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

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2. To make no payments from the money received from the Contractor for any services rendered to a person who is not eligible for dental benefits as defined in this Plan; provided, however, that Delta Dental receives timely information from the Contractor regazding the eligibility of each Subscriber and Eligible Dependent, as set forth in Section III.B.2. No retroactive eligibility updates, including additions and ternunations, will be accepted for an effective date more than 90 days prior to the date of receipt of the update by Delta DentaL 3. To endeavor to enlist Dentists to become Participating Dentists in sufficient number to ensure an adequate choice of Dentists, and to make periodic checks regarding the adequacy of care provided by Dentists to people covered by this Plan. Delta Dental is not required to schedule a dental appointment for an Eligible Person. 4. To contractually require each Participating Dentist to schedule and render all dental treatment provided under this Plan according to the standards of the dental profession in the community in which the dental procedures are rendered. 5. To make payments in the following manner for dental services provided to Eligible Persons. The program that is chosen by the Contractor (or its affiliates) will determine how payment is made: a. Delta Dental Premier If the Dentist is a Participating Dentist, Delta Dental will base payment on the Maximum Approved Fee. Delta Dental will send payment directly to Participating Dentists and the Eligible Person will be responsible for any applicable Copayments or Deductibles. Unless prohibited by state law, the Eligible Person will be responsible for the Maximum Approved Fee for most commonly-performed non-covered services. For other non-covered services, the Eligible Person will be responsible for the Dentist's Submitted Amount. ff the Dentist is a Nonparticipating Dentist, Delta Dental will base payment on the lesser of the Submitted Amount or the Nonparticipating Dentist Fee. Delta Dental will usually send payment to the Subscriber, who is responsible for making full payment to the Nonparticipating Dentist. The Eligible Person will be responsible for any difference between Delta Dental's payment and the Dentist's Submitted Amount. If the Dentist is an Out-of-Country Dentist, Delta Dental will base payxnent on the lesser of the Submitted Amount or the Out-of-Country Dentist Fee. Delta Dental will send payment to the Subscriber, who is responsible for making full payment to the Dentist. The Eligible Person will be responsible for any difference between Delta Dental's payment and the Dentist's Submitted Amount. b. Delta Dental PPO (Standard) To make payments for Covered Services provided to Eligible Persons based on the lesser of the Submitted Amount or the PPO Dentist Schedule. Delta Dental will send payment directly to Participating Dentists and the Eligible Person will be responsible for any applicable Copayments or Deductibles. If the Dentist is not a PPO Dentist, but is a Premier Dentist, the Eligible Person will also be responsible for any difference between the PPO Dentist Schedule and the Premier Dentist Schedule for Covered Services, in addition to Copayments or Deductibles. Unless prohibited by state law, the Eligible Person will be responsible for the Malcimum Approved Fee for most commonly-performed non-covered services. For other non-covered services, the Eligible Person will be responsible for the Dentist's Submitted Amount. For Covered Services rendered by a Nonparticipating Dentist or Out-of-Country Dentist, Delta Dental will usually send payment to the Subscriber, who is responsible for inaking full payment to the Denrist. The Eligible Person will be responsible for any difference between Delta Dental's payment and the DentisYs Submitted Amount. c. Delta Dental PPO plus Premier Revised 09/2011