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

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U. PPO Dentist Schedule means the ma~cimum amount allowed per procedure for services rendered by a PPO Dentist as deternuned by that Dentist's local Delta Dental Plan. V. Premier Dentist Schedule means the maximum fee allowed per procedure for services rendered by a Premier Dentist as deternuned by that Dentist's local Delta Dental Plan. W. Predetermination means a voluntary and optiona.l process where, at the request of a Subscriber, Eligible Dependent or Dentist, Delta Dental issues a written estimate of dental benefits which may be available for a proposed dental service under the terrns of the Subscriber's coverage. Predeternunation is provided for informational purposes only and is not required in advance of obtaining dental care or as a prerequisite or condition for approval of fuhue dental benefits payment. The benefits estimate provided on a Predetermination notice is determined based on the benefits available for the Subscriber or Eligible Dependent on the date the notice is issued, and is not a guarantee of future dental benefits payment. Availability of dental benefits at the time a dental service is completed depends on factors such as, but not limited to, eligibility for benefits, annual or lifetime Maximum Payrnents, coordination of benefits, Contract and Dentist status, Contract limitations and other provisions. A request for a Predeternunation is not a claim for benefits or a preauthorization, precertification or other reservation of future benefits.. X. Processing Policies means Delta Dental's policies and guidelines used for Predeternunation and payment of claims. The Processing Policies may be amended from time to time. Y. Rate means the amount, per Subscriber and Subscriber classification, the Contractor agrees to pay Delta Dental each month. This amount, or the information necessary to compute it, is specified in Exhibit A. Z. Submitted Amount means the amount a Dentist bills to Delta. Dental for a specific treatment. A Participating Dentist cannot charge the Eligible Person for the difference between this amount and the amount Delta Dental approves for the h-eatment. AA. Subscriber means all people who are a members of the group specified in Exhibit A and aze certified as being eligible by the Contractor and are enrolled to receive Benefits under this Contract. Section III. Agreements A. Delta Dental agrees: 1. To provide all claims processing, service, and administration for a group. Delta Dental shall provide all administrative services related to the Plan, including, but not limited to (a) adjudication, processing, and payment of claims; (b) providing the Plan with access to the Delta Dental National Provider network, network development, contracting and ongoing relations with dentists with respect to the Dental Plan, and interfacing with other Delta Dental Plans for network access and development activities in other states as required by the Plan; (c) assisting the Plan with establishing underwriting standazds, if any, for the Dental Plan; (d) providing all customer service functions for the Plan and the Plan Subscribers; and (e) maintaining adequate books and records of all transactions related to the services to be provided hereunder by Delta Dental. Revised 09/2011 4