthodontic Services will be limited to the annual or lifetime Maximum Payment specified in the Summary of Dental Plan Benefits. 20. If a Plan Deductible amount is specified in the Surnmary of Dental Plan Benefits, Delta Dental will not be obligated to pay for any services or supplies, in whole or in part, to which the Deductible applies until the Plan Deductible amount is met. 21. Processing Policies may limit Delta Dental's payment for dental services or supplies. Delta Dental will make no payment for services or supplies that exceed the following limitations. Participating Dentists may not charge Eligible Persons for these services or supplies. All charges from Nonparticipating Dentists that exceed these limitations wffl be the responsibility of the Eligible Person: 1. Amalgam and composite resin restorations by the same Dentist or dental office are payable once in any two-year period, regardless of the number or combination of restorations placed on a surface. 2. Core buildups and other substructures are payable only when needed to retain a crown on a tooth with excessive breakdown due to caries (decay) and/or fractures. 3. Recementation of a crown, onlay, inlay, space maintainer, or bridge by the same Denrist or dental office within six months of the seating date. 4. Retention pins are payable once in any two-year period. Only one substructure per tooth is a Covered Service. 5. Root planing by the same Dentist or dental office is payable once in any two-year period. 6. Periodontal surgery by the same Dentist or dental office is payable once in any three-year period. 7. A complete occlusal adjustment is payable once in any five-year period. The fee for a complete occlusal adjustment includes a11 adjustments that are necessary for a five-year period. A limited occlusal adjustment is not payable more than three times in any five-year period. The fee for a lunited occlusal adjustment includes a11 adjustments that are necessary for a six-month period 8. Tissue conditioning is not payable more than twice per arch in any three-year period. 9. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture. 10. Services or supplies, as determined by Deita Dental, which are not rendered in accordance with generally accepted standards of dental practice. 11. Processing Policies may limit Delta Dental's payment for dental services or supplies. VIII. Coordination of Benefits Coordination of Benefits (COB) applies to this Plan when you or your Eligible Dependents are covered under more than one Plan. In that case, North Carolina COB rules deternune whether this Plan's benefits are determined before or after another plan's benefits. When this Plan is a Primary Plan, its benefits are deternuned before the other plan's benefits and without considering those benefits. When this Plan is a Secondary Plan, its benefits are deternuned after those of the other plan and may be reiiuced because of those benefits. When you are covered by more than two plans, this Plan may be a Primaiy Plan as to one or more of "those plans and may be a Secondary Plan as to the other plans. Which Plan is Primary? In general, this Plan is a Secondary Plan. Its benefits are deternuned after the other plan's benefits, unless: 1. The other plan has rules coordinating its benefits with this Plan's benefits; and Form No. t752-NC 1 2 NCPPOpIus-A 01 /2012