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July 16, 2007
Lori Carney
Human Resources
City of Palm Desert
73-510 Fred Waring Drive
Palm Desert, CA 92260
RE: Delta Dental Group # 65
Dear Lori:
Enclosed are two (2) copies of the issued contract.
I have reviewed them for accuracy. Please obtain signatures on the signature pages and
return a copy to me in the enclosed envelope. Please retain a signed copy for your files.
Should you have any questions, please call me at (310) 543-9995.
Sincerely,
Deirdre Dwane
Account Manager
Enclosures
cc: Kristin Yokoyama
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DELTA DENTAL OF CALIFORNIA
(A Not-for-Profit Corporation Incorporated in California
and a Member of the Delta Dental Plans Association)
Home Office: 100 First Street, San Francisco, California 94105
(Herein referred to as"Delta Dental")
415-972-8300
Group Number 65
IN CONSIDERATION of the application made by CITY OF PALM DESERT, referred to in this
Contract as '�the Contractholder," and IN CONSIDERATION of payment by the Contractholder
of the Premiums as stated in Article 3, Delta Dental agrees to provide the Benefits in Artic{e 4
for a period of two years, beginning at 12:01 a.m., Standard Time, on the Effective Date,
July 1, 2007, and continuing from year to year thereafter, unless this Contract is terminated
in accordance with Article 9. Premiums are payable by the Contractholder before the
Effective Date, and thereafter as stated in Article 3.
The following documents are attached to this Contract and made a part hereof:
Appendix A Orthodontic Benefit Rider
Appendix B Current Dental Terminology
This Contract contains the following Articles:
Article 1 Definitions
Article 2 Eligibility
Article 3 Premium Payments
Article 4 Benefits Provided; Limitations and Exclusions
Article 5 Deductibles & Maximum Amount
Articfe 6 Coordination of Benefits
Article 7 Conditions Under Which Delta Dental Will Provide Benefits
Article 8 Other Delta Dental Obligations
Article 9 Termination and Renewal
Article 10 Continued Coverage Option
Article 11 General Provisions
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ARTICLE 1 - DEFiNITIONS
These terms, when used in this Contract, mean the following:
1.1 Administrator - a third party entity designated by Delta Dental to perform
administrative functions described throughout this Contract, including, but not limited
to, the collection of premium and eligibility.
1.2 Benefits - those dental services that are available under the terms of this Contract
as set out in Article 4.
1.3 Contract - this agreement between Delta Dental and the Contractholder including the
attached appendices. This Contract is the entire Contract between the parties.
1.4 Contract Term - the period beginning on the EfFective Date and ending on June 30,
2009, and each subsequent yearly period during which this Contract remains in effect.
1.5 Delta Dental PPO Dentist - a Dentist with whom Delta Dental has a written
agreement to provide services at the in-network level for Enrollees in this Delta Dental
PPO Plan.
1.6 Delta Dental PPO Dentist's Fee - the fee that a Delta Dental PPO Dentist has
contractually agreed with Delta Dental to accept for treating Enrollees under this
plan, or the Fee Actually Charged, whichever is less, for a Single Procedure.
1.7 Delta Dental PPO Dentist's Prevailing Fee - the fee for a Single Procedure that
satisfies the majority of Delta Dental PPO Dentists, as determined by Delta Dental
based upon confidential fee listing accepted by Delta Dental from Delta Dental PPO
Dentists.
1.8 Delta Dental Dentist - a Dentist who has signed an agreement with Delta Dental or a
Participating Plan, agreeing to provide services under the terms and conditions
established by Delta Dental or the Participating Plan.
1.9 Dentist - a duly licensed Dentist legally entitled to practice dentistry when and where
services are provided.
1.10 Dependent - a Primary Enrollee's Dependent who is eligible for Benefits under Article
2 of this Contract.
1.11 Eligibility Date - the date an Enrollee's eligibility for Benefits becomes effective under
the terms of this Contract.
1.12 Enrollee - a Primary Enrollee or Dependent who is eligible and enrolls for Benefits
under Article 2 of this Contract, or a person ceasing to meet such conditions who
chooses Continued Coverage as set out in Article 10, and for whom Delta Dental
receives the appropriate monthly payment as set out in Article 3.
1.13 Enrollee Co-payment - the portion of the Dentist's fees or allowances charged for
Benefits that is the Enrollee's responsibility.
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1.14 Fee Actually Charged - the fee for a particular dental service or procedure that a
Dentist submits to Delta Dental on a claim form, less any portion of such fee that is
discounted, waived or rebated, or which the Dentist does not use good faith efforts
to collect.
1.15 Participating Plan - Delta Dental and any other member of the Delta Dental Plans
Association with which Delta Dental contracts to assist it in administering the Benefits
of this Contract.
1.16 Premiums - the amounts payable by the Contractholder as provided in Article 3.
1.17 Prevailing Fee - an allowance determined by Delta Dental and/or a Participating Plan
for services provided by a dentist who is not a Delta Dental Dentist.
1.18 Primary Enrollee - an individual, who by their association with the Contractholder, is
eligible for Benefits under Article 2 of this Contract.
1.19 Procedure Numbers - the Procedure Numbers shown on Appendix B.
1.20 5ingle Procedure - a dental procedure to which a separate Procedure Number has
been assigned by the American Dental Association in the current version of Current
Dental Terminology (CDT). Many CDT codes are listed in Appendix B of this Contract.
1.21 For a Dentist who has signed a Delta Dental Dentist Agreement with Delta Dental of
California, his or her "Usual, Customary and Reasonable Fee" for any Single Procedure
is the fee that the Dentist has filed with Delta Dental and which Delta Dental has
accepted. For these Dentists, the words "Usual, Customary and Reasonable" means
the following:
Usual - the amount which a Dentist regularly charges and receives for a given
service. If the Dentist charges more than one fee for a given service, the "usual" fee
for that service is the lowest fee which the Dentist regularly charges or ofFers.
Customary - the fee is within the range of usual fees charged and received for a
particular service by Dentists of similar training in the same geographic area which
Delta Dental determines is statistically relevant.
Reasonable - a fee schedule is reasonable if it is "usual" and "customary."
Additionally, a specific fee to a specific Enrollee is reasonable if it is justifiable
considering special circumstances, or extraordinary difficulty, of the case in question.
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ARTICLE 2- ELIGIBILITY
2.1 All regular employees are required to enroll in this plan. Eligible employees are eligible
to receive Benefits on their date of hire.
2.2 Once a Primary Enrollee dects to discontinue dependent coverage, Dependents may
not be re-enrolled under this plan, unless the Dependent is the subject of a Qualified
Medical Child Support Order requiring the Primary Enrollee to provide the Dependent
Benefits under this plan.
2.3 Dependents are the Primary Enrollee's legal spouse or registered domestic partner and
unmarried dependent children from birth to age 19, or to age 23 if enrolled as full-time
students in an accredited school, college or university. Children include stepchildren,
adopted children, children placed for adoption and foster children, provided they
depend upon the Primary Enrollee for support and maintenance. The Dependents of
Primary Enrollees are eligible to enroll on the same date that the employee, of whom
they are a Dependent, becomes a Primary Enrollee. Later-acquired Dependents
become eligible as soon as they acquire dependent status.
Registered domestic partners are defined as same sex partners, who are both at least
18 years of age or older, and opposite sex partners when one or both partners are
over the age of 62 and entitled to Social Security benefits. Registered domestic
partners are required to register with the Secretary of State of the State of California
a Declaration of Domestic Partnership. A registered domestic partner is subject to the
same terms and conditions as any other Dependent enrolled under this Contract.
Registered domestic partners are eligible for continuation of coverage under COBRA.
2.4 An unmarried child, 19 years old or older, may continue to be a Dependent even
though not enrolled as a full-time student if they are incapable of self-support
because of physical or mental incapacity, if that handicap or incapacity began before
they reached age 19, and if they are chiefly dependent upon the Primary Enrollee for
support and maintenance. Proof of such handicap or incapacity and dependency must
be submitted within thirty-one (31) days after request for such proof from either the
Contractholder or Delta Dental. Neither Delta Dental nor the Contractholder will
request such proof more frequently than annually after the child in question has
reached age 21.
2.5 Dependents in military service are not eligible.
2.6 Every enrolled employee and Dependent meeting the preceding conditions of eligibility
is an Enrollee. However, Delta Dental will not provide Benefits for any employee or his
or her Dependents unless (1) the employee is included on the list of Primary Enrollees
submitted as required by this Article (or any revision or correction of such a list), and
(2) the appropriate payments are made as required by Article 3 of this Contract, for
the months in which Delta Dental provides covered dental services.
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2.7 The Contractholder agrees to enroll all of its Primary Enrollees in this plan. All
employees of the Contractholder meeting the eligibility requirements of this Article are
"Primary Enrollees" under this plan unless the Contractholder offers one or more
alternate plans of dental coverage. In that event, Primary Enrollees will continue to be
eligible under this plan unless they file a choice card with the Contractholder electing
an alternate plan during an open enrollment period agreed upon between Delta Dental
and the Contractholder. The Contractholder agrees to bear the �tire expense of
Premiums payments for employees who continue to be Primary Enrollees under this
plan.
2.8 The Contractholder will compile and furnish Delta Dental with an initial report of all
Primary Enrollees, showing their Enrollee ID numbers, their dates of hire and division
codes. The initial report shall be provided to Delta Dental or prior to the Effective
Date of this Contract. The Contractholder also agrees to report all persons electing
continued coverage under Article 10, showing their Enrollee ID numbers and date of
election.
2.9 The Contractholder may continue to submit subsequent eligibility reports monthly or
may report only additions or deletions to the initial report. If the report is not updated
by the Contractholder or has not arrived or been processed for the current month,
Delta Dental will extend the {ast report received to process claims. The extension of
the eligibility report does not waive the requirement that the Contractholder provide
an updated report to Delta Dental each month indicating additions or deletions from
any previous report. The Contractholder shall pay, as set forth in Article 3, a11
Premiums applicable for Primary Enrollees reported in the updated report.
2.10 Enrollees are not eligible during a period the Primary Enrollee does not report to work
on a regular basis and is not actively employed as determined by the Contractholder.
Eligibility resumes on the first day of the month following the return to active
employment if amounts due to Delta Dental for Enrollees have been paid. Eligibility
can continue without interruption if the Contractholder continues to report the
employee as a Primary Enrollee and the amounts due to Delta Dental are paid on the
employee's behalf.
Coverage is reinstated on the day employment is resumed for Enrollees that are
members of the National Guard or a military reserve unit absent from work due to
active military duty.
2.11 A Primary Enrollee absent from work due to a leave of absence governed by the
"Family and Medical Leave Act of 1993" (P.L. 103-3) will not be subject to Section
2.10.
2.12 A Primary Enrollee absent from work due to a leave of absence governed by the
'�Uniformed Services Employment and Re-employment Rights Act of 1994" (P.L. 103-
353) will not be subject to Section 2.10. Such Primary Enrollee shall have the right to
continue coverage for up to 24 months while he or she is on military leave. If the
Primary Enrollee elects this continued coverage, he or she must submit the Premiums
necessary to the Contractholder.
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2.13 A Primary Enrollee's eligibility ends on the last day of the month in which his or her
full-time employment ends, unless he or she chooses to continue coverage under
Article 10. A Dependent's eligibility ends along with the Primary Enrollee's, or sooner if
the Dependent loses his or her Dependent status, unless continued coverage is
chosen in a timely fashion by or on behalf of the Dependent(s) under Article 10.
Eligibility for such continued coverage will continue for the period required by the
Option. In any event, eligibility ends immediately when this Contract ends.
2.14 The Contractholder agrees to permit Delta Dental, by its auditors or other authorized
representatives, on reasonable advance written notice, to inspect the
Contractholder's records in order to verify the accuracy of lists of Primary Enrollees
prepared by the Contractholder and submitted to Delta Dental and to verify the
Contractholder's compliance with Article 3 of this Contract.
ARTICLE 3 — PREMIUM PAYMENTS
3.1 Within 10 days after receipt of Delta Dental's invoice, the Contractholder agrees to
pay the following monthly Premiums to Delta Dental, at the address shown on the first
page of this Contract, for all of the Contractholder's Primary Enrollees and their
Dependents who are Enrollees as set forth in Article 2 of this Contract:
$ 39.18 for each Primary Enrollee without Dependents;
$ 73.87 for each Primary Enrollee with one Dependent; and,
$ 124.73 for each Primary Enrollee with two or more Dependents.
The Contractholder agrees to bear the cost of such Premiums without withholding or
otherwise charging Primary Enrollees for the coverage of themselves or their
Dependents.
Contractholder agrees to pay the invoiced amount. Eligibility adjustments reported to
Delta Dental after the date the invoice is prepared will be reflected on the subsequent
month's invoice. Such adjustments are limited to the three-month period prior to the
most current month for which the Contractholder provides eligibility data.
3.2 The Premium for each person electing continued coverage under the Continued
Coverage Option in Article 10 for himself or herself will be the same as that for a
single Primary Enrollee. The Premium for a person who also elects continued coverage
for his or her Dependents is the same as that for a Primary Enrollee with the same
number of Dependents. The Contractholder may charge persons choosing coverage
under Article 10 such amounts as are permitted by law.
3.3 This Contract is not in effect until Delta Dental receives the initial Premiums from the
Contractholder.
3.4 If this Contract terminates for any reason, the Contractholder agrees to pay all
Premiums earned by Delta Dental but unpaid by the Contractholder.
3.5 Except as provided in the next paragraph, an agreement between Delta Dental and
the Contractholder is required to change the Contractholder's Premium rates during a
Contract Term.
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3.6 During a Contract Term, if any government agency imposes any new tax on Delta
Dental based on the amount of Premiums payable or the number of persons covered
under this Contract, or if the rate of any existing tax on the amount of Premiums or
the number of persons covered under this Contract increases, the Premiums stated in
this Article will increase by the amount of any such new or increased tax(es).
3.7 Premiums and eligibility may be adjusted retroactively by Delta Dental or the
Contractholder, but such adjustments are limited to the three-month period prior to
the most current month for which the Contractholder provides eligibility data.
ARTICLE 4- BENEFITS PROVIDED; LIMITATIONS AND EXCLUSIONS
4.1 Subject to the limitations and exclusions set forth below, the following services are
Benefits when they are provided by a Dentist and when they are necessary and
customary as determined by the standards of generally accepted dental practice.
4.2 DIAGNOSTIC AND PREVENTIVE BENEFITS. Delta Dental agrees to pay 100% of the
Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged,
whichever is less, or 100% of the Delta Dental PPO Dentist's Fee for the following
Diagnostic and Preventive Benefits:
Diagnostic- oral examinations including
initial examinations,
periodic examinations and
emergency examinations
x-rays
diagnostic casts
examination of biopsied tissue
palliative (emergency) treatment of dental pain
specialist consultation
Preventive- prophylaxis (cleaning)
topical application of fluoride solution
space maintainers
Note on additional Benefits during pregnancy - When an Enrollee is pregnant,
Delta Dental will pay for additional services to help improve the oral health of the
Enrollee during the pregnancy. The additional services each calendar year while the
Enrollee is covered under this Contract incfude: one (1) additional oral exam and
either one (1) additional routine cleaning or one (1) additional periodontal scaling and
root planing per quadrant. Written confirmation of the pregnancy must be provided
by the Enrollee or her dentist when the claim is submitted.
4.3 BASIC BENEFITS. Delta Dental agrees tn pay 80% of the Dentist's Usual, Customary
and Reasonable fees or the Fee Actually Charged, whichever is less, or 80% of the
Delta Dental PPO Dentist's Fees for the following Basic Benefits:
Oral Surgery- extractions and certain other surgical procedures, including pre- and
post-operative care
Restorative- amalgam, silicate or composite (resin) restorations (fillings) for
treatment of carious lesions (visible destruction of hard tooth structure
resulting from the process of dental decay)
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Endodontic- treatment of the tooth pulp
Periodontic- treatment of gums and bones supporting teeth
Sealants- topically-applied acrylic, plastic or composite material used to seal
developmental grooves and pits in teeth for the purpose of preventing
dental decay
Adjunctive
General
Services- general anesthesia; office visit for observation; ofFice visit after
regularly scheduled hours; therapeutic drug injection; treatment of
post-surgical complications (unusual circumstances); occlusal
adjustment, limited
4.4 CROWNS, INLAYS, ONLAYS AND CAST RESTORATIONS BENEFITS. Delta Dental agrees
to pay 60% of the Dentist's Usual, Customary and Reasonable fees or the Fee
Actually Charged, whichever is less, or 60% of the Delta Dental PPO Dentist's Fee for
the treatment of carious lesions (visible destruction of hard tooth structure resulting
from the process of dental decay) which cannot be restored with amalgam, silicate or
direct composite (resin) restorations.
4.5 PROSTHODONTIC BENEFITS. Delta Dental agrees to pay 60% of the Dentist's Usual,
Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or
60% of the Delta Dental PPO Dentist's Fee for the construction or repair of fixed
bridges, partial or complete dentures to replace missing, natural teeth; for implant
surgical placement and removal; and for implant supported prosthetics, including
implant repair and recementation.
4.6 ORTHODONTIC BENEFITS. Delta Dental will provide Orthodontic Benefits in accordance
with the Orthodontic Benefit Rider attached hereto as Appendix A.
4.7 LIMITATIONS:
(a) Only the first two oral examinations, including office visits for observation and
specialist consultations, or combination thereof, provided to an Enrollee twice
in a calendar year while he or she is enrolled under any belta Dental plan are
Benefits under this plan. See Note on additional Benefits during pregnancy.
(b) Delta Dental pays for full-mouth x-rays only after five (5) years have elapsed
since any prior set of full-mouth �rays was provided under any Delta Dental
plan.
(c) Bitewing �rays are provided on request by the Dentist, but not more than
twice in a calendar year for children to age 18, or once in a calendar year for
adults ages 18 and over, while the patient is an Enrollee under any Delta
Dental plan.
(d) Diagnostic casts are a Benefit only when made in connection with subsequent
orthodontic treatment covered under this plan.
(e) A prophylaxis (cleaning) or Single Procedure that includes a prophylaxis is a
Benefit twice each calendar year under any Delta Dental plan. See note on
additional Benefits during pregnancy.
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(f) Fluoride treatment is a Benefit twice each calendar year under any Delta
Dental plan.
(g) Periodontal scaling and root planing is a Benefit once for each quadrant each
24-month period. See note on additional Benefits during pregnancy.
(h) Sealant Benefits include the application of sealants only to permanent first
molars through age eight (8) and second molars through age fifteen (15) if
they are without caries (decay) or restorations on the occlusal surface.
Sealant Benefits do not include the repair or replacement of a sealant on any
tooth within two (2) years of its application.
(i) Direct composite (resin) restorations are Benefits on anterior teeth and the
facial surface of bicuspids. Any other posterior direct composite (resin)
restorations are optional services and Delta Dental's payment is limited to the
cost of the equivalent amalgam restorations.
(j) Crowns, Inlays, Onlays or Cast Restoration are Benefits on the same tooth only
once every five (5) years while the patient is an Enrollee under any Delta
Dental plan, unless Delta Dental determines that replacement is required
because the restoration is unsatisfactory as a result of poor quafity of care, or
because the tooth involved has experienced extensive loss or changes to
tooth structure or supporting tissues since the replacement of the restoration.
(k) Prosthodontic appliances and implants that were provided under any Delta
Dental plan will be replaced only after five (5) years have passed, except when
Delta Dental determines that there is such extensive loss of remaining teeth or
change in supporting tissues that the existing fixed bridge, partial denture or
complete denture cannot be made satisfactory. Replacement of a
prosthodontic appliance or implant supported prosthesis not provided under a
Delta Dental plan will be covered if it is unsatisfactory and cannot be made
satisfactory. Implant removal is limited to one for each tooth during the
Enrollee's lifetime whether provided under a Delta Dental or any other dental
care plan.
(I) Delta Dental will pay the applicable percentage of the DentisYs Fee for a
standard cast chrome or acrylic partial denture or a standard complete
denture. (A "standard" complete or partial denture is defined as a removable
prosthetic appliance provided to replace missing natural, permanent teeth and
which is constructed using accepted and conventional procedures and
materials.)
(m) If an Enrollee selects a more expensive plan of treatment than is customarily
provided, or specialized techniques, an allowance will be made for the least
expensive, professionally acceptable alternative treatment plan. Delta Dental
will pay the applicable percentage of the lesser fee and the Enrollee is
responsible for the remainder of the Dentist's fee. For example: a crown, where
an amalgam filling would restore the tooth, or a precision denture, where a
standard denture would suffice.
9
4.8 EXCLUSIONS - The following services are not Benefits:
(a) Services for injuries or conditions that are covered under Workers'
Compensation or Employer's Liability Laws.
(b) Services which are provided to the Enrollee by any, Federal or State
Government Agency or are provided without cost to the Enrollee by any
municipality, county or other political subdivision, except as provided in
California Health and Safety Code Section 1373(a).
(c) Services with respect to congenital (hereditary) or developmental (following
birth) malformations or cosmetic surgery or dentistry for purely cosmetic
reasons, including but not limited to: cleft palate, upper or lower jaw
malformations, enamel hypoplasia (lack of development), fluorosis (a type of
discoloration of the teeth) and anodontia (congenitally missing teeth).
(d) Services for restoring tooth structure lost from wear (abrasion, erosion,
attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to
teeth out of alignment or occlusion, or for stabilizing the teeth. Such services
include but are not limited to equilibration and periodontal splinting.
(e) Prosthodontic services or any Single Procedure started prior to the date the
person became eligible for such services under this Contract.
(f) Prescribed or applied therapeutic drugs, premedication or analgesia.
(g) Experimental procedures.
(h) All hospital costs and any additional fees charged by the Dentist for hospital
treatment.
(i) Charges for anesthesia, other than general anesthesia administered by a
licensed Dentist in connection with covered Oral Surgery services.
(j) Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue).
(k) Diagnosis or treatment by any method of any condition related to the
temporomandibular (jaw) joint or associated musculature, nerves and other
tissues.
(I) Replacements of existing restorations for any purpose other than active tooth
decay.
(m) Intravenous sedation, occlusal guards and complete occlusal adjustment.
4.9 An agreement between the Contractholder and Delta Dental is required to change
Benefits during a Contract Term.
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ARTICLE 5 - DEDUCTIBLES &MAXIMUM AMOUNT
5.1 If services are provided by a Delta Dental PPO Dentist:
Each Enrollee must pay the first $15.00 ("deductible amount") of fees for services
that are Benefits received by an Enrollee during the term of this Contract and
otherwise covered by this Contract. Such deductible amount will not exceed $45.00
for all Enrollees in a single family, consisting of a Primary Enrollee and his or her
Dependents, as defined.
If services are provided by any other Dentist:
Each Enrollee must pay the first $25.00 ("deductible amount") of fees for services
that are Benefits received by an Enrollee during the term of this Contract and
otherwise covered by this Contract. Such deductible amount will not exceed $75.00
for all Enrollees in a single family, consisting of a Primary Enrollee and his or her
Dependents, as defined.
Delta Dental will compute these fees based on the Dentist's Usual, Customary and
Reasonable fees.
5.2 Such deductible amounts shall apply once each calendar year or portion thereof
during which the Enrollee is continuously eligible under this Contract. The deductible
does not apply to Diagnostic and Preventive and Orthodontic Bene�ts.
5.3 The maximum amount Delta Dental will pay for Diagnostic and Preventive, Basic,
Crowns, Inlays, On{ays and Cast Restorations and Prosthodontic Benefits provided to
any Enrollee in a calendar year is $2,000.00.
ARTICLE 6 - COORDINATION OF BENEFITS
6.1 If a group insurance policy or any other group health Benefits plan, including another
Delta Dental plan, entitles a person to receive or be reimbursed for the cost of dental
services, which are also Benefits under this plan, and if this plan is "primary" under
the rules described below, Delta Dental will provide Benefits as if the other plan did
not exist. If the other plan is "primary" under these rules, then Delta Dental will
provide Benefits under this plan only to the extent that the other plan does not fully
provide the dental services. .
6.2 If the other plan mainly covers services or expenses other than dental care, this plan
is "primary." Otherwise, Delta Dental will use the following rules to determine which
plan is "primary":
(a) The plan that covers the person as other than a Dependent is primary over the
plan that covers the person as a Dependent, with the following exception:
If the person is also a Medicare Beneficiary and Medicare is:
(i) Secondary to the plan covering the person as a Dependent; and
(ii) Primary to the plan covering the person as other than a Dependent (for
example, a retired employee),
ll
Then the Benefits of the plan covering the person as a Dependent are
determined before the Benefits of the plan covering the person as other than a
Dependent.
(b) The plan which covers a child as a Dependent of a parent whose birthday
occurs earlier in a calendar year is primary over the plan which covers a child
as a Dependent of a parent whose birthday occurs later in a calendar year
(except for a dependent child whose parents are separated or divorced as
described in (c) below).
(c) In the case of a dependent child whose parents are legally separated or
divorced:
(i) If the parent with custody has not remarried, the plan that covers the
child as a Dependent of the parent with custody is primary over the
plan which covers the child as a Dependent of the parent without
custody.
(ii) If the parent with custody has remarried, the plan which covers the
child as a Dependent of the parent with custody is primary over the
plan which covers the child as a Dependent of the step-parent, and the
plan which covers the child as a Dependent of the step-parent is
primary over the policy or plan which covers the child as a Dependent
of the parent without custody.
(iii) If there is a court decree that establishes financial responsibility for
dental services which are Benefits under this plan, then
notwithstanding (i) and (ii), the plan which covers the child as a
Dependent of the parent with such financial responsibility is primary
over any other plan which covers the child.
6.3 The Benefits of a plan covering a laid-off or retired employee (or Dependent of such
person) shall be determined after the Benefits of any other plan covering such person
as an employee.
6.4 If a person whose coverage is provided under federal or state law requiring
continuation is covered under more than one plan, Benefits order shall be determined
as follows:
(a) The Benefits of the plan covering the person as an employee or Dependent
shall be primary.
(b) The Benefits under continuation coverage shall be secondary.
6.5 If the primary plan cannot be determined by the rules described in this Article 6, the
plan that has covered the person longer shall be primary.
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6.6 An Enrollee will provide Delta Dental with any information about the person that is
needed to administer this Article, and Delta Dental may release any information to or
obtain any information from any insurance compa�y or other organization in order to
coordinate the Benefits of an Enrollee. Delta Dental in its sole discretion will determine
whether any reimbursement is warranted to an insurance company or other
organization under this provision, and it is agreed that any such reimbursement paid
by Delta Dental will be Benefits under this Contract. Delta Dental has the right to
recover the value of any Benefits provided by Delta Dental which exceed its
obligations under the terms of this provision from a Delta Dental Dentist, Enrollee,
insurance company or other organization, as Delta Dental chooses.
ARTICLE 7 - CONDITIONS UNDER WHICH DELTA DENTAL WILL PROVIDE BENEFITS
7.1 Benefits, unless otherwise provided in Article 4, are available from the Eligibility Date
of an Enrollee.
7.2 An Enrollee may choose the services of any licensed Dentist, but neither Delta Dental
nor the Contractholder guarantees the availability of any particular Dentist.
7.3 Before Delta Dental is obligated to approve and/or satisfy any claims under this
Contract, Delta Dental is entitled to receive, to such extent as is lawful, such
information and records relating to attendance to or examination of or treatment
provided to an Enrollee from any attending or examining Dentist, or from hospitals in
which a Dentist's care is provided, as may be required in the administration of such
claims, or to require that an Enrollee be examined by a dental consultant retained by
Delta Dental in or near his or her community or residence. Delta Dental agrees in every
case to hold such information and records as confidential.
7.4 The process Delta Dental uses to determine or deny payment for services are
distributed to all Delta Dental Dentists. They describe in detail the dental procedures
covered as Benefits, the conditions under which coverage is provided and the
limitations and exclusions applicable to the plan. Claims are reviewed for eligibility and
are paid according to these processing policies. Those claims that require additional
review are evaluated by Delta Dental's Dentist consultants. If any claims are not
covered or if limitations or exclusions apply to services the Enrollee has received by a
Delta Dental Dentist, the Enrolfee will be notified by an adjustment notice on the
Notice of Payment or Action. The Enrollee may contact Delta Dental's Customer
Service department for more information regarding Delta Dental's processing policies.
7.5 Second Opinions. Delta Dental reserves the right to obtain second opinions through
regional consultant members of its quality review committee. This committee conducts
clinical examinations, prepares objective reports of dental conditions, and evaluates
treatment that is proposed or has been proposed.
Delta Dental will authorize such an examination prior to treatment when necessary to
make a Benefit determination in response to a request for a predetermination of
treatment cost by a Dentist. Delta Dental will also authorize a second opinion after
treatment if an Enroliee has a complaint regarding the quality of care provided. Delta
Dental will notify the Enrollee and the treating Dentist when a second opinion is
necessary and appropriate, and direct the Enrollee to the regional consultant selected
by Delta Dentaf to pertorm the clinical examination. When Delta Dental authorizes a
second opinion through a regional consultant Delta Dental will pay for all charges.
13
The Enrollee may otherwise obtain second opinions about treatment from any Dentist
they choose, and claims for the examination may be submitted to Delta Dental for
payment. Delta Dental will pay such claims in accordance with the Benefits of the
plan.
A copy of Delta Dental's formal policy on second opinions is available from Delta
Dental's Customer Service department, upon request.
7.6 For senrices provided by a dentist who is not a Delta Dental PPO Dentist or a Delta
Dental Dentist, Delta Dental will not pay more than the lesser of the fees entered on
the claim form reporting such services to Delta Dental or the Prevailing Fee, multiplied
by the applicable percentage specified in Article 4 for such services. However, if the
Dentist discounts, waives, rebates or does not use good faith efforts to collect some
portion of the fees entered on the claim form from the Enrollee, Delta Dental will not
pay more than the applicable percentage specified in Article 4 of the lesser of (1) the
fees entered on the claim form, reduced by the portion discounted, waived, rebated
or not collected, or (2) the Prevailing Fee, reduced by the portion discounted, waived,
rebated or not collected.
7.7 Delta Dental will pay a Delta Dental Dentist directly for services provided by that
Dentist. Contracts between Delta Dental of California and its Delta Dental Dentists
provide that, in the event Delta Dental fails to pay the Dentist, the Enrollee will not
owe the Dentist for any sums owed by Delta Dental.
7.8 Delta Dental will pay an Enrollee directly for services provided by a Dentist who is not
a Delta Dental Dentist, and those payments are not assignable. The Enrollee is liable
to the Dentist for payment to the Dentist for the cost of the service. In addition,
Delta Dental will pay for services from dental school clinics by students of dentistry or
instructors who are not licensed by the State of California. In the event Delta Dental
fails to pay the Dentist who has not contracted with Delta Dental as a Delta Dental
Dentist, the Enrollee may be liable to the Dentist for the cost of the service.
7.9 Delta Dental is not obligated to pay claims submitted more than 12 months after the
date the service was provided. If a claim is denied because a Delta Dental Dentist
failed to make a timely submission, the Enrollee does not owe the Dentist the amount
which would have been �yable by Delta Dental, provided that the Enrollee advised
the Dentist of his or her eligibility for Benefits at the time of treatment.
7.10 Detta Dental, with the assistance of Participating Plans, will give each Delta Dental
Dentist, and any other Dentist or Enrollee on request, a standard form to make a claim
for payment for services covered by this Contrad. In order to make a claim for
payment, such form, completed by the Dentist who provided the service and by the
Enrollee (or the Enrollee's parent cr guardian if such Enrollee is a minor) must be
submitted to Delta Dental.
7.11 If an Enrollee has any questions about the services received from a Delta Dental
Dentist, Delta Dental recommends that he or she first discuss the matter with the
Dentist. If he or she continues to have concerns, the Enrollee may call or write Delta
Dental. Delta Dental will provide notifications if any dental services or claims are
denied, in whole or part, stating the specific reason or reasons for denial. Any
questions of ineligibility should first be handled directly between the Enrollee and the
group. If an Enrollee has any question or complaint regarding the denial of dental
services or claims, the policies, procedures and operations of Delta Dental, or the
quality of dental services performed by a Delta Dental Dentist, he or she may call
14
Delta Dental toll-free at 800-765-6003, contact Delta Dental on the Internet through
the web site: www.deltadentalca.org or write Delta Dental at P. O. Box 997330,
Sacramento, CA 95899-7330 Attention: Customer Service Department.
If an Enrollee's claim has been denied or modified, the Enrollee may file a request for
review (a grievance) with Delta Dental within 180 days after receipt of the denial or
modification. If a request for review is not made within this 180-day period, the right
to further review of the claim determination will be lost. If in writing, the
correspondence must include the group name and number, the Primary Enrollee's name
and Enrollee ID number, the inquirer's telephone number and any additional information
that would support the claim for benefits.
The correspondence should also include a copy of the treatment form, Notice of
Payment and any other relevant information. Upon request and free of charge, Delta
Dental will provide the Enrollee with copies of any pertinent documents that are
relevant to the claim, a copy of any internal rule, guideline, protocol, and/or
explanation of the scientific or clinical judgment if relied upon in denying or modifying
the claim.
Delta Dental's review will take into account all information, regardless of whether such
information was submitted or considered initialfy. Certain cases may be referred to one
of Delta Dental's regional consultants, to a review committee of the dental society or
to the state dental association for evaluation. Delta Dental's review shall be
conducted by a person who is neither the individual who made the original claim
denial, nor the subordinate of such individual, and Delta Dental will not give deference
to the initial decision. If the review of a claim denial is based in whole or in part on a
lack of inedical necessity, experimental treatment, or a clinical judgment in applying
the terms of the contract terms, Delta Dental shall consult with a dentist who Fas
appropriate training and experience. The identity of such dental consultant is available
upon request.
Delta Dental will provide the Enrollee a written acknowledgement within five calendar
days of receipt of the request for review. Delta Dental will ma ke a written decision
within 30 calendar days of receipt of the request for review. Delta Dental will respond,
within three calendar days of receipt, to complaints involving severe pain and
imminent and serious threat to an Enrollee's health. An Enrollee rray file a complaint
with the Department of Managed Health Care after he or she has completed Delta
Dental's grievance procedure or after he or she has been involved in Delta Dental's
grievance procedure for 30 calendar days. An Enrollee may file a complaint with the
department immediately in an emergency situation, which is one involving severe pain
and/or imminent and serious threat to the Enrollee's health.
The California Department of Managed Health Care is responsible for regulating health
care service plans. If an Enrollee has a grievance against Delta Dental, the health
pfan, the Enrollee should first telephone Delta Dental at 800-765-6003 and use Delta
Dental's grievance process before contacting the department. Utilizing this grievance
procedure does not prohibit any potential legal rights or remedies that may be
available to an Enrollee. If help is needed with a grievance involving an emergency, a
grievance that has not been satisfactorily resolved by this health plan, or a grievance
that has remained unresolved for more than 30 calendar days, the Enrollee may call
the department for assistance.
15
An Enrollee may also be eligible for an Independent Medical Review (IMR). If eligible for
an IMR, the IMR process will provide an impartial review of inedical decisions made by
a health plan related to the medical necessity of a proposed service or treatment,
coverage decisions for treatments that are experimental or investigational in nature
and payment disputes for emergency or urgent medical services. The department also
has a toll-free telephone number (888-HMO-2219) and a TDD line (877-688-9891)
for the hearing and speech impaired. The department's Internet Web site
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and
instructions online.
IMR is generally not applicable to a dental plan, unless that dental plan covers
services related to the practice of inedicine or offered pursuant to a contract with a
health plan involving medical, surgical or hospital services.
If the group health plan is subject to the Employee Retirement Income Security Act of
1974 (ERISA), the Enrollee may contact the U.S. Department of Labor, Employee
Benefits Security Administration (EBSA)for further review of the claim or if the Enrollee
has questions about the rights under ERISA. The Enrollee may also bring a civil action
under section 502(a) of ERISA. The address of the U.S. Department of Labor is: U.S.
Department of Labor, Employee Benefits Security Administration (EBSA), 200
Constitution Avenue, N.W. Washington, D.C. 20210.
7.12 The Benefits that Delta Dental provides are limited to the applicable percentages of
the Dentist's fees or allowances specified in Article 4. The Contractholder requires the
Enrollee to pay the balance of any such fee or allowance, known as the "Enrollee Co-
payment," as a method of sharing the costs of providing dental Benefits between the
Contractholder and Enrollees. If the Dentist discounts, waives or rebates any portion
of the Enrollee Co-payment to the Enrollee, Delta Dental only provides as Benefits the
Dentist's fees or allowances reduced by the amount that such fees or allowances are
discounted, waived or rebated.
ARTICLE 8- OTHER DELTA DENTAL OBLIGATIONS
8.1 Delta Dental shall encourage Delta Dental Dentists to submit a standardized claim form
before providing service, showing the Enrollee's dental needs and the treatment
necessary in the professional judgment of the Dentist.
Delta Dental shall predetermine, from the claim and other data, what would be
payable by Delta Dental and an Enrollee for the proposed service under the terms of
this plan as of the date of predetermination.
Such predetermination shall not constitute a guaranty or authorization of Benefits
under this Contract, and any actual payment by Delta Dental will depend upon the
Enrollee's eligibility and remaining annual maximum when completed services are
reported to Delta Dental.
Delta Dental shall advise Delta Dental Dentists to notify the Enrollee of a!I information
provided by Delta bental in the predetermination.
8.2 A Dentist may file a statement before treatment, showing the services to be provided
to an Enrollee. Delta Dental will predetermine the amount of Benefits payable under
this Contract for the listed services. A predetermination will become invalid at the end
of the Contract Term or the date the Enrollee's eligibility ends.
16
8.3 Delta Dental will not make any payment for services provided to an Enrollee who is not
reported to Delta Dental as an Enrollee under this Contract when the service is
provided. Delta Dental shall not be obligated to recover claims paid to a Dentist as a
result of Contractholder's retroactive eligibility adjustments to eligibility reports. The
Contractholder agrees to reimburse Delta Dental for any erroneous claim payments
made by Delta Dental as a result of incorrect eligibility reporting by the
Contractholder.
8.4 Delta Dental will provide professional review of the adequacy of service provided by
Delta Dental Dentists.
8.5 Delta Dental, with the assistance of Participating Plans, agrees to furnish to the
Contractholder on the effective date, and at reasonable times thereafter, a directory
of Delta Dental Dentists and Delta Dental PPO Dentists who have agreed to provide
the services described in this Contract. It is understood that the Dentists listed in
that directory may change from time to time and Delta Dental reserves the right to
update the directory without prior notice to the Contractholder. However, Delta
Dental agrees to give notice to the Contractholder within a reasonable time of any
Delta Dental Dentist's termination or breach of Contract, or inability to perform, which
will materially and adversely affect the Contractholder.
Current information concerning the Delta Dental Dentist status of any Dentist may be
obtained by telephoning the Delta Dental Customer Service department at 1-800-765-
6003. The Dentists providing or contracting to provide dental services under this
Contract are solely responsible for those dental services, and in no case will Delta
Dental or the Contractholder be liable for any act or omission by such Dentists, their
agents or employees.
8.6 Delta Dental agrees to give to the Contractholder, and the Contractholder agrees to
make available to each Primary Enrollee, an Evidence of Coverage summarizing
Benefits to which the Enrollee is entitled and other provisions of this Contract. If an
amendment to this Contract materially affects any Benefits described in such
Evidence of Coverage, Delta Dental will issue a corrected Evidence of Coverage, rider
or inserts.
8.7 Enrollees have access to dental care when they are outside of the United States
through Delta Dental's partnership with International SOS Assistance, Inc. (I-SOS). I-
SOS is a worldwide network of dentists and dental clinics. English-speaking operators
are available around the clock to answer questions and assist with scheduling care.
Delta Dental coverage outside the United States is the same as Delta Dental coverage
within the United States and is determined by the Contractholder's plan design.
Access to the I-SOS network is offered through a partnership agreement and will not
be avai{able if the agreement terminates.
17
ARTICLE 9 - TERMINATION AND RENEWAL
9.1 This Contract may be terminated for the following causes:
(a) By Delta Dental, if the Contractholder faits (1) to give Delta Dental a list of all
Primary Enrollees, as required under Article 2, or (2) to permit the inspection of
the Contractholder's records as called for under Article 2, or (3) to pay
Premiums, in the amounts and manner required in Article 3, provided the
Contractholder has been duly notified of such failure (and billed for Premiums, if
applicable) and at least 15 days have elapsed since the date of notification.
(b) By either the Contractholder or Delta Dental, upon expiration of a Contract
Term.
(c) By Delta Dental, if the number of Primary Enrollees reported by the
Contractholder is less than ten in each of three consecutive months, but only
if Delta Dental gives written notice not more than 15 days after it receives the
list of Primary Enrollees which indicates that such grounds for termination
exists. Termination is effective as of the last day of the month in which
written notice is given.
9.2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and
Delta Dental is released from all further obligations of this Contract, efFective the last
day of the month in which written notice of termination is given. The Contractholder
will remain liable to Delta Dental for the greater of: (1) the unpaid Premiums applicable
for the period this Contract was in effect before termination; or (2) the full amount of
all Dentist's statements paid or otherwise discharged by Delta Dental during the full
term of this Contract, plus 13.01% of such amount (to compensate Delta Dental for
its administration of the dental plan), less amounts actually paid by the
Contractholder to Delta Dental during the term of such Contract.
9.3 A party choosing to terminate this Contract at the end of a Contract Term must give
at least 60 days written notice of termination to the other party. If Delta Dental
wants to change the Premiums or Benefits effective at the beginning of the next
Contract Term, Delta Dental will give at least 60 days advance written notice of such
changes to the Contractholder. Such an advance notice will have the effect of a
notice of termination as of the end of the Contract Term, unless the Contractholder
agrees to the new Contract provisions.
9.4 If the Contractholder notifies Delta Dental in writing of its intention to terminate this
Contract as of any date other than the end of the Contract Term, such notice will be
treated as a failure to pay Premiums, and such notice will constitute a waiver of
notification and billing required of Delta Dental by paragraph 9.1(a)(3).
9.5 If an Enrollee believes that this Contract, or coverage hereunder, has been terminated
or not renewed due to their health status or requirements for health care services,
they may request a review by the California Director of Managed Health Care under
California Health and Safety Code Section 1365(b).
9.6 If this Contract is terminated for any cause, Delta Dental is not required to
predetermine services beyond the termination date or to pay for services provided
after such termination date, except for the completion of Single Procedures begun
while this Contract was in effect which are otherwise Benefits under this Contract.
18
9.7 Within 30 days after the end of this Contract, Delta Dental will return to the
Contractholder any Premiums paid which are applicable to a time period after the
termination date, together with amounts due on claims, if any, less any amounts due
to Delta Dental.
9.8 If Delta Dental accepts the proper amount of Premiums after termination of this
Contract and without requiring a new application, that acceptance will reinstate the
Contract as though never terminated, unless Delta Dental within 20 business days
after it receives such payment, either (1) refunds the payment so made or (2) issues
to the Contractholder a new Contract accompanied by written notice stating clearly
those respects in which the new Contract differs from the terminated Contract in
Benefits, coverage or otherwise.
9.9 All Benefits end for all Enrollees, when this Contract ends, and Delta Dental will not
provide any right to continuation, renewal or reinstatement of Senefits to such
persons in that event.
9.10 Delta Dental must notify the Contractholder in writing of any termination by Delta
Dental under paragraph 9.1, and the Contractholder shall promptly mail a copy of such
notice to each Primary Enrollee and provide Delta Dental with proof of mailing and the
date thereof.
ARTICLE 10- OPTIONAL CONTINUATION OF COVERAGE (COBRA)
10.1 The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to
certain employers having 20 or more employees) and the California Continuation
Benefits Replacement Act (or Cal-COBRA, pertaining to employers with two to 19
employees), both require that continued health care coverage be made available to
"Qualified Beneficiaries" who lose health care coverage under the group plan as a
result of a "Qualifying Event." Enrollees may be entitled to continue coverage under
this plan, at the Qualified Beneficiary's expense, if certain conditions are met. The
period of continued coverage depends on the Qualifying Event and whether the
Enrollee is covered under federal COBRA or Cal-COBRA.
10.2 DEFINITIONS
The meaning of key terms used in this Article are shown below and apply to both
federal and Cal-COBRA.
Qualified Beneficiary means:
1. Enrollees who are enrolled in the Delta Dental plan on the day before the
Qualifying Event, or
2. A child who is born to or placed for adoption with the Primary Enrollee during
the period of aontinued coverage, provided such child is enrolled within 30
days of birth or placement for adoption.
Qualifying Event means any of the following events which, except for the election of
this continued coverage, would result in a loss of coverage under the dental plan:
19
Event 1: The termination of employment (other than termination for gross
misconduct), or the reduction in work hours, by the Primary Enrollee's
employer;
Event 2: The death of the Primary Enrollee;
Event 3: Divorce or legal separation from the Primary Enrollee;
Event 4: A dependent child ceasing to meet the description of dependent child;
Event 5: As to dependents only, a Primary Enrollee becoming entitled to Medicare.
10.3 PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for 18 months following the occurrence
Qualifying Event 1.
This 18-month period can be extended for a total of 29 months, provided:
1. A determination is made under Title II or Title XVI of the Social Security Act
that an individual is disabled on the date of the Qualifying Event or became
disabled at any time during the first 60 days of continued coverage; and
2. Notice of the determination is given to the employer during the initial 18
months of continued coverage and within 60 days of the date of the
determination.
This period of coverage will end on the first of the month that begins more than 30
days after the date of the final determination that the disabled individual is no longer
disabled. The Primary Enrollee must notify the employer/administrator within 30 days
of any such determination.
If, during the 18 month continuation period resulting from Qualifying Event 1, the
Primary Enrollee's dependents experience Qualifying Events 2, 3, 4 or 5, they rray
choose to extend coverage for up to a total of 36 months (inclusive of the period
continued under Qualifying Event 1).
The Primary Enrollee's dependents may continue coverage for 36 months following the
month in which Qualifying Events 2, 3, 4 or 5 occur.
Under federal COBRA law only, when an employer has filed for bankruptcy under Title
II, United States Code, benefits may be substantially reduced or eliminated for retired
employees and their dependents, or the surviving spouse of a deceased retired
employee. If this benefit reduction or elimination occurs within one year before or one
year after the filing, it is considered a Qualifying Event. If the Primary Enrollee is a
retiree, and has lost coverage because of this Qualifying Event, he or she may choose
to continue coverage until his or her death. The Primary Enrollee's dependents who
have lost coverage because of this Qualifying Event may choose to continue
coverage for up to 36 months following the Primary Enrollee's death.
20
10.4 PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (groups of 2 - 19)
In the case of Cal-COBRA, Delta Dental wi�l act as the administrator. Notification and
Premium payments should be made directly to Delta Dental. Notifications and
payments should be delivered by first-class mail, certified mail, or other reliable means
of delivery.
Individuals who are eligible for coverage under the federal COBRA law are not eligible
for coverage under Cal-COBRA. The employer must notify Delta Dental in writing within
30 days of the date when the Enrollee becomes subject to COBRA.
Qualified Beneficiaries may continue coverage for 36 months following the month in
which Qualifying Events 1, 2, 3, 4 or 5 occur.
If, during the 36-month continuation period resulting from Qualifying Event 1, the
Qualified Beneficiary is determined under Title II or Title XVI of the Social Security Act
to be disabled on the date of the Qualifying Event or became disabled at any time
during the first 60 days of continuation coverage; and notice of the determination is
given to the employer during the initial period of continuation coverage and within 60
days of the date of the social security determination letter, the Qualified Beneficiary
may continue coverage for a total of 36 months following the month in which
Qualifying Event 1 occurs.
This period of coverage will end on the first of the month that begins more than 30
days after the date of the final determination that the disabled individual is no longer
disabled. The Qualified Beneficiary must notify the employer or administrator within 30
days of any such determination.
If, during the 36-month continuation period resulting from Qualifying Event 1, the
Qualified Beneficiary experiences Qualifying Events 2, 3, 4 or 5, he or she must notify
the employer wthin 60 days of the second qualifying event and has a total of 36
months continuation coverage after the date of the date of the first Qualifying Event.
Delta Dental shall notify the Primary Enrollee of the date his or her continued
coverage will terminate. This termination notification will be sent during the 180-day
period prior to the end of coverage.
10.5 ELECTION OF CONTINUED COVERAGE
The Primary Enrollee's employer shall notify Delta Dental in writing within 30 days of
Qualifying Event 1. A Qualified Beneficiary must notify his or her employer or the
administrator in writing within 60 days of Qualifying Events 2, 3, 4 or 5, or within 50
days of receiving the election notice from the employer. Otherwise, the option of
continued coverage will be lost.
Within 14 days of receiving notice of a Qualifying Event, the employer or the
administrator will provide a Qualified Beneficiary with the necessary benefits
information, monthly Premium charge, enrollment forms, and instructions to allow
election of continued coverage.
A Qualified Beneficiary will then have 60 days to give the employer or the
administrator written notice of the election to continue coverage. Failure to provide
��
this written notice of election to the employer or the administrator within 60 days will
result in the loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to
pay the initial Premium to his or her employer or the administrator, which includes the
Premium for each month since the loss of coverage. Failure to pay the required
Premium within the 45 days will result in loss of the right to continued coverage, and
any Premiums received after that date will be returned to the Qualified Beneficiary.
10.6 CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to
active employees and their dependents who are still enrolled in the dental plan. If the
employer changes the coverage for active employees, the continued coverage will
change as well. Premiums will be adjusted to reflect the changes made.
10.7 TERMINATION OF COVERAGE
A Qualified Beneficiary's coverage will terminate at the end of the month in which any
of the following events first occur:
1. The allowable number of consecutive months of continued coverage is
reached;
2. Failure to pay the required Premium in a timely manner;
3. The employer ceases to provide any group dental plan to its employees;
4. The individual moves out of the plan's service area;
5. The individual first obtains coverage for dental benefits, after the date of the
election of continued coverage, under another group health plan (as an
employee or dependent) which does not contain or apply any exclusion or
limitation with respect to any pre-existing condition of such person, if that
pre-existing condition is covered under this plan;
6. Entitlement to Medicare.
The employer or Primary Enrollee shall notify Delta Dental or the administrator within
30 days of the occurrence of any of the above events. Once continued coverage
terminates, it cannot be reinstated.
22
10.8 TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the
time that the continuation coverage would otherwise terminate, the employer shall
notify a Qualified Beneficiary (either 30 days prior to the termination or when all
Enrollees are notified whichever is later) of that person's ability to elect continuation
coverage under the employer's subsequent dental plan, if any. The employer must
notify the successor plan of the Qualified Beneficiaries receiving continuation
coverage so they may be notified of how to continue coverage under that plan.
The continuation coverage will be provided only for the balance of the period that a
Qualified Beneficiary would have remained covered under the Delta Dental plan had
such plan with the former employer not terminated. The continuation coverage will
terminate if a Qualified Beneficiary fails to comply with the requirements pertaining to
enrollment in, and payment of Premium to the new group benefit plan within 30 days
of receiving notice of the termination of the Delta Dental plan.
10.9 OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any
subsequent open enrollment period, if the employer has contracted with another plan
to provide coverage to its active employees. The continuation coverage under the
other plan will be provided only for the balance of the period that a Qualified
Beneficiary would have remained covered under the Delta Dental plan.
ARTICLE 11 - GENERAL PROVISIONS
11.1 No agent has authority to change this Contract or waive any of its provisions. Delta
Dental may not change Premium rates, copayments or deductibles, if any, during any
of the following time periods:
(a) After the Contractholder has delivered written acceptance of the Contract,
(b) After the start of an annual open enrollment period, and;
(c) After receipt of the Premium for the first month of the contract term.
Premiums may be changed under the following exceptions:
(a) When authorized or required in the Contract,
(b) When Premiums are subject to execution of a definitive agreement, and;
(c) When Delta Dental and the Contractholder mutually agree in writing.
No change in this Contract is valid unless approved by an executive officer of Delta
Dental and included in this Contract by written amendment.
11.2 The provisions of this Contract are severable. If any portion of this Contract or any
Amendment of it is determined to be illegal, void or unenforceable by any arbitrator,
court or other competent authority, all other provisions of this Contract will remain in
effect.
23
11.3 The parties agree that the laws of the State of California, where the Contract was
entered into and is to be performed, govern all questions regarding the interpretation
or enforcement of this Contract. Delta Dental is subject to the requirements of
Chapter 2.2 of Division 2 of the California Health and Safety Code and Chapter 1 of
Division 1 of Title 28 of the California Code of Regulations. Any provisions required to
be in the Contract by those laws bind Delta Dental whether or not stated in this
Contract,
11.4 Delta Dental and the Contractholder agree to consult each other to the extent
reasonably practical concerning all materials published or distributed relating to this
Contract. Neither Delta Dental nor the Contractholder will publish or distribute
materials that are contrary to the terms of this Contract.
11.5 Delta Dental and the Contractholder agree to permit and encourage the professional
relationship between Dentist and Enrollee to be maintained without interference.
11.6 The Contractholder shall designate in writing a representative for purposes of
receiving notices from Delta Dental under this Contract. The Contractholder may
change its representative at any time on 30 days notice to Delta Dental. Any notice
required from Delta Dental to any Enrollee may be given to the Contractholder's
representative, who shall disseminate such notice to the Enrollee by the next regular
communication but in no event later than 30 days after receipt thereof.
11.7 The Contractholder shall comply in all respects with all applicable federal, state and
local laws and regulations relating to administrative simplification, security and privacy
of individually identifiable Enrollee information. The Contractholder agrees that this
Contract may be amended as necessary to comply with federal regulations issued
under the Health Insurance Portability and Accountability Act of 1996 or to comply
with any other enacted administrative simplification, security or privacy laws or
regulations.
11.8 Any notice under this Contract will be sufFicient if given by either the Contractholder
or Delta Dental to the other or, in the case of employees of the Contractholder, to its
representative at the addresses below:
For the Contractholder:
City of Palm Desert
21250 Hawthorne Blvd., Suite #600
Torrance, CA 90503
24
For Delta Dental:
100 First Street
San Francisco, CA 94105
Such notice will be effective 48 hours after deposit in the United States mail with
postage fully prepaid thereon.
CITY OF PALM DESERT
BY:
Printed Name:
Title:
Date:
FOR:
Delta Dental of Caifornia
BY:
. 4
�-
Belinda Martinez
Senior Vice President
Sales/Marketing
and BY:
�-� �. �_.._.o-___�
`
Vice President, Underwriting &Actuarial Services
Date: 7une 7, 2007
2�
APPENDIX A
ORTHODONTIC BENEFIT RIDER
In consideration of the payments stated in Article 3 of the attached Contract, and subject to
all of the terms and conditions thereof, except as herein otherwise specified, Delta Dental
agrees to provide Orthodontic Benefits to eligible enrollees, as follows:
1. Orthodontics are the procedures pertormed by a licensed Dentist, involving surgical
repositioning of the teeth or jaws in whole or in part and/or the use of an active
orthodontic appliance and post-treatment retentive appliances for treatment of mal-
alignment of teeth and/or jaws which significantly interferes with their function.
2. Delta Dental will pay or otherwise discharge 50% of the lesser of the Usual,
Customary and Reasonable fees or of the Fee Actually Charged for Orthodontics.
3. The lifetime maximum amount payable by Delta Dental for all Orthodontics rendered to
each Enrollee shall be $1,000.00 and the limitations on maximum amounts payable
during a calendar year, if any, specified in the attached Contract, shall not apply to
Orthodontics.
EXCLUSIONS AND LIMITATIONS: In addition to Exclusions and Limitations stated in Article 4
to the attached Contract, the following exclusions and limitations shall apply to Orthodontic
Benefits:
(a) The obligation of Delta Dental to make payments for an Orthodontic treatment
plan begun prior to the Eligibility Date of the patient shall commence with the
first payment due following the patient's Eligibility Date. The above-mentioned
maximum amount payable will apply fully to this and subsequent payments.
(b) The obligation of Delta Dental to make payments for Orthodontics shall
terminate on the payment due next following the date the Dependent loses
eligibility or the employee loses eligibility, or upon the termination of treatment
for any reason prior to completion of the case, or upon termination of the
Contract, whichever shall occur first.
(c) Delta Dental will not make any payment for repair or replacement of an
Orthodontic appliance furnished, in whole or in part, under this plan.
(d) X-rays and extraction procedures incident to Orthodontics are not covered by
Orthodontic Benefits, but may be covered under the provisions of the attached
Contract, subject to all of the terms and provisions thereof.
(e) Delta Dental will pay the applicable percentage of the Dentist's fee for a
standard orthodontic treatment plan involving surgical and/or non-surgical
procedures. If the Enrollee selects specialized orthodontic appliances or
procedures, an allowance will be made for the cost of the standard orthodontic
treatment plan and the patient is responsible for the remainder of the Dentist's
fee.
t
APPENDDC B
CODE ON DENTAL PROCEDURES AND NOMENCLATURE
N07E: Aii the listed procedures may not be benefits under the terms of your contract.
Refer to your contract for your specific benefits.
D0100 - D0999 DIAGNOSTIC
Clinical oral evaluations
D0120 Periodic oral evaluation - established patient
D0140 Limited oral evaluation — problem focused
D0145 Oral evaluation for a patient under three years of age and counseling
with primary caregiver
DO150 Comprehensive oral evaluation — new or established patient
D0160 Detailed and extensive oral evaluation — problem focused, by report
D0170 Re-evaluation — limited, problem focused (established patient; not
post-operative visit)
D0180 Comprehensive periodontal evaluation — new or established patient
Radiographs/diagnostic imaging (including interpretation)
D0210 Intraoral — complete series (including bitewings)
D0220 Intraoral — periapical first film
D0230 Intraoral — periapical each additional film
D0240 Intraoral — occlusal film
D0250 Extraoral — first film
D0260 Extraoral — each additional film
D0270 Bitewing - single film
D0272 Bitewings - two films
D0273 Bitewings - three films
D0274 Bitewings - four films
D0277 Vertical bitewings — 7 to 8 films
D0290 Posterior — anterior or lateral skull and facial bone survey film
D0310 Sialography
D0320 Temporomandibular joint arthrogram, including injection
D0321 Other temporomandibular joint films, by report
D0322 Tomographic survey
D0330 Panoramic film
D0340 Cephalometric film
D0350 Oral/facial photographic images
Tests and examinations
D0415 Collection of microorganisms for culture and sensitivity
D0416 Viral culture
D0421 Genetic test for susceptibility to oral diseases
D0425 Caries susceptibility tests
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal
abnormalities including pre-malignant and malignant lesions, not to
include cytology or biopsy procedures
D0460 Pulp vitality tests
D0470 Diagnostic casts
2
Oral pathology laboratory
D0472 Accession of tissue, gross examination, preparation and transmission of
written report
D0473 Accession of tissue, gross and microscopic examination, preparation
and transmission of written report
D0474 Accession of tissue, gross and microscopic examination, including
assessment of surgical margins for presence of disease, preparation and
transmission of written report
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
D0479 Tissue in-situ hybridization, including interpretation
D0481 Electron microscopy - diagnostic
D0482 Direct immunofluorescence
D0483 Indirect immunofluorescence
D0484 Consultation on slides prepared elsewhere
D0485 Consultation, including preparation of slides from biopsy material
supplied by referring source
D0502 Other oral pathology procedures, by report
D0999 Unspecified diagnostic procedure, by report
D1000 — D1999 PREVENTIVE
Dental prophylaxis
D1110 Prophylaxis — adult
D1120 Prophylaxis — child through age 13
Topical fluoride treatment (office procedure)
D1203 Topical application of fluoride (prophylaxis not included) — child through
age 13
D1204 Topical application of fluoride (prophylaxis not included) — adult
D1206 Topical fluoride varnish; therapeutic application for moderate to high
caries risk patients
Other preventive services
D1310 Nutritional counseling for control of dental disease
D1320 Tobacco counseling for the control and prevention of oral disease
D1330 Oral hygiene instructions
D1351 Sealant — per tooth
Space maintenance (passive appliances)
D1510 Space maintainer — fixed — unilateral
D1515 Space maintainer — fixed — bilateral
D1520 Space maintainer — removable — unilateral
D1525 Space maintainer — removable — bilateral
D1550 Recementation of space maintainer
D1555 Removal of fixed space maintainer
D2000 — D2999 RESTORATIVE
Amalgam restorations (including polishing)
D2140 Amalgam — one surFace, primary or permanent
D2150 Amalgam — two surfaces, primary or permanent
3
D2160 Amalgam — three surfaces, primary or permanent
D2161 Amalgam — four or more surfaces, primary or permanent
Resin-based composite restorations-direct
D2330 Resin-based composite — one surface, anterior
D2331 Resin-based composite — two surfaces, anterior
D2332 Resin-based composite — three surfaces, anterior
D2335 Resin-based composite — four or more surfaces or involving incisal
angle (anterior)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite — one surtace, posterior
D2392 Resin-based composite — two surfaces, posterior
D2393 Resin-based composite — three surfaces, posterior
D2394 Resin-based composite — four or more surfaces, posterior
Gold foil restorations
D2410 Gold foil — one surface
D2420 Gold foil — two surfaces
D2430 Gold foil — three surfaces
Inlay/onlay restorations
D2510 Inlay — metallic — one surface
D2520 Inlay — metallic — two surfaces
D2530 Inlay — metallic — three or more surfaces
D2542 Onlay — metallic — two surfaces
D2543 Onlay — metallic — three surtaces
D2544 Onlay — metallic — four or more surfaces
D2610 Inlay — porcelain/ceramic — one surface
D2620 Inlay — porcelain/ceramic — two surfaces
D2630 Inlay — porcelain/ceramic — three or more surfaces
D2642 Onlay — porcelain/ceramic — two surtaces
D2643 Onlay — porcelain/ceramic — three surfaces
D2644 Onlay — porcelain/ceramic — four or more surfaces
D2650 Inlay — resin-based composite — one surface
D2651 Inlay — resin-based composite — two surfaces
D2652 Inlay — resin-based composite — three or more surtaces
D2662 Onlay — resin-based composite — two surfaces
D2663 Onlay — resin-based composite — three surfaces
D2664 Onlay — resin-based composite — four or more surfaces
Crowns — single restorations only
D2710 Crown — resin-based composite (indirect)
D2712 Crown — 3/4 resin-based composite (indirect)
D2720 Crown — resin with high noble metal
D2721 Crown — resin with predominantly base metal
D2722 Crown — resin with noble metal
D2740 Crown — porcelain/ceramic substrate
D2750 Crown — porcelain fused to high noble metal
D2751 Crown — porcelain fused to predominantly base metal
D2752 Crown — porcelain fused to noble metal
D2780 Crown — 3/4 cast high noble metal
D2781 Crown — 3/4 cast predominantly base metal
D2782 Crown — 3/4 cast noble metal
4
D2783 Crown — 3/4 porcelain/ceramic
D2790 Crown — full cast high noble metal
D2791 Crown — full cast predominantly base metal
D2792 Crown — full cast noble metal
D2794 Crown — titanium
D2799 Provisional crown
Other restorative services
D2910 Recement inlay, onlay, or partial coverage restoration
D2915 Recement cast or prefabricated post and core
D2920 Recement crown
D2930 Prefabricated stainless steel crown — primary tooth
D2931 Prefabricated stainless steel crown — permanent tooth
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown with resin window
D2934 Prefabricated esthetic coated stainless steel crown — primary tooth
D2940 Sedative filling
D2950 Core buildup, including any pins
D2951 Pin retention — per tooth, in addition to restoration
D2952 Post and core in addition to crown, indirectly fabricated
D2953 Each additional indirectly fabricated post — same tooth
D2954 Prefabricated post and core in addition to crown
D2955 Post removal (not in conjunction with endodontic therapy)
D2957 Each additional prefabricated post — same tooth
D2960 Labial veneer (resin laminate) — chairside
D2961 Labial veneer (resin laminate) — laboratory
D2962 Labial veneer (porcelain laminate) — laboratory
D2970 Temporary crown (fractured tooth)
D2971 Additional procedures to construct new crown under existing partial
denture framework
D2975 Coping
D2980 Crown repair, by report
D2999 Unspecified restorative procedure, by report
D3000 — D3999 ENDODONTICS
Pulp capping
D3110 Pulp cap — direct (excluding final restoration)
D3120 Pulp cap — indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp
coronal to the dentinocemental junction and application of inedicament
D3221 Pulpal debridement, primary and permanent teeth
Endodontic therapy on primary teeth
D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding
final restoration)
D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding
final restoration)
Endodontic therapy (including treatment plan, clinical procedures and follovw
up care)
D3310 Anterior (excluding final restoration)
D3320 Bicuspid (excluding final restoration)
5
D3330 Molar (excluding final restoration)
D3331 Treatment of root canal obstruction; non-surgical access
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured
tooth
D3333 Internal root repair of perforation defects
Endodontic retreatment
D3346 Retreatment of previous root canal therapy — anterior
D3347 Retreatment of previous root canal therapy — bicuspid
D3348 Retreatment of previous root canal therapy — molar
Apexification/recalcification procedures
D3351 Apexification/recalcification — initial visit (apical closure/calcific repair
of perforations, root resorption, etc.)
D3352 Apexification/recalcification — interim medication replacement (apical
closure/calcific repair of perforations, root resorption, etc.)
D3353 Apexification/recalcification — final visit (includes completed root canal
therapy — apical closure/calcific repair of perforations, root resorption,
etc.)
Apicoectomy/periradicular services
D3410 Apicoectomy/periradicular surgery — anterior
D3421 Apicoectomy/periradicular surgery — bicuspid (first root)
D3425 Apicoectomy/periradicular surgery — molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling — per root
D3450 Root amputation — per root
D3460 Endodontic endosseous implant
D3470 Intentional reimplantation (including necessary splinting)
Other endodontic procedures
D3910 Surgical procedure for isolation of tooth with rubber dam
D3920 Hemisection (including any root removal), not including root canal
therapy
D3950 Canal preparation and fitting of preformed dowel or post
D3999 Unspecified endodontic procedure, by report
D4000 — D4999 PERIODONTICS
Surgical services (including usual post-operative care)
D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or
bounded teeth spaces per quadrant
D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or
bounded teeth spaces per quadrant
D4240 Gingival flap procedure, including root planing — four or more
contiguous teeth or bounded teeth spaces per quadrant
D4241 Gingival flap procedure, including root planing — one to three
contiguous teeth or bounded teeth spaces per quadrant
D4245 Apically positioned flap
D4249 Clinical crown lengthening — hard tissue
D4260 Osseous surgery (including flap entry and closure) — four or more
contiguous teeth or bounded teeth spaces per quadrant
6
D4261 Osseous surgery (including flap entry and closure) — one to three
contiguous teeth or bounded teeth spaces per quadrant
D4263 Bone replacement graft — first site in quadrant
D4264 Bone replacement graft — each additional site in quadrant
D4265 Biologic materials to aid in soft and osseous tissue regeneration
D4266 Guided tissue regeneration — resorbable barrier, per site
D4267 Guided tissue regeneration — nonresorbable barrier, per site (includes
membrane removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure
D4271 Free soft tissue graft procedure (including donor site surgery)
D4273 Subepithelial connective tissue graft procedures, per tooth
D4274 Distal or proximal wedge procedure (when not performed in conjunction
with surgical procedures in the same anatomical area)
D4275 Soft tissue allograft
D4276 Combined connective tissue and double pedicle graft, per tooth
Non-surgical periodontal service
D4320 Provisional splinting — intracoronal
D4321 Provisional splinting — extracoronal
D4341 Periodontal scaling and root planing — four or more teeth per quadrant
D4342 Periodontal scaling and root planing, — one to three teeth, per
quadrant
D4355 Full mouth debridement to enable comprehensive evaluation and
diagnosis
D4381 Localized delivery of antimicrobial agents via a controlled release
vehicle into diseased crevicular tissue, per tooth, by report
Other periodontal services
D4910 Periodontal maintenance
D4920 Unscheduled dressing change (by someone other than treating dentist)
D4999 Unspecified periodontal procedure, by report
D5000 - D5899 PROSTHODONTICS(REMOVABLE)
Complete dentures (including routine post-delivery care)
D5110 Complete denture — maxillary
D5120 Complete denture — mandibular
D5130 Immediate denture — maxillary
D5140 Immediate denture — mandibular
Partial derrtures (including routine post-delivery care)
D5211 Maxillary partial denture — resin base (including any conventional
clasps, rests and teeth)
D5212 Mandibular partial denture — resin base (including any conventional
clasps, rests and teeth)
D5213 Maxillary partial denture — cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
D5214 Mandibular partial denture — cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
D5225 Maxillary partial denture — flexible base (including any clasps, rests and
teeth)
7
D5226 Mandibular partial denture — flexible base (including any clasps, rests
and teeth)
D5281 Removable unilateral partial denture — one piece cast metal (including
clasps and teeth)
Adjustments to dentures
D5410 Adjust complete denture — maxillary
D5411 Adjust complete denture — mandibular
D5421 Adjust partial denture — maxillary
D5422 Adjust partial denture — mandibular
Repairs to complete dentures
D5510 Repair broken complete denture base
D5520 Replace missing or broken teeth — complete denture (each tooth)
Repairs to partial dentures
D5610 Repair resin denture base
D5620 Repair cast framework
D5630 Repair or replace broken clasp
D5640 Replace broken teeth — per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
Denture rebase procedures
D5710 Rebase complete maxillary denture
D5711 Rebase complete mandibular denture
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
Denture reline procedures
D5730 Reline complete maxillary denture (chairside)
D5731 Reline complete mandibular denture (chairside)
D5740 Reline maxillary partial denture (chairside)
D5741 Reline mandibular partial denture (chairside)
D5750 Reline complete maxillary denture (laboratory)
D5751 Reline complete mandibular denture (laboratory)
D5760 Reline maxillary partial denture (laboratory)
D5761 Reline mandibular partial denture (laboratory)
Interim prosthesis
D5810 Interim complete denture (maxillary)
D5811 Interim complete denture (mandibular)
D5820 Interim partial denture (maxillary)
D5821 Tnterim partial denture (mandibular)
Other removable prosthetic services
D5850 Tissue conditioning — maxillary
D5851 7issue conditioning — mandibular
D5860 Overdenture — complete, by report
D5861 Overdenture — partial, by report
D5862 Precision attachment, by report
D5867 Replacement of replaceable part of semi-precision or precision
attachment (male or female component)
x
D5875 Modification of removable prosthesis following implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
D5900 — D5999 MAXILLOFACIAL PROSTHETICS
D5911 Facial moulage (sectional)
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis
D5916 Ocular prosthesis
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis, replacement
D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical
D5932 Obturator prosthesis, definitive
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with guide flange
D5935 Mandibular resection prosthesis without guide flange
D5936 Obturator prosthesis, interim
D5937 Trismus appliance (not for TMD treatment)
D5951 Feeding aid
D5952 Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult
D5954 Palatal augmentation prosthesis
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim
D5959 Palatal lift prosthesis, modification
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier
D5987 Commissure splint
D5988 Surgical splint
D5999 Unspecified maxillofacial prosthesis, by report
D6000 — D6199 IMPLANT SERVICES
D6010 Surgical placement of implant body: endosteal implant
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
9
Implant supported prosthetics
D6053 Implant/abutment supported removable denture for completely
edentulous arch
D6054 Implant/abutment supported removable denture for partially edentulous
a rch
D6055 Dental implant supported connecting bar
D6056 Prefabricated abutment — includes placement
D6057 Custom abutment — includes placement
D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly
base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium
alloy, high noble metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble
metal)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Autment supported retainer for porcelain fused to metal FPD (high noble
metal)
D6070 Autment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
D6071 Autment supported retainer for porcelain fused to metal FPD (noble
metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base
metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium,
titanium alloy, or high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy,
or high noble metal)
D6078 Implant/abutment supported fixed denture for completely edentulous
arch
D6079 Implant/abutment supported fixed denture for partially edentulous arch
Other implant services
D6080 Implant maintenance procedures, including remo val of prosthesis,
cleansing of prosthesis and abutments and reinsertion of prosthesis
D6090 Repair implant supported prosthesis, by report
D6094 Abutment supported crown — (titanium)
D6095 Repair implant abutment, by report
D6100 Implant removal, by report
D6190 Radiographic/surgical implant index, by report
D6194 Abutment supported retainer crown for FPD — (titanium)
D6199 Unspecified implant procedure, by report
10
D6200 — D6999 PROSTHODONTICS, FIXED
(Each retainer and each pontic constitutes a unit in a fixed partial denture)
Fixed partial denture pontics
D6205 Pontic — indirect resin based composite
D6210 Pontic — cast high noble metal
D6211 Pontic — cast predominantly base metal
D6212 Pontic — cast noble metal
D6214 Pontic — titanium
D6240 Pontic — porcelain fused to high noble metal
D6241 Pontic — porcelain fused to predominantly base metal
D6242 Pontic — porcelain fused to noble metal
D6245 Pontic — porcelain/ceramic
D6250 Pontic — resin with high noble metal
D6251 Pontic — resin with predominantly base metal
D6252 Pontic — resin with noble metal
D6253 Provisional pontic
Fixed partial denture retainers— inlays/ onlays
D6545 Retainer — cast metal for resin bonded fixed prosthesis
D6548 Retainer — porcelain/ceramic for resin bonded fixed prosthesis
D6600 Inlay — porcelain/ceramic, two surfaces
D6601 Inlay — porcelain/ceramic, three or more surfaces
D6602 Inlay — cast high metal, two surfaces
D6603 Inlay — cast high metal, three or more surfaces
D6604 Inlay — cast predominantly base metal, two surfaces
D6605 Inlay — cast predominantly base metal, three or more surfaces
D6606 Inlay — cast noble metal, two surfaces
D6607 Inlay — cast noble metal, three or more surfaces
D6608 Onlay — porcelain/ceramic, two surfaces
D6609 Onlay — porcelain/ceramic, three or more surFaces
D6610 Onlay — cast high noble metal, two surfaces
D6611 Onlay — cast high noble metal, three or more surfaces
D6612 Onfay — cast predominantly base metal, two surfaces
D6613 Onlay — cast predominantly base metal, three or more surfaces
D6614 Onlay — cast noble metal, two surfaces
D6615 Onlay — cast noble metal, three or more surfaces
D6624 Inlay — titanium
D6634 Onlay — titanium
Fixed partial denture retainers— crowns
D6710 Crown — indirect resin based composite
D6720 Crown — resin with high noble metal
D6721 Crown — resin with predominantly base metal
D6722 Crown — resin with noble metal
D6740 Crown — porcelain/ceramic
D6750 Crown — porcelain fused to high noble metal
D6751 Crown — porcelain fused to predominantly base metal
D6752 Crown — porcelain fused to noble metal
D6780 Crown — 3/4 cast high noble metal
D6781 Crown — 3/4 cast predominantly base metal
D6782 Crown — 3/4 cast noble metal
D6783 Crown — 3/4 porcelain/ceramic
D6790 Crown — full cast high noble metal
11
D6791 Crown — full cast predominantly base metal
D6792 Crown — full cast noble metal
D6793 Provisional retainer crown
D6794 Crown — titanium
Other fixed partial denture services
D6920 Connector bar
D6930 Recement fixed partial denture
D6940 Stress breaker
D6950 Precision attachment
D6970 Post and core in addition to fixed partial denture retainer, indirectly
fabricated
D6972 Prefabricated post and core in addition to fixed partial denture retainer
D6973 Core buildup for retainer, including any pins
D6975 Coping — metal
D6976 Each additional indirectly fabricated post — same tooth
D6977 Each additional prefabricated post — same tooth
D6980 Fixed partial denture repair, by report
D6985 Pediatric partial denture, fixed
D6999 Unspecified, fixed prosthodontic procedure, by report
D7000 — D7999 ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing, if needed, and routine
postoperative care)
D7111 Extraction, coronal remnants — deciduous tooth
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
Surgical extractions (includes local anesthesia, suturing, if needed, and routine
postoperative care)
D7210 Surgical removal of erupted tooth requiring elevation if mucoperiosteal
flap and removal of bone and/or section of tooth
D7220 Removal of impacted tooth — soft tissue
D7230 Removal of impacted tooth — partially bony
D7240 Removal of impacted tooth — completely bony
D7241 Removal of impacted tooth — completely bony, with unusual surgical
complications
D7250 Surgical removal of residual tooth roots (cutting procedure)
Other surgical procedures
D7260 Oroantral fistual closure
D7261 Primary closure of a sinus perforation
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or
displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another
and splinting and/or stabilization)
D7280 Surgical access of an unerupted tooth
D7282 Mobilization of erupted or malpositioned tooth to aid eruption
D7283 Placement of device to facilitate eruption of impacted tooth
D7285 Biopsy of oral tissue — hard (bone, tooth)
D7286 Biopsy of oral tissue — soft
12
D7287 Exfoliative cytological sample collection
D7288 Brush biopsy — transepithelial sample collection
D7290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy/supra crestal
fiberotomy, by report
Alveoloplasty — surgical preparation of ridge for dentures
D7310 Alveoloplasty in conjunction with extractions — four or more teeth or
tooth spaces, per quadrant
D7311 Alveoloplasty in conjunction with extractions — four or more teeth or
tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions — four or more teeth
or tooth spaces, per quadrant
D7321 Alveoloplasty not in conjunction with extractions — one to three teeth
or tooth spaces, per quadrant
Vestibuloplasty
D7340 Vestibuloplasty — ridge extension (secondary epithelialization)
D7350 Vestibuloplasty — ridge extension (including soft tissue grafts, muscle
reattachment, revision of soft tissue attachment and management of
hypertrophied and hyperplastic tissue)
Surgical excision of soft tissue lesions
D7410 Excision of benign lesion up to 1.25 cm
D7411 Excision of benign lesion greater than 1.25 cm
D7412 Excision of benign lesion, complicated
D7413 Excision of malignant lesion up to 1.25 cm
D7414 Excision of malignant lesion greater than 1.25 cm
D7415 Excision of malignant lesion complicated
D7465 Destruction of lesion(s) by physical or chemical method, by report
Surgical excision of intra-osseous lesions
D7440 Excision of malignant tumor — lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm
D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to
1.25 cm
D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater
than 1.25 cm
D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up
to 1.25 cm
D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter
greater than 1.25 cm
Excision of bone tissue
D7471 Removal of lateral exostosis (maxilla or mandible)
D7472 Removal of torus palatinus
D7473 Removal of torus manibularis
D7485 Surgical reduction of osseous tuberosity
D7490 Radical resection of maxilla or mandible
Surgical incision
D7510 Incision and drainage of abscess — intraoral soft tissue
D7511 Incision and drainage of abscess — intraoral soft tissue — comp(icated
(includes drainage of multiple fascial spaces)
13
D7520 Incision and drainage of abscess — extraoral soft tissue
D7521 Incision and drainage of abscess — extraoral soft tissue — complicated
(includes drainage of multiple fascial spaces)
D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar
tissue
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
Treatment of fractures— simple
D7610 Maxilla — open reduction (teeth immobilized, if present)
D7620 Maxilla — closed reduction (teeth immobilized, if present)
D7630 Mandible — open reduction (teeth immobilized, if present)
D7640 Mandible — closed reduction (teeth immobilized, if present)
D7650 Malar and/or zygomatic arch — open reduction
D7660 Malar and/or zygomatic arch — closed reduction
D7670 Alveolus — closed reduction, may include stabilization of teeth
D7671 Alveolus — open reduction, may include stabilization of teeth
D7680 Facial bones — complicated reduction with fixation and multiple surgical
approaches
Treatment of fractures— compound
D7710 Maxilla — open reduction
D7720 Maxilla — closed reduction
D7730 Mandible — open reduction
D7740 Mandible — closed reduction
D7750 Malar and/or zygomatic arch — open reduction
D7760 Malar and/or zygomatic arch — closed reduction
D7770 Alveolus — open reduction splinting stabilization of teeth
D7771 Alveolus — closed reduction stabilization of teeth
D7780 Facial bones — complicated reduction with fixation and multiple surgical
approaches
Reduction of dislocation and management of other temporomandibular joint
dysfunctions
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with/without implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non-arthroscopic lysis and lavage
D7872 Arthroscopy — diagnosis, with or without biopsy
D7873 Arthroscopy — surgical: lavage and lysis of adhesions
D7874 Arthroscopy — surgical: disc repositioning and stabilization
D7875 Arthroscopy — surgical: synovectomy
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D7876 Arthroscopy — surgical: discectomy
D7877 Arthroscopy — surgical: debridement
D7880 Occlusal orthotic device, by report
D7899 Unspecified TMD therapy, by report
Repair of traumatic wounds
D7910 Suture of recent small wounds up to 5 cm
Complicated suturing (reconstruction requiring delicate handling of tissues and
wide undermining for meticulous closure)
D7911 Complicated suture — up to 5 cm
D7912 Complicated suture — greater than 5 cm
Other repair procedures
D7920 Skin graft (identify defect covered, location and type of graft)
D7940 Osteoplasty — for orthognathic deformities
D7941 Osteotomy — mandibular rami
D7943 Osteotomy — mandibular rami with bone graft; includes obtaining the
g raft
D7944 Osteotomy — segmented or subapical
D7945 Osteotomy — body of mandible
D7946 LeFort I (maxilla — total)
D7947 LeFort I (maxilla — segmented)
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface
hypoplasia or retrusion) — without bone graft
D7949 LeFort II or LeFort III — with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla -
autogenous or nonautogenous, by report
D7953 Bone replacement graft for ridge preservation — per site
D7955 Repair of maxillofacial soft and/or hard tissue defect
D7960 Frenulectomy (frenectomy or frenotomy) — separate procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue — per arch
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous tuberosity
D7980 Sialolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoidectomy
D7995 Synthetic graft — mandible or facial bones, by report
D7996 Implant — mandible for augmentation purposes (excluding alveolar
ridge), by report
D7997 Appliance removal (not by dentist who placed appliance), includes
removal of archbar
D7999 Unspecified oral surgery procedure, by report
D8000 — D8999 ORTHODONTICS
Limited orthodontic treatment
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
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D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition
Interceptive orthodontic treatment
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
Minor treatment to control harmful habits
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
Other orthodontic services
D8660 Pre-orthodontic treatment visit
D8670 Periodic orthodontic treatment visit (as part of contract)
D8680 Orthodontic retention (removal of appliances, construction and
placement of retainer[s))
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
D8692 Replacement of lost or broken retainer
D8999 Unspecified orthodontic procedure, by report
D9000 — D9999 AD7UNCTIVE GENERAL SERVICES
Unclassified treatment
D9110 Palliative (emergency) treatment of dental pain — minor procedure
D9120 Fixed partial denture sectioning
Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical
procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia
D9220 Deep sedation/general anesthesia — first 30 minutes
D9221 Deep sedation/general anesthesia — each additional 15 minutes
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide
D9241 Intravenous conscious sedation/ analgesia — first 30 minutes
D9242 Intravenous conscious sedation/ analgesia — each additional 15
minutes
D9248 Non-intravenous conscious sedation
Professional consultation
D9310 Consultation (diagnostic service p�ovided by dentist or physician other
than requesting dentist or physician
Professional visits
D9410 House/extended care facility call
D9420 Hospital call
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D9430 Office visit for observation (during regufarly scheduled hours) — no
other services performe d
D9440 Office visit — after regularly scheduled hours
D9450 Case presentation, detailed and extensive treatment planning
Drugs
D9610 Therapeutic parenteral drug, single administration
D9612 Therapeutic parenteral drugs, two or more administrations, different
medications
D9630 Other drugs and/or medicaments, by report
Miscellaneous services
D9910 Application of desensitizing medicament
D9911 Application of desensitizing resin for cervical and/or root surface, per
tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post-surgical) — unusual circumstances,
by report
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9942 Repair and/or reline of occlusal guard
D9950 Occlusion analysis — mounted case
D9951 Occlusal adjustment — limited
D9952 Occlusal adjustment — complete
D9970 Enamel microabrasion
D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections
D9972 External bleaching — per arch
D9973 External bleaching — per tooth
D9974 Internal bleaching — per tooth
D9999 Unspecified adjunctive procedure, by report
Note: This Appendix represents codes and nomenclature excerpted from the version of
Current Dental Terminology (CDT) in effect at the date of this printing. CDT coding and
nomenclature are the mpyright of the American Dental Association, and have been
accepted as the standard for data transmission purposes under federal Administrative
Simplification regulations. For the purposes of this Appendix, Delta Dental's
administration of Benefits, Limitations and Exclusions under this Contract will at all
times be based on the then-current version of CDT whether or not a revised Appendix
B is provided.
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