HomeMy WebLinkAboutC27550 - Delta Dental & HIPAA Contract No. C27650
DELTA DENTAL OF CALIFORNIA
12898 Towne Center Drive, Cerritos, California 90703-8579
562-924-8311 800-801-7105
APPLICATION FOR DeltaCare� USA GROUP DENTAL SERVICE CONTRACT
The undersigned client("Applicant") hereby applies for a DeltaCare USA GROUP DENTAL SERVICE
CONTRACT with DELTA DENTAL OF CALIFORNIA ("Delta Dental") on the following terms:
I. Applicant hereby authorizes Delta Dental to furnish the dental Benefits described in the attached
Contract, subject to all of the terms and conditions of the Contract.
II. Applicant or Enrollees agree to pay to Delta Dental, in advance, the Premiums specified in
Schedule C to the Contract.
Itl. Upon acceptance of this Application by Delta Dental, and payment of the initial Premiums, the
Contract shall be effective at 12:01 a.m. on the Effective Date shown on Schedule C and the
Contract shall continue until terminated as provided. Payment of Premiums constitutes
acceptance of the terms and conditions of this Contract.
IV. Applicant agrees to receive, on behalf of Enrollees, all applicable notices concerning Benefits
under this Contract.
V. Applicant agrees to make available to Eligible Employees or Enrollees any notices concerning
Benefits required to be furnished by Delta Dental.
VI. Delta Dental will provide directly to each Eligible Person or Enrollee a combined Evidence
of Coverage and Disclosure Form (EOC). Delta Dental's enrollment materials advise
Eligible Persons that an EOC is also available upon request, prior to enrollment by
contacting Delta Dental's Customer Service department. The EOC will disclose the terms
and conditions of coverage, but will constitute only a summary of the program. As
required by the California Health & Safety Code, the Contract must be consulted to
determine the exact terms and conditions of the coverage provided. A copy of the
Contract will be furnished upon request. Enrollees should read the EOC carefully.
Persons with special healthcare needs should read the section entitied "Special Needs".
Pursuant to California Health and Safety Code, the EOC provides Enrollees with
information regarding the societal benefits of organ donation and the method whereby an
Enrollee may elect to be an organ or tissue donor. Enrollees may also obtain information
about Benefits by calling Delta Dental's Customer Service department at 800-422-4234.
(Date)
02012-0074�02012-0075(COBRA)
(Group Number)
City of Palm Desert
(Applicant)
73510 Fred Waring Drive, Palm Desert, CA 92260
(Applicant Address)
By: By:
(Authorized Signature) (Licensed Registered Agent)
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Contract No. C27650 � '
DELTA DENTAL OF CALIFORNIA
12898 Towne Center Drive, Cerritos, California 90703-8579
562-924-8311 800-801-7105
DeltaCare� USA GROUP DENTAL SERVICE CONTRACT
NOTICE: THE PREMIUMS PAYABLE UNDER THIS CONTRACT ARE SUBJECT TO INCREASE
UPON RENEWAL AFTER THE END OF THE INITIAL CONTRACT TERM OR ANY SUBSEQUENT
CONTRACT TERM.
IN CONSIDERATION of the Application, a copy of which is attached hereto and made a part of this
DeltaCare USA GROUP DENTAL SERVICE CONTRACT ("ContracY') and IN CONSIDERATlON of
payment of the required Premiums, DELTA DENTAL OF CALIFORNIA("Delta Dental")agrees to provide
the Benefits described for the Cont�act Term shown on Schedule C and from year to year thereafter,
unless this Contract is terminated as provided. �Premiums are payable in advance of the Effective Date
and thereafter as provided. This Contract is issued and delivered in the State of California, is governed
by the laws thereof, and is subject to the terms and conditions recited on the following pages.
IN WITNESS WHEREOF, Delta Dental has caused this Contract to be executed on:
Date: January 10, 2008
DELTA DENTAL OF CALIFORNIA
�-=��:�' �
� Belin Ma �nez �
Senior Vice President, Sales/Marketing
(��---�-� � �__..--o..-�---
Kenneth E. Bemardi
Vice President, Underwriting 8�Actuarial
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Contract No. C27650
TABLE OF CONTENTS
Article1. Definitions........................................................................................................................... 1
Article 2. Eligibility, Enrollment and Cancellation of Enrollment.........................................................3
Article 3. Premiums and Copayments ...............................................................................................5
Article 4. Benefits, Limitations and Exclusions ..................................................................................6
A�ticle 5. Coordination of Benefits .....................................................................................................9
Article 6. Enrollee Complaint Procedure.......................................................................................... 11
Article 7. General Provisions ........................................................................................................... 13
Article 8. Termination and Renewal................................................................................................. 14
Article 9. Optional Continuation of Coverage (COBRA) .................................................................. 15
Article10. Attachments.................................................................................................................... 18
Schedule A- Description of Benefits and Copayments.................................................................... 19
Schedule B - Limitations and Exclusions of Benefits........................................................................20
Schedule C - Group Variables and Premiums..................................................................................21
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ARTICLE 1. DEFINITIONS
For the purpose of this Contract, the following definitions shall apply:
1.01 "ApplicanY'means the client(employer,or other organization)contracting to obtain dental Benefits
for Eligible Employees.
1.02 "Benefits" mean those dental services which are provided under the terms of this Contract as
specified in Article 4 and Schedule A.
1.03 "ContracY'means this agreement between Delta Dental and Applicant including the Application for
this Contract, the attached schedules, and any appendices, endorsements or riders. This
Contract constitutes the entire agreement between the parties.
1.04 "Contract DentisY' means a Dentist who provides services in general dentistry and who has
agreed to provide Benefits to Enrollees under this Contract.
1.05 "Contract OrthodontisY'means a Dentist who specializes in orthodontics, and who has agreed to
provide Benefits to Enrollees under this Contract.
1.06 "Contract SpecialisY' means a Dentist who provides Specialist Services and who has agreed to
provide Benefits to Enrollees under this Contract.
1.07 "Contract Tesm" means the period commencing and terminating on the dates shown on
Schedule C, and each yearly period thereafter during which this Contract remains in effect.
1.08 "CopaymenY' means the amount charged to an Enrollee by a Dentist for the Benefits provided
under this Contract.
1.Q9 "DentisY' means a duly licensed Dentist legally entitled to practice dentistry at the time and in the
state or jurisdiction in which services are performed.
1.10 "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 registerwith 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.
1.11 "Effective Date" means the date this Contract becomes effective as provided in Schedule C.
1.12 "Eligibility Date" means the date upon which an Eligible Person's eligibility for Benefits becomes
effective under this Contract.
1.13 "Eligible DependenY' means any of the dependents of an Eligible Employee who are eligible to
enroll for Benefits and who meet the conditions of efigibility outlined in Article 2.
1.14 "Eligible Employee" means any employee or member wha meets the conditions of eligibility
outlined in Article 2.
1.15 "Eligible Person" means an Eligible Employee or Eligible Dependent.
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1.16 "Emergency Service"means care provided by a Dentist to treat a dental condition which manifests
as a symptom of sufficient severity, including severe pain, such that the absence of immediate
attention could reasonably be expected by the Enrollee to result in either: (i)placing the Enrollee's
dental health in serious jeopardy, or(ii) serious impairment to dental functions.
1.17 "Enrollee"means an Eligible Employee("Primary Enrollee")or an Eligible Dependent("Dependent
Enrollee") enrolled to receive Benefits.
1.18 "Full-Time StudenY' means a student who is regularly attending an accredited school with an
academic schedule of at least 12 credits.
1.19 "Open Enrollment Period"means the period preceding the date of commencement of the Contract
Term or the 30-day period immediately preceding the annual anniversary of the commencement of
the Contract Term or a period as otherwise requested by the Applicant and agreed to by Delta
Dental.
1.20 "Out-of-Network" means treatment by a Dentist who has not signed an agreement with Delta
Dental to provide Benefits under the terms of this Contract.
1.21 "Preauthorization" means the process by which Delta Dental determines if a procedure or
treatment is a referable Benefit under the Enrollee's plan.
1.22 "Premium" means payments by Applicant or an Enrollee as provided in Article 3 and in amounts
stated in Schedule C.
1.23 "Reasonable" means that an Enrollee exercises prudent judgment in determining that a dental
emergency exists and makes at least one attempt to contact his/her Contract Dentist to obtain
Emergency Services and, in the event the Dentist is not available, makes at least one attempt to
contact Delta Dental for assistance before seeking care from another Dentist.
1.24 "Special Health Care Need," means a physical or mental impairment, limitation pr condition that
substantially interferes with an Enrollee's ability to obtain Benefits. Examples of such a Special
Health Care Need are (i) the Enrollee's inability to obtain access to the assigned Contract
DentisYs facility because of a physical disability and(ii)the Enrollee's inability to comply with the
Contract Dentist's instructions during examination or treatment because of physical disability or
mental incapacity.
1.25 "Specialist Services"mean services performed by a Dentist who specializes in the practice of oral
surgery, endodontics, periodontics or pediatric dentistry and which must be preauthorized in
writing by Delta Dental.
1.26 "Treatment in Progress" means any single dental procedure, as defined by the CDT Code, that
has been started while the Enrollee was eligible to receive Benefits, and for which multiple
appointments are necessary to complete the procedure whether or not the Enrollee continues to
be eligible for Benefits under the DeltaCare USA plan. Examples include: teeth that have been
prepared for crowns, root canals where a working length has been established, full or partial
dentures for which an impression has been taken and orthodontics when bands have been placed
and tooth movement has begun.
1.27 "We, Us and Our" means Delta Dental of California.
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ARTICLE 2. ELIGIBILITY, ENROLLMENT AND CANCELLATION OF ENROLLMENT
2.01 Eligible Employees are those employees or group members described in Schedule C. New
employees shall become eligible for coverage as specified in Schedule C.
Eligible Dependents become eligible on:
1) the date the Eligible Employee is eligible for coverage;
2) as soon as an Eligible Dependent becomes the dependent of an Eligible Employee, or at
any time subject to a change in legal custody or lawful order to provide Benefits.
Eligible Dependents include:
1) spouse(unless legally separated or divorced)or Registered Domestic Partner(until such
partnership is terminated by either or both parties);
2) unmarried children from birth up to age 19;
3) unmarried children from 19 to age 23 if they are wholly dependent on the Eligible
Employee for suppo�t and are Full-Time Students.
Chi�dren include natural children, stepchildren, adopted children,foster children,and children of a
Registered Domestic Partner provided all such children are dependent on the Eligible Employee
for support. Newborn children (including newborn adopted children) are covered from and after
the moment of birth. Notice of birth must be received within 31 days after the date of birth for
coverage to continue beyond 31 days. Legally adopted children(other than newborns)are eligible
from and after the moment the child is placed in the physical custody of the Eligible Employee for
adoption.
An unmarried dependent child may continue eligibility if:
1) he or she is incapable of self-support because of a mental or physical disability that began
prior to reaching the limiting age;
2) he or she is chiefly dependent on the Eligible Employee for support; and
3) proof of dependenYs disability is provided within 31 days of request. Such requests will
not be made more than once a year after this dependent reaches age 23. Eligibility will
continue as long as the dependent relies on the Eligible�mployee for support because of
a mental or physical disability that began before he or she reached the limiting age.
Dependents in active military service are not eligible. No Eligible Dependent may be enrolled
under more than one Eligible Employee. Medicare eligibility shall not affect eligibility of an Eligible
Employee or Eligible Dependent.
2.02 Eligible Employees must complete the enrollment process during the Open Enrollment Period in
order to receive Benefits and for their Eligible Dependents to receive Benefits. Persons not
originally eligible during the Open Enrollment Period may be enrolled immediately upon attainment
of dependent status. Subject to cancellation as provided under this Contract, enrollment of
Eligible Employees and any Eligible Dependents is for a minimum period of one year.
On or prior to the first day of every month,Applicant shall compile and furnish to Delta Dental the
names of all Primary Enrollees showing their identification numbers and, if applicable, location
codes and all Dependent Enroflees. Enrollee names must be presented in a format acceptable to
Delta Dental. Delta Dental shall be obligated to provide Benefits only to Primary Enrollees and
their Dependent Enrollees who have been reported by the Applicant. The appropriate Premium
must be paid pursuant to Article 3 and Schedule C of this Contract for the period in which covered
dental services are provided.
2.03 Subject to any rights provided under Article 6 and Article 9, an Eligible Employee's or Eligible
DependenYs enrollment under this Contract may be canceled, or renewal of enrollment refused, in
the following events:
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1) Immediately upon loss of eligibility as described in this Contract;
2) Upon 15 days written notice if:
a) an Enrollee engages in conduct detrimental to safe operations and the delivery of
services while in a Contract Dentist's faciliry; or
b) the Premiums are not paid by or on behalf of the Enrollee on the date due.
However, the Enrollee may continue to receive Benefits during the 15-day period
and may be reinstated during the term of this Contract upon payment of any
unpaid Premium; or
c) the Enrollee knowingly commits or permits another person to commit fraud or
deception in obtaining Benefits under this Contract;
3) Upon 30 days written notice if:
a) the Contract is terminated or not renewed; or
b) the Enrollee fails to pay Copayments. However, the Enrollee may be reinstated
during the term of this Contract upon payment of all delinquent charges.
Cancellation of a Primary Enrollee's enrollment, as described above, shall automatically cancel
the enrollment of any of his or her Dependent Enrollees. Any cancellation is subject to the written
notification requirements set forth in this Contract.
2.04 An Enrollee who believes that enrollment has been cancelled or not renewed because of the
Enrollee's health status or requirements for health care services, may request a review by the
Director of the California Department of Managed Health Care in accordance with Section 1365(b)
of the California Health and Safety Code.
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ARTICLE 3. PREMIUMS AND COPAYMENTS
3.01 In accordance with Schedule C,Applicant agrees to pay Premiums on behalf of Primary Enrollees
and Dependent Enrollees enrolled for Benefits under this Contract. Applicant shall remit one
check each period as required by Schedule C. Should an Enrollee voluntarily cancel enrollment
and subsequently desire to re-enroll, all Premiums retroactive to the date of cancellation (but not
to exceed 12 months) must be paid before the Enrollee shall be re-enrolled.
3.02 This Contract shall not be in effect until initial Premiums are received. Benefits shall not be
provided unless subsequent Premiums are received in accordance with this Contract.
3.03 Delta Dental may change the amount of Premiums whenever the terms of this Contract are
changed by amendment or Delta Dental's fiabiliry is changed by law or regulation. However, in
the absence of an amendment mutually agreed upon between Applicant and Delta Dental or such
a change in liability, no change in the Premiums shall become effective within a Contract Term
except as provided in Section 3.04.
3.04 If during a Contract Term, any new tax is imposed on Delta Dental by any government agency on
the amount of Premiums payable under this Contract or the number of persons covered, or if the
rate of an existing tax on the amount of Premiums or the number of persons covered is increased,
the Premiums stated in Schedule C may be increased by the amount of any such new tax or
increased taxes upon 30 days written notice.
3.05 Upon discovery of clerical errors made by Delta Dental with respect to enrollment data for an
Enrollee, Premiums may be adjusted back to the Enrollee's enrollment date.
3.06 Upon discovery of clerical errors made by the Applicant with respect to enrollment data, the
amount of credit which may be taken with respect to an Enrollee shall not exceed the Premiums
for the current month in which Premiums are due plus two months of retroactive Premiums. In
addition, the total amount of credit which may be taken on any due date shall not exceed 10% of
the billed amount for that due date.
3.07 Enrollees are required to pay any Copayments listed in Schedule A directly to the Dentist.
Charges for broken appointments (unless notice is received by the Dentist at least 24 hours in
advance or an emergency prevented such notice)and charges for emergency visits after normal
visiting hours are also shown on Schedule A.
3.08 In the event of cancellation of enrollment by Delta Dental, Delta Dental shall return to Applicant
the pro rata portion of the Premiums paid to Delta Dental which corresponds to any unexpired
period for which payment had been received, together with any amounts due on claims, if any,
less any amounts owed to Delta Dental. This provision does not apply if the Enrollee engaged in
fraud or deception in obtaining Benefits from Delta Dental or knowingly permitted such fraud or
deception by another.
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ARTICLE 4. BENEFITS, LIMITATIONS AND EXCLUSIONS
4.01 Delta Dental shal!provide the Benefits in Schedule A, subject to the limitations and exclusions in
Schedule B. Benefits are available to each Enroilee who has elected the DeltaCare USA program
on the Eligibility Date.
4.02 Delta Dental shall provide Contract Dentists at convenient locations during the term of this
Contract. A list of Contract Dentists shall be furnished to all Primary Enrollees. Enrollees may
select any Contract Dentist whose name is on said list at the time of enrollment. Enrollees in the
same family may collectively select no more than three Contract Dentist facilities. If an Enrollee
fails to select a Contract Dentist or the Contract Dentist selected becomes unavailable, Delta
Dental shall request the selection of another Contract Dentist or shall assign that Enrollee to
another Contract Dentist. An Enrollee may make a change to any other Contract Dentist by
directing a request to the Customer Service department at 800-422-4234. The change must be
requested prior to the 21 st of the month to become effective on the first day of the following
month.
4.03 All services which are Benefits shall be rendered at the Contract Dentist's facility selected by the
Enrollee. Delta Dental shall have no obligation or liability with respect to services rendered by
Out-of Network Dentists,with the exception of Emergency Services as provided in Section 4.04,or
Specialist Services recommended by a Contract Dentist, and preauthorized in writing by Delta
Dental. All preauthorized Specialist Services claims will be paid by Delta Dental less any
applicable Copayments. A Contract Dentist may provide services either personally, or through
associated Dentists, or the other technicians or hygienists who may lawFully perform the services.
If an Enrollee is assigned to a dental school clinic for Specialist Services, those services may be
provided by a Dentist, a dental student, a clinician or a dental instructor.
4.04 If Emergency Services are needed, the Enrollee should contact their Contract Dentist whenever
possible. A new Enrollee needing Emergency Services who does not have an assigned Contract
Dentist yet, should contact Delta Dental's Customer Service department at 800-422-4234 for help
in locating a Contract Dentist. Benefits for Emergency Services by an Out-of-Network Dentist are
limited to necessary care to stabilize the Enrollee's condition and/or provide palliative relief when
the Enrollee:
1) has made a Reasonable attempt to contact the Contract Dentist and the Contract Dentist
is unavailable or unable to see the Enrollee within 24 hours of making contact; or
2) has made a Reasonable attempt to contact Delta Dental prior to receiving Emergency
Services, or it is reasonable for the Enrollee to access Emergency Services without prior
contact with Delta Dental; or
3) reasonably believes that his or her condition makes it dentally/medically inappropriate to
travel to the Contract Dentist to receive Emergency Services.
Benefits for Emergency Services not provided by the Contract Dentist are limited to a maximum of
$100.00 per emergency, less the applicable copayment. If the maximum is exceeded, or the
above conditions are not met, the Enrollee is responsible for any charges for services by a
provider other than their Contract Dentist.
Enrollees can obtain referrals for emergency dental care outside of the United States through
Delta Dental's partnership with International SOS Assistance Inc. (I-SOS). I-SOS provides
referrals to Dentists and dental clinics in nearly 200 countries worldwide. English-speaking
operators are available around the clock to answer questions and assist with scheduling care.
DeltaCare USA emergency coverage outside the U.S. is the same as DeltaCare USA out-of-
network emergency coverage within the U.S. Reimbursement is determined by the Applicant's
specific plan design and is based on the out-of-network emergency benefit provided through the
plan. The I-SOS referral service is offered through a partnership agreement and will not be
available if the agreement terminates.
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4.05 Claims for covered Emergency Services or preauthorized Specialist Services should be sent to
Delta Dental within 90 days of the end of treatment. Valid claims received after the 90-day period
will be reviewed if the Enrollee can show that it was not reasonably possible to submit the claim
within that time.
4.06 In the event Delta Dental fails to pay a Contract Dentist, the Enrollee will not be liable to that
Dentist for any sums owed by Delta Dental. By statute, the DeltaCare USA provider contract
contains a provision prohibiting a Contract Dentist from charging an Enrollee for any sums owed
by Delta Dental.
If the Enrollee has not received Preauthorization for treatment from an Out-of-Network Dentist,
and Delta Dental fails to pay that Out-of-Network Dentist,the Enrollee will be liable to that Dentist
for the cost of services.
4.07 Upon termination of a Contract DentisYs agreement, Delta Dental shall be liable for Benefits for
the completion of treatment for single procedures begun prior to the termination of the agreement.
The terminating Contract Dentist will complete (a) a pa�tial or full denture for which final
impressions have been taken, and (b) all work on every tooth upon which work has started (such
as completion of root canals in progress and delivery of crowns when teeth have been prepared).
If for any reason the Contract Dentist is unable to complete treatment, Delta Dental shall make
reasonable and appropriate provisions for the completion of such treatment by another Contract
Dentist. Delta Dental shall give written notice to Applicant within a reasonable time of any
termination or breach of contract,or inabiliry to perform, by any Contract Dentist if Applicant will be
materially and adversely affected.
4.08 In the absence of an amendment mutually agreed upon between Applicant and Delta Dental, no
change in Benefits shall be made during a Contract Term.
4.09 All Benefits shall terminate for any Enrollee as of the date that this Contract is terminated, such
person ceases to be eligible under the terms of this Contract, or such person's enrollment is
cancelled under this Contract. Delta Dental shall not be obligated to continue to provide Benefits
to any such person in such event, except for completion of single procedures commenced while
this Contract was in effect.
4.10 A Contract Dentist is compensated by Delta Dental through monthly capitation(an amount based
on the number of Enrollees assigned to the Dentist}, and by Enrollees through required
Copayments for treatment received. A Contract Specialist is compensated by Delta Dental
through an agreed-upon amount for each covered procedure, less any applicable Copayments
paid by the Enrollee. In no event does Delta Dental pay a Dentist or a Specialist any
incentive as an inducement to deny, reduce, limit or defay any appropriate treatment. An
Enroflee may obtain further information concerning compensation of providers by calling Delta
Dentaf at 800-422-4234.
4.11 Delta Dental does not authorize or deny services provided by a Contract Dentist. All Benefits
provided by a Contract Dentist are in accordance with dental care guidelines which establish the
standard of care to be followed by Contract Dentists. The dental care guidelines for the DeltaCare
USA Program are reviewed by Delta Dental's Dental Advisory Committee and updated as needed.
An Enrollee may contact Delta Dental's Customer Service department at 800-422-4234 for
information regarding the dental care guidelines for DeltaCare USA.
4.12 An Enrollee may request a second opinion if he or she disagrees with or questions the diagnosis
and/or treatment plan determination made by his or her Contract Dentist. Delta Dental may also
request that an Enrollee obtain a second opinion to verify the necessity and appropriateness of
dental treatment or the application of Benefits.
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Second opinions will be rendered by a licensed Dentist in a timely manner appropriate to the
nature of the Enrollee's condition. Requests involving cases of imminent and serious health threat
wiN be expedited (authorization approved or denied within 72 hours of receipt of the request,
whenever possible). For assistance or additional information regarding the procedures and
timeframes for second opinion authorizations, the Enrollee should contact Delta Dental's
Customer Service department at 800-422-4234 or write to Delta Dental.
Second opinions will be provided at another Contract DentisYs facility, unless otherwise
authorized by Delta Dental. Delta Dental will authorize a second opi�ion by an Out-of Network
provider if an appropriately qualified Contract Dentist is not available. Delta Dental will only pay
for a second opinion which Delta Dental has approved or authorized. The Enrollee will be sent a
written notification should Delta Dental decide not to authorize a second opinion. If the Enrollee
disagrees with this determination, the Enrollee may file a grievance with the plan or with the
Department of Managed Health Care. Refer to Article 6 for information on Enrollee Complaint
Procedures.
4.13 If an Enrollee believes he or she has a Special Health Care Need, the Enrollee should contact
Delta Dental's Customer ServiGe department at 800-422-4234. Delta Dental will confirm whether
such a Special Health Care Need exists, and what arrangements can be made to assist the
Enrollee in obtaining Benefits. Delta Dental shall not be responsible for the failure of any Contract
Dentist to comply with any law or regulation concerning treatment of persons with Special Health
Care Needs which is applicable to the Dentist.
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ARTICLE 5. COORDINATION OF BENEFITS
5.01 This Contract provides Benefits without regard to coverage by any other group insurance policy or
any other group health benefits program if the other policy or program covers services or
expenses in addition to dental care. Otherwise, Benefits provided under this Contract by
specialists or Out-of-Network Dentists are coordinated with such other group dental insurance
policy or any group dental benefits program.
5.02 When Benefits are coordinated with another group insurance policy or group health benefits
program, the determination of which policy or program is primary shall be governed by the
foliowing rules:
1) The policy or program covering the Enrollee as other than a dependent shall be primary
over the policy or program covering the Enrollee as a dependent.
2) The policy or program covering a child as a dependent of a parent whose birthday occurs
earlier in a calendar year shall be primary over the policy or program covering 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 3) below). If
both parents have the same birthday,the plan that covered either of the parenis longer is
primary.
3) In the case of a dependent child whose parents are legally separated or divorced:
a) If the parent with custody has not remarried, the policy or program covering the
child as a dependent of the parent with custody shal4 be primary over the policy or
program covering the child as a dependent of the parent without custody.
b) If the parent with custody has remarried, the policy or program covering the child
as a dependent of the parent with custody shall be primary over the policy or
program covering the child as a dependent of the step-parent, and the policy or
program covering the child as a dependent of the step-parent shall be primary over
the policy or program covering the child as a dependent of the parent without
custody. •
c) If there is a cou�t decree that establishes financial responsibility for dental services
which are Benefits under this program, and if the plan with responsibility for
payment has actual knowledge of the existence of the court decree,
notwithstanding 3) a) and b), the policy or program covering the child as a
dependent of the parent with such financial responsibility shall be primary over any
other policy or program covering the child.
4) If the primary policy or program cannot be determined by the rules described in 1), 2) or
3), the policy or program which has covered the Enrollee for a longer period of time shall
be primary, with the following exception: A policy or program covering the Enrollee as a
laid-off or retired employee or the dependent of a laid-off or retired employee shall not be
primary under this rule 4)over a policy or program covering the Enrollee as an errmployee
or the dependent of an employee. However, if the provisions of the other policy or
program do not include this exception, which results in benefits under neither being
primary, then this exception shall not apply.
5.03 When this plan is secondary, it may reduce its Benefits so that the total Benefits paid or provided
by all plans during a claim determination period are not more than 100 percent of total Allowable
Expenses. "Allowable Expense" is defined as a service or expense, including deductibles and
Copayments, that is covered at least in part by any of the plans covering the person.
If a covered person is enrolled in two or more closed panel plans and if, for any reason, incfuding
the provision of service by a non-panel provider, benefits are not payable by one closed panel
plan, COB shall not appiy between that plan and other closed panel plans.
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5.04 An Enrollee shall provide to Delta Dental, and Delta Dental may release to or obtain from any
insurance company or other organization, any information about the Enrollee that is needed to
administer coordination of benefits. Delta Dental shall, in its sole discretion, determine whether
any reimbursement to an insurance company or other organization is warranted under these
coordination of benefits provisions, and any such reimbursement paid shall be deemed to be
Benefits under this Contract. Delta Dental shall have the right to recover from a Dentist, Enrollee,
insurance company or other organization, as Delta Dental chooses, the amount of any Benefits
paid by Delta Dental which exceed its obligations under these coordination of benefit provisions.
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ARTICLE 6. ENROLLEE COMPLAINT PROCEDURE
6.01 Delta Dental shall provide notification if any dental services or claims are denied, in whole or in
part, stating the specific reason or reasons for the denial. If an Enrollee has any complaint
regarding eligibility,the denial of dental services or claims,the policies, procedures or operations
of Delta Dental, or the quality of dental services performed by a Contract Dentist, he or she may
call Delta Dental's Customer Service department at 800-422 4234, or the complaint may be
addressed in writing to:
Delta Dental of California
Quality Management Department
MS: QM600
12898 Towne Center Drive
Cerritos, Califomia 90703-8579
Written communication must include 1)the name of the patient, 2)the name, address,telephone
number and identification number of the Primary Enrollee, 3)the name of the Applicant and 4)the
DentisYs name an�d facility location.
6.02 For complaints involving an adverse benefit determination (e.g. a denial, modification or
termination of a requested benefit or claim) the Enrollee must file a request for review (a
complaint) with Delta Dental within 180 days after receipt of the adverse determination. Delta
Dental's review will take into account all information, regardless of whether such information was
submitted or considered initially. The review shall be conducted by a person who is neither the
individual who made the original benefit determination, nor the subordinate of such individual.
Upon request and free of charge, Delta Dental will provide the Enrollee with copies of any
pertinent documents that are relevant to the benefit determination, a copy of any internal rule,
guideline, protocol, and/or explanation of the scientific or clinical judgment if relied upon in making
the benefit determination. If the review of a denial is based in whole or in part on a lack of inedical
necessity, experimental treatment, or a c{inical judgment in applying the terms of the Contract,
Delta Dental shall consult with a Dentist who has appropriate training and experience. If any
consulting Dentist is involved in the review,the identity of such consulting Dentist will be available
upon request.
6.03 Within five calendar days of the receipt of any complaint, including adverse benefit determinations
as described above, the quality management coordinator will forward to the complainant an
acknowledgment of receipt ofthe complaint. Certain complaints may require that the complainant
be referred to a regional dental consultant for clinical evaluation of the dental services provided.
Delta Dental will forward to the complainant a determination,in writing,within 30 days of receipt of
a complaint. If the complaint involves severe pain and/or imminent and serious threat to a
patienYs dental health, Delta Dental will provide the Enrollee written notification regarding the
disposition or pending status of the complaint within three days.
6.04 If the Enrol{ee has completed Delta Dental's grievance process,or he or she has been involved in
Delta Dental's grievance procedure for more than 30 days, he or she may file a complaint with the
California Department of Managed Health Care. 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 dental health.
The California Department of Managed Health Care is responsible for regulating health care
service plans. If you have a grievance against your health plan, you should first telephone your
health plan at 800-422-4234 and use your health plan'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 you. If you need help with a grievance involving an emergency,
a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has
remained unresolved for more than 30 days, you may call the Department for assistance. You
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Contract No. C27650
may also be eligible for an Independent Medical Review(IMR). If you are eligible for 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(1-888-HMO-2219) and a TDD
line(1-877-688-9891)for the hearing and speech impaired. The DepartmenYs Internet Web site
http://www.hmohelp.ca.gov has complaintforms, IMR application forms and instructions online.
IMR has limited application to your dental program.You may request IMR only if the dental claim
concerns a life-threatening or seriously debilitating condition(s)and is denied or modified because
it was deemed an experimental procedure.
6.05 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, 200 Constitution Avenue, N.W. Washington, D.C. 20290.
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Contract No. C27650
ARTICLE 7. GENERAL PROVISIONS
7.01 The Contract,the Contract application,and any attached schedules, appendices,endorsements
and riders, constitute the entire agreement between Delta Dentai and Applicant. No agent has
authority to amend this Contract or waive any of its provisions. No amendment to this Contract
shall be valid unless approved by an executive officer of Delta Dental and evidenced by
endorsements.
7.02 If any portion of this Contract or any amendment thereof shall be determined by any arbitrator,
court or other competent authority to be illegal, void or unenforceable, such determination shall
not abrogate this Contract or any portion thereof other than such portion determined to be illegal,
void or unenforceable, and all other portions of this Contract shall remain in full force and effect.
7.03 The parties agree that all questions regarding interpretation or enforcement of this Contract shall
be governed by the laws of the State of California,where the Contract is entered into and is to be
performed. Delta Dental is subject to the requirements of Chapter 2.2 of Division 2 of the
California Health and Safety Code and of Chapter 1 of Division 1, of Title 28 of the California Code
of Regulations. Any provisions required to be in the Contract by either of the above shall bind
Delta Dental whether or not provided in this Contract.
7.04 Unless this task has been delegated to the Applicant or a third party, Delta Dental will issue to
each Primary Enrollee an evidence of coverage summarizing the Benefits to which each Enrollee
is entitled. If any amendment to this Contract shall materially affect any provisions described in
such evidence of coverage, new evidence of coverage booklets or riders showing the change
shall be issued. Any direct conflict between the evidence of coverage and this Contract shall be
resolved according to the terms most favorable to the Enrollee.
7.05 Both parties to this Contract agree to consult to the extent reasonably practical concerning all
material published or distributed relating to this Contract. No such material shall be published or
distributed which is contrary to the terms of this Contract. ,
7.06 Applicant shall designate in writing a representative for purposes of receiving notices from Delta
Dental under this Contract. Applicant may change its representative at any time on 30 days notice
to Delta Dental. Any notice under this Contract shall be sufficient if given by either Applicant or
Delta Dental to the other addressed as stated on the Application of this Contract, and shall be
effective 48 hours after deposit in the United States mail with postage fully prepaid. Any notice
required from Delta Dental to any Enrollee may be given to Applicant's representative,who shall
disseminate such notice to Enrollees by next regular communication but in no event later than 30
days after receipt thereof.
7.07 Delta Dental shall be excused from performance under this Contract for any period and to the
extent that it is prevented from performing any services in whole or in part as a result of an act of
God,war, civil disturbance, court order, or other cause beyond its reasonable control and which it
could not have prevented by reasonable precautions.
7.08 Both parties to this Contract 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. Both parties agree 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.
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Contract No. C27650
ARTICLE 8. TERMINATION AND RENEWAL
8.01 This Contract may be terminated by Delta Dental upon ApplicanYs failure (i) to furnish Delta
Dental with the names of eligible Enrollees as required by Article 2,or(ii)to pay Premiums in the
amount and manner required by Article 3, provided Applicant has been notified of such failure and
at least 15 days have elapsed since such notification.
8.02 Delta Dental may terminate this Contract upon 30 days written notice in the event the minimum
enrollment of five Primary Enrollees is not maintained in three consecutive months at any time
during a Contract Term.
8.03 In the event of termination of this Contract, Applicant will promptly mail a legible, true copy of
termination to each Enrollee at least 15 days prior to the effective date of termination. Applicant
shall provide Delta Dental with proof of such mailing and the date thereof. Termination will not
occur unless the Applicant has mailed this notice at least 15 days prior to the termination date.
8.04 Termination at the end of a Contract Term�, for any reason, shall be by at least 30 days advance
written notice of termination by certified mail given by the party desiring to terminate to the other
party.
In the event that Delta Dental shall desire to change Premiums or Benefits effective at the end of
any Contract Term, advice of such changes will be given to Applicant upon at least 30 days
written notice. Such notice shall renew the Contract for another Contract Term at the rates and
with the coverage as stated in the notice unless Applicant provides written notification to Delta
Dental by certified mail on or before the date sfafed in the notice that Applicant does not choose to
renew.
8.05 Acceptance by Delta Dental of the proper Premiums after termination of this Contract and without
requiring a new application,shall reinstate this Contract as though it had never terminated, unless
Delta Dental shall, within 20 business days of receipt of such payment, either 1) refuse the
• payment so made, or 2) issue to Applicant a new Contract accompanied by written notice stating .
clearly those respects in which the new Contract differs from this terminated Contract in Benefits,
coverage or otherwise.
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Contract No. C27650 '
ARTICLE 9. OPTIONAL CONTINUATION OF COVERAGE (COBRA)
9.01 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.
9.02 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
continued 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:
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.�
9.03 PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for 18 months following the occurrence of
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 may 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.
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Contract No.C27650
Under federal COBRA law only,when an employer has filed for bankruptcy under Title XI, 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.
9.04 PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (qroups of 2 - 19�
In the case of Cal-COBRA, Delta Dental will 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-008RA. The employer must notify Delta Dental in writing within 30 days of
the date when the employer becomes subject to COBRA.
Qualified Beneficiaries may continue covera`ge 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 I I 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 within �
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 Enrol(ee 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.
9.05 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
wi�hin 60 days of Qualifying Events 2, 3, 4, or 5, or within 60 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 a(low 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
DELTA-CA(2005R) 16 V7 STD CONT
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Contract No. C27650 •
result in loss of the right to continued coverage, and any premiums received after that date will be
returned to the Qualified Beneficiary.
9.06 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.
9.07 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 respectto 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.
9.08 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)bf that
person's abiliry 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 notifed 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 DeltaCare USA program had such program
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
DeltaCare USA program.
9.09 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 emp{oyees. The continuation coverage under the other pfan will be provided only for the
balance of the period that a Qualified Beneficiary would have remained covered under the
DeltaCare USA program.
DELTA-CA(2005R) 17 V7 STD CONT
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Contract No. C27650
ARTICLE 10. ATTACHMENTS
The following schedules are a part of this Contract:
Schedule A- Description of Benefits and Copayments
Schedule B— Limitations and Exclusions of Benefits
Schedule C - Group Variables and Premiums
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Contract No. C27650
SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS
REFER TO APPENDED SCHEDULES
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Contract No. C27650
SCHEDULE B
LIMITATIONS AND EXCLUSIONS OF BENEFITS
REFER TO APPENDED SCHEDULES
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Contract No. C27650
SCHEDULE C
GROUP VARIABLES AND PREMIUMS
A. Client Name: City of Palm Desert
B. Group Number: 02012-0074 & 02012-0075 (COBRA)
C. Effective Date: January 1, 2008
D. Contract Term: 18 Months
E. Eligible Present Employees: As defined by the Applicant.
Eligible New Employees: As defined by the Applicant.
F. Premiums per Month:
Plan Type: CA10A
California Primary Enrollee: $19.02
California Primary Enrollee Plus
One Dependent Enrollee: $34.27
California Primary Enrollee Plus
Two or More Dependent Enrollees: $50.71
G. Remit Premium Payment to: Delta Dental of California
Dept. #0170
. Los Angeles, CA 90084-0170 .
DELTA-CA(2005R) 21 SCH C
02012-0074.REV.AT
. Contract No. C27650
SCHEDULE A
Description of Benefits and Copayments
The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to
the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits.
Enrollees should discuss all treatment options with their Contract Dentist prior to services being
ren dered.
Text that appears in italics below is specifically intended to clarify the delivery of benefits under the
DeltaCare USA program and is not to be interpreted as CDT-2007 procedure codes,descriptors or
nomenclature that are under copyright by the American Dental Association. The American Dental
Association may periodically change CDT codes or detinitions. Such updated codes,descriptors and
nomenclature may be used to describe these covered procedures in compliance with federal
legislation.
ENROLLEE
CODE DESCRIPTION ` PAYS
DO100-D0999 I. DIAGNOSTIC
D0120 Periodic oral evaluation - established patient ....................................................... No Cost
D0140 Limited oral evaluation -problem focused ........................................................... No Cost
D0145 Oral evaluation for a patient under three years of age and counseling with primary
caregiver .......................................................................................................... No Cost
DO150 Comprehensive oral evaluation -new or established patient .................................. No Cost
D0160 Detailed and extensive orat evaluation -problem focused, by report ...................... No Cost
D0170 Re-evaluation - limited, problem focused(established patient; not post-operative
visit) ................................................................................................................ No Cost
D0180 Comprehensive periodontal evaluation - new or established patient ....................... No Cost
D0210 ' Intraoral radiographs - complete series (including bitewings) - limited to 1 series
every24 months ................................................................................................ No Cost
D0220 Intraoral -periapical first film ............................................................................ No Cost
D0230 Intraoral -periapical each additional film ............................................................ No Cost
D0240 Intraoral - occlusal film ..................................................................................... No Cost
D0250 Extraoral - first film .......................................................................................... No Cost
D0260 Extraoral - each additional film .......................................................................... No Cost
D0270 Bitewing radiograph - single film ....................................................................... No Cost
D0272 Bitewings radiographs - two films ...................................................................... No Cost
D0273 Bitewings radiographs - three films .................................................................... No Cost
D0274 Bitewings radiographs - four films - limited to 1 series every 6 months .................. No Cost
D0277 Vertical bitewings - 7 to 8 films .......................................................................... No Cost
D0330Panoramic film ................................................................................................. No Cost
D0415 Collection of microorganisms for culture and sensitivity ....................................... No Cost
D0425 Caries susceptibility tests ................................................................................... No Cost
D0460Pulp vitality tests ............................................................................................... No Cost
D0470 Diagnostic casts ................................................................................................ No Cost
D0472 Accession of tissue, gross examination, preparation and transmission of written
report ............................................................................................................... No Cost
D0473 Accession of tissue, gross and microscopic examination, preparation and
transmission of written report ............................................................................. No Cost
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Contract No. C2765�
D0474 Accession of tissue, gross and microscopic examination, including assessment of
surgical margins for presence of disease,preparation and transmission of written
report ............................................................................................................... No Cost
D0999 Unspecified diagnostic procedure, by report- includes office visit,per visit(in
addition to other services) .................................................................................. No Cost
D1000-D1999 II. PREVENTIVE
D 1110 Prophylaxis cleaning- adult- 1 per 6 month period.............................................. No Cost
D 1110 Additional prophylaxis cleaning-adult (within the 6 month period) ...................... $45.00
D1120 Prophylaxis cleaning- child- 1 per 6 month period.............................................. No Cost
D 1120 Additional prophylaxis cleaning- child(within the 6 month period) ....................... $35.00
D1203 Topical application of fluoride (prophylaxis not included) - child - to age 19; 1 per
6 month period.................................................................................................. No Cost
D 1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk
patients - child to age 19; 1 per 6 month period ................................................... No Cost
D1310 Nutritional counseling for control of dental disease .............................................. No Cost
D1330 Oral hygiene instructions ................................................................................... No Cost
D1351 Sealant-per tooth - limited to permanent molars through age IS .......................... $5.00
D 1510 Space maintainer- fixed-unilateral .................................................................... $10.00
D1515 Space maintainer- fixed-bilateral ..................................................................... $10.00
D 1520 Space maintainer-removable - unilateral ............................................................ $10.00
D 1525 Space maintainer- removable -bilateral .............................................................. $10.00
D1550 Re-cementation of space maintainer .................................................................... No Cost
D 1555 Removal of fixed space maintainer ..................................................................... No Cost
D2000-D2999 IlI. RESTORATIVE
Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch
procedures.
- 6Vhen there are more than six crowns in the same treatment plan, an Enrollee may be charged an
' additional$100.00 per crown, beyond the 6th unit. '
-Replacement of crowns, inlays and onlays requires the existing restoration to be 5+years old.
D2140 Amalgam - one surface, primary or permanent ..................................................... No Cost
D2150 Amalgam - two surfaces, primary or permanent ................................................... No Cost
D2160 Amalgam - three surfaces, primary or permanent ................................................. No Cost
D2161 Amalgam - four or more surfaces, primary or permanent ...................................... No Cost
D2330 Resin-based composite - one surface, anterior ...................................................... No Cost
D2331 Resin-based composite -two surfaces, anterior .................................................... No Cost
D2332 Resin-based composite - three surfaces, anterior .................................................. No Cost
D2335 Resin-based composite - four or more surfaces or involving incisal angle
(anterior) .......................................................................................................... No Cost
D2390 Resin-based composite crown, anterior ............................................................... No Cost
D2391 Resin-based composite - one surface, posterior .................................................... $45.00
D2392 Resin-based composite -two surfaces, posterior ................................................... $55.00
D2393 Resin-based composite -three surfaces, posterior ................................................. $65.00
D2394 Resin-based composite - four or more surfaces, posterior ...................................... $75.00
D2510 Inlay - metallic - one surface .............................................................................. No Cost
D2520 Inlay- metallic- two surfaces ............................................................................ No Cost
D2530 Inlay- metallic - three or more surfaces .............................................................. No Cost
D2542 Onlay - metallic -two surfaces ........................................................................... No Cost
D2543 Onlay- metallic - three surfaces ......................................................................... No Cost
D2544 Onlay- metallic - four or more surfaces .............................................................. No Cost
S-A-DELTA-CA(2007) Pagc:2 CA]OA BP-V7
Contract No. C27650
D2610 Inlay-porcelain/ceramic - one surface ................................................................ $135.00
D2620 Inlay-porcelain/ceramic -two surfaces .............................................................. $150.00
D2630 Inlay- porcelain/ceramic - three or more surfaces ................................................ $160.00
D2642 Onlay -porcelain/ceramic -two surfaces ............................................................. $150.00
D2643 Onlay - porcelain/ceramic -three surfaces ........................................................... $165.00
D2644 Onlay - porcelain/ceramic - four or more surfaces ................................................ $175.00
D2650 Inlay -resin-based composite- one surface .......................................................... $85.00
D2651 Inlay- resin-based composite -two surfaces ........................................................ $95.00
D2652 Inlay- resin-based composite- three or more surfaces .......................................... $115.00
D2662 Onlay - resin-based composite - two surfaces ....................................................... $110.00
D2663 Onlay - resin-based composite - three surfaces ..................................................... $120.00
D2664 Onlay - resin-based composite - four or more surfaces .......................................... $145.00
D2710 Crown - resin-based composite (indirect) ............................................................ $35.00
D2712 Crown -'/4 resin-based composite (indirect) ......................................................... $35.00
D2720 Crown - resin with high noble metal ................................................................... $155.00
D2721 Crown- resin with predominantly base metal ...................................................... $55.00
D2722 Crown - resin with noble metal ........................................................................... $95.00
D2740 Crown - porcelain/ceramic substrate ...............................:................................... $195.00
D2750 Crown - porcelain fused to high noble metal ........................................................ $195.00
D2751 Crown -porcelain fused to predominantly base metal ........................................... $95.00
D2752 Crown-porcelain fused to noble metal ............................................................... $135.00
D2780 Crown- 3/4 cast high noble metal ........................................................................ $170.00
D2781 Crown - '/4 cast predominantly base metal ........................................................... $70.00
D2782 Crown- 3/4 cast noble metal ................................................................................ $110.00
D2783 Crown- '/4 porcelain/ceramic ............................................................................. $195.00
D2790 Crown- full cast high noble metal ...................................................................... $170.00
D2791 Crown- full cast predominantly base metal ......................................................... $70.00
D2792 Crown - full cast noble metal ............................................................................. $1 10.00
D2794Crown -titanium ............................................................................................... $195.00
D2910 Recement inlay, onlay or partial coverage restoration ........................................... No Cost
D2915 Recement cast or prefabricated post and core ....................................................... No Cost
D2920 Recement crown ....................................................... No Cost
........................................
D2930 Prefabricated stainless steel crown -primary tooth ............................................... No Cost
D2931 Prefabricated stainless steel crown- permanent tooth ........................................... No Cost
D2932 Prefabricated resin crown -anterior primary tooth ............................................... $15.00
D2933 Prefabricated stainless steel crown with resin window -anterior primary tooth ....... $10.00
D2940 Sedative filling ................................................................................................. No Cost
D2950 Core buildup, including any pins ........................................................................ No Cost
D2951 Pin retention -per tooth, in addition to restoration ................................................ No Cost
D2952 Post and core in addition to crown, indirectly fabricated - includes canal
preparation ...:.................................................................................................. No Cost
D2953 Each additional indirectly fabricated post - same tooth - includes canal
preparation ...................................................................................................... No Cost
D2954 Prefabricated post and core in addition to crown - base metal post; includes canal
preparation ...................................................................................................... No Cost
D2957 Each additional prefabricated post- same tooth- base metal post; includes canal
preparation ...................................................................................................... No Cost
D2970 Temporary crown(fractured tooth) -palliative treatment only ............................... $5.00
D2971 Additional procedures to construct new crown under existing partial denture
framework ........................................................................................................ $19.00
D2980 Crown repair, by report ...................................................................................... $10.00
S-A-DELTA-CA(2007) Page:3 CAlOA BP-V7
Contract No. C27650
D3000-D3999 IV. ENDODONTICS
D3110 Pulp cap - direct(excluding final restoration) ....................................................... No Cost
D3120 Pulp cap - indirect(excluding final restoration) .................................................... No Cost
D3220 Therapeutic pulpotomy (excluding final restoration) -removal of pulp coronal to
the dentinocemental junction and application of inedicament ................................ No Cost
D3221 Pulpal debridement,primary and permanent teeth ................................................ $5.00
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final
restoration) ....................................................................................................... $5.00
D3240 Pulpal therapy(resorbable filling) - posterior,primary tooth(excluding final
restoration) ....................................................................................................... $5.00
D3310 Root canal- anterior(excluding final restoration) ................................................ $45.00
D3320 Root canal- bicuspid(excluding final restoration) ............................................... $90.00
D3330 Root canal- molar(excluding final restoration) ................................................... $205.00
D3331 Treatment of root canal obstruction; non-surgical access ....................................... $45.00
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth ............ $45.00
D3333 Internal root repair of perforation defects ............................................................ $45.00
D3346 Retreatment of previous root canal therapy- anterior ............................................ $60.00
D3347 Retreatment of previous root canal therapy-bicuspid ........................................... $105.00
D3348 Retreatment of previous root canal therapy- molar .............................................. $220.00
D3351 Apexification/recalcification - initial visit(apical closure/calcific repair of
perforations, root resorption, etc.) ....................................................................... $70.00
D3352 Apexification/recalcification- interim medication replacement (apical
closure/calcific repair of perforations,root resorption, etc.) ................................... $45.00
D3353 Apexification/recalcification- final visit(includes completed root canal therapy-
apical closure/calcific repair of perforations, root resorption, etc.) ......................... $45.00
D3410 Apicoectomy/periradicular surgery- anterior ....................................................... No Cost
D3421 Apicoectomy/periradicular surgery- bicuspid (first root) ...................................... No Cost
D3425 Apicoectomy/periradicular surgery- molar(first root) .......................................... No Cost
, D3426 Apicoectomy/periradicular surgery(each additional root) ..................................... No Cost
D3430 Retrograde filling-per root ................................................................................ No Cost
D3450 Root amputation, per root .................................................................................. No Cost
D3920 Hemisection(including any root removal), not including root canal therapy ........... No Cost
D4000-D4999 V. PERIODONTICS
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth
spacesper quadrant ........................................................................................... $80.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth
�spaces per quadrant ........................................................................................... $50.00
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or
bounded teeth spaces per quadrant ...................................................................... $80.00
D4241 Gingival flap procedure, including root planing -one to three contiguous teeth or
bounded teeth spaces per quadrant ...................................................................... $50.00
D4245 Apically positioned flap ..................................................................................... $75.00
D4249 Clinical crown lengthening-hard tissue .............................................................. $75.00
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth
or bounded teeth spaces per quadrant .................................................................. $175.00
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant ...................................................................... $140.00
S-A-DELTA-CA(2007) Pagc:4 CA I OA BP-V7
Contract No. C27650
D4263 Bone replacement graft- first site in quadrant ...................................................... $195.00
D4264 Bone replacement graft- each additional site in quadrant ...................................... $60.00
D4270 Pedicle soft tissue graft procedure ....................................................................... $195.00
D4271 Free soft tissue graft procedure (including donor site surgery) ............................... $195.00
D4274 Distal or proximal wedge procedure (when not performed in conjunction with
surgical procedures in the same anatomical area) ................................................. $45.00
D4341 Periodontal scaling and root planing - four or more teeth per quadrant- limited to 4
quadrants during any 12 consecutive months ....................................................... No Cost
D4342 Periodontal scaling and root planing- one to three teeth per quadrant- limited to 4
quadrants during any 12 consecutive months ....................................................... No Cost
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited
to I tr.eatment in any 12 consecutive months ........................................................ No Cost
D4910 Periodontal maintenance - limited to 1 treatment each 6 month period ................... No Cost
D4910 Additional periodontal maintenance (within the 6 month period) ........................... $55.00
D5000-D5899 VI. PROSTHODONTICS (removable)
-For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue
conditioning, if needed,for the first six months after placement. The Enrollee must continue to be eligible,
and the service must be provided at the Contract Dentist's facility where the denture was originally
delivered.
-Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.
-Replacement of a denture or a partial denture requires the existing denture to be S+years old.
D5110 Complete denture -maxillary ............................................................................. $100.00
D5120 Complete denture-mandibular .......................................................................... $100.00
D5130 Immediate denture -maxillary ............................................................................ $120.00
D5140 Immediate denture- mandibular ......................................................................... $120.00
D5211 Maxillary partial denture -resin base (including any conventionai clasps, rests and
teeth) ............................................................................................................... $80.00
D5212 Mandibular partial denture -resin base (including any conventional clasps, rests and
teeth) ............................................................................................................... $80.00
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including
any conventional clasps, rests and teeth) .............................................................. $120.00
D5214 Mandibular partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) .............................................. $120.00
D5225 Maxillary partial denture- flexible base(including any clasps, rests and
teeth) ............................................................................................................... $170.00
D5226 Mandibular partial denture - flexible base (including any clasps, rests and
teeth) ............................................................................................................... $170.00
D5410 Adjust complete denture - maxillary ................................................................... No Cost
D5411 Adjust complete denture - mandibular ................................................................. No Cost
D5421 Adjust partial denture -maxillary ....................................................................... No Cost
D5422 Adjust partial denture -mandibular ..................................................................... No Cost
D5510 Repair broken complete denture base .................................................................. $15.00
D5520 Replace missing or broken teeth - complete denture (each tooth) ........................... $5.00
D5610 Repair resin denture base ................................................................................... $15.00
D5620 Repair cast framework ....................................................................................... $15.00
D5630 Repair or replace broken clasp ............................................................................ $15.00
D5640 Replace broken teeth-per tooth ......................................................................... $5.00
D5650 Add tooth to existing partial denture ................................................................... $5.00
D5660 Add clasp to existing partial denture ................................................................... $5.00
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) ......................... $75.00
S-A-DELTA-CA(2007) Page:5 CAlOA BP-V7
Contract No. C27650 �
D5671 Replace all teeth and acrylic on cast metal framework(mandibular) ....................... $75.00
D5710 Rebase complete maxillary denture ..................................................................... $35.00
D5711 Rebase complete mandibular denture .................................................................. $35.00
D5720 Rebase maxillary partial denture ......................................................................... $35.00
D5721 Rebase mandibular partial denture ...................................................................... $35.00
D5730 Reline complete maxillary denture(chairside) ..................................................... No Cost
D5731 Reline complete mandibular denture (chairside) ................................................... No Cost
D5740 Reline maxillary partial denture (chairside) ......................................................... No Cost
D5741 Reline mandibular partial denture(chairside) ....................................................... No Cost
D5750 Reline complete maxillary denture(laboratory) .................................................... $35.00
D5751 Reline complete mandibular denture (laboratory) ................................................. $35.00
D5760 Reline maxillary partial denture (laboratory) ........................................................ $35.00
D5761 Reline mandibular partial denture (laboratory) ..................................................... $35.00
D5820 Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months ........ $45.00
D5821 Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months ..... $45.00
D5850 Tissue conditioning, maxillary ................................ .......... No Cost
.................................
D5851 Tissue conditioning, mandibular ......................................................................... No Cost
D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS -Not Covered
D6000-D6199 VIII. IMPLANT SERVICES-Not Covered
D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a
fixed partial denture [bridge])
- When a crown andlor pontic exceeds six units in the same treatment plan, an Enrollee may be charged an
additional$100.00 per unit, beyond the 6th unit.
-Replacement of a crown,pontic, inlay, onlay or stress breaker requires the existing bridge to be S+years
old.
I)6210 Pontic - cast high noble metal ............................................................................. $170.00 .
D6211 Pontic - cast predominantly base metal ................................................................ $70.00
D6212 Pontic - cast noble metal .................................................................................... $110.00
D6240 Pontic- porcelain fused to high noble metal ........................................................ $195.00
D6241 Pontic -porcelain fused to predominantly base metal ........................................... $95.00
D6242 Pontic -porcelain fused to noble metal ................................................................ $135.00
D6245 Pontic - porcelain/ceramic .................................................................................. $195.00
D6250 Pontic - resin with high noble metal .................................................................... $155.00
D6251 Pontic -resin with predominantly base metal ....................................................... $55.00
D6252 Pontic -resin with noble metal ........................................................................... $95.00
D6600 Inlay- porcelain/ceramic,two surfaces ............................................................... $150.00
D6601 Inlay- porcelain/ceramic,three or more surfaces ................................................. $160.00
D6602 Inlay- cast high noble metal,two surfaces ........................................................... $100.00
D6603 Inlay- cast high noble metal,three or more surfaces ............................................. $100.00
D6604 Inlay- cast predominantly base metal,two surfaces .............................................. No Cost
D6605 Inlay- cast predominantly base metal,three or more surfaces ................................ No Cost
D6606 Inlay- cast noble metal, two surfaces .................................................................. $40.00
D6607 Inlay- cast noble metal, three or more surfaces .................................................... $40.00
D6608 Onlay -porcelain/ceramic, two surfaces .............................................................. $150.00
D6609 Onlay -porcelain/ceramic, three or more surfaces ................................................ $165.00
D6610 Unlay- cast high noble metal, two surfaces ......................................................... $100.00
D6611 Onlay -cast high noble metal,three or more surfaces ........................................... $100.00
S-A-DELTA-CA(2007) Page:6 CA I OA BP-V7
. � Contract No. C27650
D6612 Onlay- cast predominantly base metal,two surfaces ............................................ No Cost
D6613 Onlay - cast predominantly base metal,three or more surfaces .............................. No Cost
D6614 Onlay- cast noble metal, two surfaces ................................................................ $40.00
D6615 Onlay- cast noble metal, three or more surfaces .................................................. $40.00
D6720 Crown - resin with high noble metal ................................................................... $155.00
D6721 Crown - resin with predominantly base metal ...................................................... $55.00
D6722 Crown -resin with noble metal ........................................................................... $95.00
D6740 Crown -porcelain/ceramic ................................................................................. $195.00
D6750 Crown - porcelain fused to high noble metal ........................................................ $195.00
D6751 Crown- porcelain fused to predominantly base metal ........................................... $95.00
D6752 Crown-porcelain fused to noble metal ............................................................... $135.00
D6780 Crown-3/4 cast high noble metal ........................................................................ $170.00
D6781 Crown - 3/4 cast predominantly base metal ........................................................... $70.00
D6782 Crown - '/4 cast noble metal ................................................................................ $110.00
D6783 Crown- 3/4 porcelain/ceramic ............................................................................. $195.00
D6790 Crown - full cast high noble metal ...................................................................... $170.00
D6791 Crown - full cast predominantly base metal ......................................................... $70.00
D6792 Crown - full cast noble metal .....................................................�........................ $110.00
D6930 Recement fixed partial denture ........................................................................... No Cost
D6940 Stress breaker ................................................................................................... No Cost
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated-
includes canal preparation ................................................................................. No Cost
D6972 Prefabricated post and core in addition to fixed partial denture retainer- base metal
post; includes canal preparation ......................................................................... No Cost
D6973 Core buildup for retainer, including any pins ....................................................... No Cost
D6976 Each additional indirectly fabricated post - same tooth - includes canal
preparation ...................................................................................................... No Cost
D6977 Each additional prefabricated post- same tooth- base metal post; includes canal
preparation ...................................................................................................... No Cost
D6980 Fixed partial denture repair,by report ................................................................. $10.00
D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
D7111 Extraction, coronal remnants - deciduous tooth .................................................... No Cost
D7140 Extraction, erupted tooth or exposed root(elevation and/or forceps removal) .......... No Cost
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and
removal of bone and/or section of tooth ............................................................... $15.00
D7220 Removal of impacted tooth - soft tissue ............................................................... $25.00
D7230 Removal of impacted tooth -partially bony ......................................................... $50.00
D7240 Removal of impacted tooth - completely bony ..................................................... $70.00
D7241 Removal of impacted tooth - completely bony, with unusual surgical
complications ................................................................................................... $90.00
D7250 Surgical removal of residual tooth roots (cutting procedure) .................................. No Cost
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced
tooth ................................................................................................................ $50.00
D7280 Surgical access of an unerupted tooth .................................................................. $85.00
D7282 Mobilization of erupted or malpositioned tooth to aid eruption .............................. $85.00
D7283 Placement of device to facilitate eruption of impacted tooth .................................. No Cost
D7286 Biopsy of oral tissue - soft- does not include pathology laboratory procedures ...... No Cost
D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces,
perquadrant ..................................................................................................... No Cost
S-A-DELTA-CA(2007) Pagc:7 CAlOA BP-V7
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces,
perquadrant ..................................................................................................... No Cost
D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth
spaces,per quadrant .......................................................................................... No Cost
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth
spaces, per quadrant .......................................................................................... No Cost
D7450 Rennoval of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm ....... No Cost
D7451 Removal of benign odontogenic cyst or tumor- lesion diameter greater than
1.25 cm ............................................................................................................ No Cost
D7471 Rennoval of lateral exostosis (maxilla or mandible) .............................................. No Cost
D7472 Removal of torus palatinus ................................................................................. No Cost
D7473 Removal of torus mandibularis ........................................................................... No Cost
D7510 Incision and drainage of abscess - intraoral soft tissue .......................................... No Cost
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure .............................. No Cost
D7970 Excision of hyperplastic tissue- per arch ............................................................. $50.00
D7971 Excision of pericoronal gingiva .......................................................................... $50.00
D8000-D8999 XI. ORTHODONTICS `
- The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive)
covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed
$125.00, may apply.
- The Retention Copayment includes adjustments and/or office visits up to 24 months.
Pre and post orthodontic records include:
The benefit for pre-treatment records and diagnostic services includes: ................. $200.00
D0210 Intraoral - complete series (including bitewings)
D0322 Tomographic survey
D0330 Panoramic film
D0340 Cephalometric film
D0350 OraUfacial photographic images
D0470 Diagnostic casts
The benefit for post-treatment records includes: ................................................... $70.00
D0210 Intraoral - complete series (including bitewings)
D0470 Diagnostic casts
D8010 Limited orthodontic treatment of the primary dentition ......................................... $950.00
D8020 Limited orthodontic treatment of the transitional dentition - child or adolescent to
age19 .............................................................................................................. $950.00
D8030 Limited orthodontic treatment of the adolescent dentition -adolescent to age 19 ..... $950.00
D8040 Limited orthodontic treatment of the adult dentition- adults, including covered
dependent adult children .................................................................................... $1,150.00
D8050 Interceptive orthodontic treatment of the primary dentition ................................... $950.00
D8060 Interceptive orthodontic treatment of the transitional dentition .............................. $950.00
D8070 Comprehensive orthodontic treatment of the transitional dentition - child or
adolescent to age 19 .......................................................................................... $1,700.00
D8084 Comprehensive orthodontic treatment of the adolescent dentition - adolescent to
age19 .............................................................................................................. $1,700.00
D8090 Comprehensive orthodontic treatment of the adult dentition -adults, including
covered dependent adult children ....................................................................... $1,900.00
S-A-UFLTA-CA(2007) Page:8 CAlOA BP-V7
' Contract No. C27650
D8660 Pre-orthodontic treatment visit ........................................................................... $25.00
D8680 Orthodontic retention (removal of appliances, construction and placement of
removable retainers) .......................................................................:.................. $275.00
D8999 Unspecified orthodontic procedure, by report- includes treatment planning
session ............................................................................................................. $100.00
D9000-D9999 XII.ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency)treatment of dental pain - minor procedure ......................... $5.00
D9211 Regional block anesthesia .................................................................................. No Cost
D9212 Trigeminal division block anesthesia .................................................................. No Cost
D9215 Local anesthesia ................................................................................................ No Cost
D9220 Deep sedation/general anesthesia - first 30 minutes .............................................. $165.00
D9221 Deep sedation/general anesthesia - each additional 15 minutes .............................. $80.00
D9241 Intravenous conscious sedation/analgesia - first 30 minutes ................................... $165.00
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes .................. $80.00
D9310 Consultation-diagnostic service provided by dentist or physician other than
requesting dentist or physician ........................................................:.................. No Cost
D9430 Office visit for observation(during regularly scheduled hours) - no other services
performed ......................................................................................................... $5.00
D9440 Office visit- after regularly scheduled hours ........................................................ $20.00
D9450 Case presentation, detailed and extensive treatment planning ................................ No Cost
D9940 Occlusal guard, by report- limited to 1 in 3 years ................................................. $95.00
D9951 Occlusal adjustment, limited .............................................................................. $20.00
D9952 Occlusal adjustment, complete ........................................................................... $40.00
D9972 External bleaching - per arch- limited to one bleaching tray and gel for two weeks
ofself treatment ................................................................................................ $125.00
D9999 Unspecified adjunctive procedure,by report- includes failed appointment without
24 hour notice-per 1 S minutes of appointment time- up to an overall maximum of
$40.00 .............................................................................................................. $10.40
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the
specified Copayment. Listed procedures which require a Dentist to provide specialized services, and are
referred by the assigned Contract Dentist, must be preauthorized in writing by Delta Dental. The Enrollee
pays the Copayment specified for such services.
Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed
fees." "Filed fees" means the Contract Dentist's fees on file with Delta Dental. Questions regarding these
fees should be directed to Delta Dental's Customer Service department at(800) 422-4234.
S-A-DELTA-CA(2007) Pagc:9 CAlOA BP-V7
Contr��ct No. C27650 '
SCHEDULE B
Limitations of Benefits
Limitations
1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A,
Description of Benefrts and Copayments.
2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of
more than six crowns,bridge pontics and/or bridge retainers, the Enrollee may be charged an
additional $100.00 above the listed Copayment for each of these services after the sixth unit has
been provided.
3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted
oral surgeon and in conjunction with an approved referral for the removal of one or more partial or
full bony impactions, (Procedures D7230, D7240, and D7241).
4. Benefits provided by a pediatric Dentist are limited to children through age seven following an
attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta
Dental, less applicable Copayments. Exceptions for medical conditions,regardless of age
limitation, will be considered on an individual basis.
5. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated
for any reason will be based on the Contract Orthodontist's usual fee for the treahnent plan. The
Contract Orthodontist will prorate the amount for the number of months remaining to complete
treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged.
6. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of
their original effective date, are in active treatment started under their previous employer
sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program.
Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments
and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible
only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.
S-B-DELTA-CA(2005R) Pagc: 10 CAlOA BP-V7
• � Contract No. C27650
Exclusions of Benefits
Exclusions
1. Any procedure that is not specifically listed under Schedule A,Description of Benefits and
Copayments.
2. Any procedure that in the professional opinion of the Contract Dentist:
a. has poor prognosis for a successful result and reasonable longevity based on the condition of
the tooth or teeth and/or surrounding structures, or
b. is inconsistent with generally accepted standards for dentistry.
3. Services solely for cosmetic purposes,with the exception of procedure D9972, External bleaching,
per arch, or for conditions that are a result of hereditary or developmental defects, such as cleft
palate,upper and lower jaw malformations, congenitally missing teeth and teeth that are
discolored or lacking enamel, except for the treatment of newborn children with congenital defects
or birth abnormalities.
4. Porcelain crowns,porcelain fused to metal, cast metal or resin with metal type crowns and fixed
partial dentures (bridges) for children under 16 years of age.
5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers
and crowns and fixed partial dentures (bridges).
6. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose
or treat abnormal conditions of the temporomandibular joint (TMJ).
7. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures,
porcelain denture teeth, precision abutments for removable partials or fixed partial dentures �
(overlays, implants, and appliances associated therewith) and personalization and characterization
of complete and partial dentures.
8. Implant-supported dental appliances and attachments, implant placement, maintenance, removal
and all other services associated with a dental implant.
9. Consultations for non-covered benefits.
10. Dental services received from any dental facility other than the assigned Contract Dentist, a
preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as
described in the Contract and/or Evidence of Coverage.
11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care
facility, or other similar care facility.
12. Prescription drugs.
]3. Dental expenses incurred in connection with any dental or orthodontic procedure started before the
Enrollee's eligibility with the DeltaCare USA program. Examples include: teeth prepared for
crowns, root canals in progress, full or partial dentures for which an impression has been taken and
orthodontics unless qualified for the orthodontic treatment in progress provision.
S-B-DELTA-CA(2005R) Page: 11 CAlOA F3P-V7
Contract No. C27650 ' '
14. Lost, stolen or broken orthodontic appliances.
15. Changes in orthodontic treatment necessitated by accident of any kind.
16. Myofunctional and parafunctional appliances and/or therapies.
17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or
cosmetic alternatives to standard fixed and removable orthodontic appliances.
18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic
services.
S-B-DELTA-CA(2005R) Page: 12 CAIOA BP-V7
Contract No. C�7650
HIPAA BUSINESS ASSOCIATE ADDENDUM:
GROUP HEALTH PLAN
This HIPAA Business Associate Addendum ("Business Associate Addendum")
supplements and is made a part of the applicable group dental and/or visian contract
("AgreemenY') by and between the employer identified on the signatory page
("Employer") on behalf of the group health plan identified in the Agreement ("Group
Health Plan") and the business associate identified on the signatory page of this
Business Associate Addendum ("Business Associate"). This Business Associate
Addendum is effective on April 14, 2003, the effective date of your applicable group
dental and/or vision contract or such other applicable compliance date, whichever comes
later.
RECITALS
Whereas, the administrative simplification provisions of the Health Insurance Portability
and Accountability Act of 1996 and related regulations require that contracts between
covered entities and entities known as business associates comply with enumerated
standards and requirements;
Whereas, the Sponsor/Contractholder executes this Business Associate Addendum on
behalf of the Group Health Plan;
Whereas, Business Associate's administration of the applicable group dental and/or
vision program makes Business Associate a business associate of the Group Health
Plan as described or defined under HIPAA;
Whereas, the purpose of this Business Associate Addendum is to satisfy the HIPAA
standards and requirements;
Now therefore, in consideration of the mutual promises below, the Sponsor/
Contractholder, the Group Health Plan and Business Associate agree as follows:
SECTION 1 - DEFINITIONS
1.1 "Business Associate" shall mean the entiry listed on the signatory page which
issued the applicable group dental and/or vision contract to the Employer and/or the
Group Health Plan. If the applicable group dental and/or vision contract is issued by an
entity other than Delta Dental of California ("Delta Dental"), the term "Business
Associate" shall include Delta Dental which may perform administrative services on
behalf of the affiliate or subsidiary which issued the applicable group dental and/or vision
contract.
1.2 "HIPAA" shall mean the administrative simplification provisions of the Health
Insurance Portability and Accountability Act of 1996 and related regulations, Titie 45
Parts 160 and 164 of the Code of Federal Regulations, as amended from time to time.
1.3 "Protected Health Information" (PHI) shall have the same meaning as defined in
HIPAA and shall apply to those individuals who are eligible and/or enrolled in the Group
Health Plan's applicable dental and/or vision benefit program administered by Business
Associate.
1.4 Terms used, but not otherwise defined, in this Business Associate Addendum
shall have the same meaning as those terms have in HIPAA.
STD BA-GRP 1 Rev 04/2007
SECTION 2 - BUSINESS ASSOCIATE AGREEMENT
2.1 The provisions of this Section 2 control over any provision in this Contract that
conflicts with this Section 2.
2.2 Permitted Uses and Disclosures.
a. Business Associate shall use and/or disclose PHI received, created or
maintained by Business Associate in accordance with the uses and disclosures
described in Exhibit A.
b. Business Associate shall not use or further disclose PHI other than as
permitted or required by this Business Associate Addendum, any law or regulation.
c. Except as othenroise limited in this Business Associate Addendum,
Business Associate may use PHI for Business Associate's proper management and
administration or to carry out Business Associate's legal responsibilities.
d. Except as otherwise limited in this Business Associate Addendum,
Business Associate may disclose PHI for Business Associate's proper management and
administration, provided that disclosures are Required By Law, or Business Associate
obtains reasonable assurances from the person to whom the PHI is disclosed that it will
remain confidential and used or further disclosed only as Required By Law or for the
purpose for which it was disclosed to the person, and the person notifies Business
Associate of any instances of which it is aware in which the confidentiality of the PHI has
been breached.
2.3 Appropriate Safequards. Business Associate agrees to use appropriate
safeguards to prevent its use or disclosure of PHI other than as provided for by this
Business Associate Addendum.
2.4 Mitiqation. Business Associate agrees to mitigate, to the extent practicable, any
harmful effect that is known to Business Associate of a use or disclosure of PHI by
Business Associate in violation of the requirements of this Business Associate
Addendum.
2.5 Reportinq of Disclosures of PHI. As soon as practical after discovery, Business
Associate shall report to the Group Health Plan, or its designate, any use or disclosure
of PHI by Business Associate not provided for in this Business Associate Addendum of
which Business Associate becomes aware.
2.6 Aqents and Contractors. Business Associate shall ensure that any Business
Associate agent or subcontractor to whom Business Associate discloses PHI agrees, in
writing, to be bound by the same restrictions and conditions that apply to Business
Associate through this Business Associate Addendum.
2.7 Access to and Availabilitv of PHI. Business Associate shall, in accordance with
HIPAA and as appropriate:
a. Provide access to the requested PHI within Business Associate's or its
agenYs or subcontractor's possession. The Group Health Plan shall as soon as
practicable forward to Business Associate any requests the Group Health Plan receives
from the individual. Business Associate shall be responsible for responding to the Group
Health Plan or individual who sent the request to Business Associate. If the response is
to be sent to the Group Health Plan, Business Associate shall send the PHI to the Group
Health Plan within fifteen (15) days of Business Associate's receipt of the request.
STD BA-GRP 2 Rev 04/2007
Contract No. C27650
b. Amend, notify appropriate recipients of any amendment, and incorporate
any amendment to the requested PHI within Business Associate's possession or its
agenYs or subcontractor's. The Group Health Plan shall as soon as practicable forward
to Business Associate any requests the Group Health Plan receives from the individual.
Business Associate shall be responsible for responding to the Group Health Plan or
individual who sent the request to Business Associate. If the response is to be sent to
the Group Health Plan, Business Associate shall send the response to the Group Health
Plan within forty-five (45) days of Business Associate's receipt of the request.
c. Provide an accounting of disclosures of PHI as required by HIPAA. The
Group Health Plan shall as soon as practicable forward to Business Associate any
requests the Group Health Plan receives from the individual. Business Associate shall
be responsible for responding to the Group Health Plan or individual who sent the
request to Business Associate. Business Associate agrees to track, and request that its
agents or subcontractors track, all such disclosures of PHI that would be required to
respond to a request for accounting of disclosures of PHI as required by HIPAA. If the
response is to be sent to the Group Health Plan, Business Associate shall send the
accounting to the Group Health Plan within forty-five (45) days of Business Associate's
receipt of the request.
2.8 Availabilitv of Business Associate's Internal Practices, Books and Records.
Business Associate agrees to make its internal practices, books and records, including
policies and procedures and PHI, relating to its use and disclosure of PHI available to
the Group Health Plan, upon reasonable notice from the Group Health Plan, and the
Secretary of Health and Human Services for purposes of determining Group Health
Plan's and Business Associate's compliance with this Business Associate Addendum
and the HIPAA privacy standards.
2.9 Sponsor/Contractholder Compliance. If the Sponsor/Contractholder and/or
Group Health Plan receives non-enrollment PHI from Business Associate, then the
Sponsor/Contractholder and/or Group Health Plan, as appropriate, shall be responsible
for their compliance with HIPAA's administrative requirements resulting from the
Sponsor/Contractholder's and/or Group Health Plan's activities including but not limited
to, privacy officer designation, training, etc.
2.10 Sponsor/Contractholder Responsibilities. Sponsor/Contractholder and/or Group
Health Plan agree to timely:
a. Forward any request it receives to the appropriate party as set forth in
section 2.7 above,
b. Notify Business Associate of any restriction, or any change thereto, to the
use or disclosure of PHI that the Group Health Plan has agreed to in accordance with 45
CFR 164.522, to the extent that such restriction(s) and/or change(s) may affect Business
Associate's use or disclosure of PHI; and
c. Notify Business Associate of any changes in, or withdrawal of, any
authorizations provided to the Group Health Plan by the individual and forwarded by the
Group Health Plan to Business Associate.
Unless otherwise specifically provided in this Business Associate Addendum,
Business Associate shall only be responsible to comply with the authorizations,
restrictions or limitations conveyed by the Sponsor/Contractholder in accordance with
this Section 2.9.
STD BA-GRP 3 Rev 04/2007
2.11 Term and Termination of the Aqreement and this Business Associate Addendum.
a. Term. The term of this Business Associate Addendum shall be effective
on the effective date of this Contract and shall continue until this Contract is terminated.
b. Termination for Cause. The Sponsor/Contractholder may terminate this
Business Associate Addendum and this Contract upon the Sponsor/Contractholder's
knowledge that Business Associate has materially breached this Business Associate
Addendum if, within thirty (30) days after receipt of written notice of such material
breach, Business Associate fails to take action to cure the breach or end the violation.
Sponsor/Contractholder may immediately terminate this Business Associate Addendum
and this Contract if Business Associate has breached a material term of this Business
Associate Addendum and cure is not possible. If neither termination nor cure is feasible,
Sponsor/Contractholder may report the violation to the Secretary of Health and Human
Services.
c. In the event of any termination of this Business Associate Addendum,
Business Associate shall return or destroy all PHI that Business Associate still maintains
in any form and shall retain no copies. If return or destruction is not feasible because
such PHI is necessary to fulfill Business Associate's legal responsibilities or other
management and administrative purposes, Business Associate shall retain the PHI and
shall continue to protect the confidentiality of PHI as required by this Business Associate
Addendum. Business Associate shall limit any use or disclosure of PHI to those
purposes that make the return or destruction of PHI infeasible. Business Associate
agrees to require that any PHI in the possession of its agents or subcontractors retained,
returned or destroyed, as applicable.
d. The following sections shall survive termination of this Agreement: 2.7,
2.8, 2.11, 5.2, and5.3.
2.12 Notice of Privacv Practices. Business Associate's notice of privacy practices
will be provided to the primary enrollees covered under the applicable group dental
and/or vision plan administered by Business Associate.
2.13 Securitv Rule Provisions. Business Associate will comply with the following
provisions by April 21, 2005, or such other applicable compliance date. For purposes of
this section, "electronic protected health information" (ePHI) shall have the same
meaning as defined in HIPAA and shall apply to those individuals who are eligible and/or
enrolled in the Group Health Plan's applicable dental and/or vision benefit program
administered by Business Associate.
a. Business Associate shall implement administrative, physical, and
technical safeguards that reasonably and appropriately protect the confidentiality,
integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on
behalf of the Group Health Plan.
b. Business Associate shall ensure that any agent, including a
subcontractor, to whom Business Associate provides ePHI agrees to implement
reasonable and appropriate safeguards to protect ePHI.
c. As soon as practical after discovery, Business Associate shall report to
the Group Health Plan any Security Incident of which Business Associate becomes
aware.
d. Business Associate agrees to authorize termination of this Business
Associate Addendum and the Contract as described in Section 2.11, above, by the
Sponsor/Contractholder if the Sponsor/Contractholder has knowledge that Business
Associate has violated a material term of this Business Associate Addendum.
STD BA-GRP 4 Rev 04/2007
- Conr_act No. C27650
SECTION 3—DISCLOSURE TO PLAN SPONSOR/CONTRACTHOLDER
This Section 3 applies only if the Sponsor/Contractholder will receive non-enrollment PHI
and if this Contract is the group health plan document that must be amended to permit
disclosure of non-enrollment PHI to the Sponsor/Contractholder.
3.1 Amendment of the Contract. Business Associate and Sponsor/Contractholder
agree to amend this Contract as set forth in this section to allow the Group Health Plan
and/or Business Associate to disclose non-enrollment PHI to the Sponsor/
Contractholder.
3.2 Notice of Privacv Practices. Business Associate's notice of privacy practices will
advise that Business Associate may disclose non-enrollment PHI to the Sponsor/
Contractholder.
3.3 Disclosure of PHI to Plan Sponsor/Contractholder. 7he Sponsor/Contractholder
represents and warrants that if the prior conditions in Sections 3.1 and 3.2 have been
met, Business Associate may disclose non-enrollment PHI to the classes of employees
and other persons identified by Sponsor/Contractholder to carry out the plan
administration functions. Business Associate shall not disclose PHI to such persons for
the purpose of employment-related actions or decisions or in connection with any other
benefit plan of the Sponsor/Contractholder.
3.4 Identification of Emplovees and Other Persons. The Sponsor/Contractholder
agrees that Business Associate may rely upon the most recent list of classes of
employees (or update thereofl provided by the Sponsor/Contractholder.
3.5 Disclosure of Enrollment and Summary Health Information. Sections 3.1 and 3.2
do not apply to disclosures of enrollment information and summary information as
defined in HIPAA. Business Associate may disclose to the SponsoNContractholder
summary health information:
a. To obtain premium bids for providing the applicable dental and/or vision
benefits coverage under the Group Health Plan;
b. To modify, amend or terminate the Group Health Plan; or
c. As otherwise permitted by HIPAA.
3.6 Amendment of this Contract as Group Health Plan Document.
Sponsor/Contractholder and Business Associate acknowledge that this Contract
constitutes the group health plan document for the applicable dental and/or vision
program administered by Business Associate. This section 3.6 shall serve as the
amendment to the group health plan document as required by HIPAA to permit Business
Associate to disclose non-enrollment PHI to the Sponsor/Contractholder. The provisions
of this Section 3.6 control over any provision in this Contract that conflicts with this
section.
a. Sponsor/Contractholder Certification. The following terms of this section
incorporate the requirements of HIPAA to permit the Group Health Plan or Business
Associate to lawfully disclose non-enrollment PHI to the SponsoNContractholder or its
agents. This section shall serve as the Sponsor/Contractholder's certification as
req ui red by H I PAA.
STD BA-GRP 5 Rev 04/2007
b. Permitted Uses and Disclosures.
i. Sponsor/Contractholder, its directors, officers, employees,
contractors and agents shall use and/or disclose PHI received by Sponsor/
Contractholder solely in accordance with the uses and disclosures described in Exhibit B
which is attached to and made a part of this Business Associate Addendum.
ii. Sponsor/Contractholder shall not, and shall ensure that its
directors, officers, employees contractors and agents do not, use or further disclose PHI
in any manner except as permitted or required by this Business Associate Addendum or
as required by law or regulation.
c. AQents and Subcontractors. Sponsor/Contractholder shall ensure that
any agent or subcontractor that will have access to PHI from Sponsor/Contractholder
agrees to be bound by the same restrictions, terms and conditions that apply to
Sponsor/Contractholder pursuant to this Business Associate Addendum.
d. Emplovment-Related Actions and Decisions. The Sponsor/
Contractholder shall not use or disclose PHI for employment-related actions or decisions
or in connection with any other benefit plan of the Sponsor/Contractholder.
e. Reportin4 of Disclosures of PHI. Sponsor/Contractholder shall, as soon
as possible after becoming aware of an actual or suspected disclosure of PHI in violation
of this Business Associate Addendum by Sponsor/Contractholder, its officers, directors,
employees, subcontractors or agents or by a third party to which Sponsor/Contractholder
disclosed PHI pursuant to this Business Associate Addendum, report any such
disclosure to the Group Health Plan.
f. Access to and Availabilitv of PHI. Sponsor/Contractholder shall timely
and in compliance with HIPAA requirements:
i. Make available to the Group Health Plan or Business Associate,
as appropriate, the requested PHI to respond to an individual's request for access to
PHI.
ii. Provide to the Group Health Plan or Business Associate, as
appropriate, the requested PHI to respond to a request for amendment and shall
incorporate any amendment received from the Group Health Plan or Business
Associate.
iii. Make available to the Group Health Plan or Business Associate,
as appropriate, the requested PHI to respond to an individual's request for an accounting
of disclosures of PHI. The Sponsor/Contractholder agrees to track all disclosures of PHI
that would be required to respond to a request for accounting of disclosures of PHI as
required by HIPAA.
g. Availabilitv of Sponsor's/Contractholder's Internal Practices, Books and
Records. Sponsor/Contractholder agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the Group Health Plan or
Business Associate available to the Secretary of Health and Human Services for
purposes of determining the Group Health Plan's and Sponsor/Contractholder's
compliance with the HIPAA privacy standards.
h. Return or Destruction of PHI. Sponsor/Contractholder shall return or
destroy all PHI received from the Group Health Plan or its agent that the Sponsor/
Contractholder maintains in any form and shall retain no copies when such PHI is no
longer needed for the purpose for which the disclosure was made. If return or
destruction is not feasible, SponsoNContractholder shall continue to protect the
confidentiality of PHI as required by this Business Associate Addendum and limit any
use or disclosure of PHI to those purposes that make the return or destruction of PHI
infeasible.
STD BA-GRP 6 Rev 04/2007
Contract No. C27650
i. Adequate Separation. Sponsor/Contractholder shall ensure adequate
separation as required by HIPAA by doing the following:
i. Sponsor/Contractholder shall identify the Sponsor/
Contractholder's classes of employees or other persons to whom the Group Health Plan,
its agent, or Business Associate shall disclose PHI.
ii. Sponsor/Contractholder shall restrict access to PHI and use of
PHI by such employees or other persons to the plan administration functions that
Sponsor/Contractholder performs for the Group Health Plan.
iii. Sponsor/Contractholder shall implement an effective mechanism
for resolving any issues of noncompliance by such employees or other persons, and
such mechanism shall be consistent with the terms of this Business Associate
Addendum.
j. Securitv Rule Provisions. Sponsor/Contractholder will comply with the
following provisions by April 21, 2005, or such other applicable compliance date. For
purposes of this section, "electronic protected health information" (ePHI) shall have the
same meaning as defined in HIPAA and shall apply to those individuals who are eligible
and/or enrolled in the Group Health Plan's applicable dental and/or vision benefit
program administered by Business Associate.
i. Sponsor/Contractholder shall implement administrative, physical,
and technical safeguards that reasonably and appropriately protect the confidentiality,
integriry, and availabiliry of the ePHI that it creates, receives, maintains, or transmits on
behalf of the Group Health Plan.
ii. Sponsor/Contractholder shall ensure that any agent, including a
subcontractor, to whom the Sponsor/Contractholder provides ePHI agrees to implement
reasonable and appropriate safeguards to protect ePHI.
iii. As soon as practical after discovery, Sponsor/Contractholder shall
report to the Group Health Plan any Security Incident of which Sponsor/Contractholder
becomes aware.
iv. Sponsor/Contractholder shall ensure adequate separation as
required by HIPAA by complying with Section 3.6 (i) above for the ePHI created and
received by the Sponsor/Contractholder.
SECTION 4—DISCLOSURE TO BUSINESS ASSOCIATE
4.1 The Sponsor/Contractholder represents and warrants that prior to requesting
Business Associate to disclose PHI to the Group Health Plan's business associate(s),
including but not limited to, a broker, consultant, TPA or auditor, the Group Health Plan,
or the Sponsor/Contractholder on the Group Health Plan's behalf, shall have entered into
a business associate contract or have other satisfactory arrangement with such business
associate(s) that complies with the requirements of HIPAA. Sponsor/Contractholder
and/or the Group Health Plan agree to provide Business Associate with documentation
relating to the business associate's permission to receive PHI from Business Associate.
4.2 Disclosure to a business associate pursuant to this Section 4 shall not include a
disclosure to the Sponsor/Contractholder nor to its identified employees.
SECTION 5—GENERAL
5.1 Amendment to Business Associate Addendum. Sponsor/Contractholder and
Business Associate agree to amend this Business Associate Addendum as necessary to
comply with federal or state laws or regulations relating to the administrative
simplification provisions of HIPAA.
STD BA-GRP 7 Rev 04l2007
5.2 Indemnification bv Business Associate. Business Associate agrees to indemnify,
defend and hold harmless the Group Health Plan, or the SponsoNContractholder on the
Group Health Plan's behalf, and their employees, directors, officers, subcontractors,
agents or other members of its workforce, each of the foregoing hereinafter referred to
as "Indemnified Party," against all actual and direct losses suffered by the Indemnified
Party and all liability to third parties arising from or in connection with Business
Associate's breach of sections 2 or 3 of this Business Associate Addendum.
Accordingly, on demand, Business Associate shall reimburse any Indemnified Party for
any and all actual and direct losses, liabilities, fines, penalties, costs or expenses
(including reasonable attorneys' fees) which may for any reason be imposed upon any
Indemnified Party by reason of any suit, claim, action, proceeding or demand by any
third party which results from Business Associate's breach hereunder. Business
Associate's obligation to indemnify any Indemnified Party shall survive the expiration or
termination of this Business Associate Addendum for any reason.
5.3 Indemnification bv Grouq Health Plan or Sponsor/Contractholder. The Group
Health Plan, or the SponsoNContractholder on the Group Health Plan's behalf, agrees to
indemnify, defend and hold harmless Business Associate and its employees, directors,
officers, subcontractors, agents or other members of its workforce, each of the foregoing
hereinafter referred to as "Indemnified Party," against all actual and direct losses
suffered by the Indemnified Party and all liability to third parties arising from or in
connection with the Group Health Plan's or Sponsor/Contractholder's breach of Sections
2, 3 or 4 of this Business Associate Addendum. Accordingly, on demand, the Group
Health Plan or Sponsor/Contractholder shall reimburse any Indemnified Party for any
and all actual and direct losses, liabilities, fines, penalties, costs or expenses (including
reasonable attorneys' fees) which may for any reason be imposed upon any Indemnified
Party by reason of any suit, claim, action, proceeding or demand by any third party
which results from the Group Health Plan's or Sponsor/Contractholder's breach
hereunder. The obligation to indemnify any Indemnified Party shall survive the
expiration or termination of this Business Associate Addendum for any reason.
5.4 Interpretation. This Business Associate Addendum shall be interpreted to allow
the parties to comply with HIPAA, provided, however, that nothing herein shall be
construed to grant rights beyond those provided under HIPAA or applicable law.
5.5 No Third Party Beneficiary. Nothing express or implied in this Business
Associate Addendum is intended to confer, nor shall anything in this Business Associate
Addendum confer, upon any person other than the parties to this Business Associate
Addendum and their respective successors and assigns, any rights, remedies,
obligations or liabilities whatsoever.
STD BA-GRP 8 Rev 04/2007
Contract No. C27650
IN WITNESS WHEREOF, Employer and Business Associate have duly executed this
Business Associate Addendum as of the date listed below.
Employer represents and warrants that it is signing this Agreement in its capacity as the
sponsor of the Group Health Plan and not in a capacity of a business associate to the
Group Health Plan.
EMPLOYER: Citv of Palm Desert
(print entity's name)
Group Number: 02012-0074 & 02012-0075 (COBRA)
Signature:
Print Name:
Print Title:
Date:
BUSINESS ASSOCIATE:
This Business Associate Addendum applies to the entity identified by a checkmark
below which issued the applicable group dental and/or vision contract to the Employer
and/or Group Health Plan:
STD BA-GRP 9 Rev 04/2007
❑ Alpha Dental of Alabama, Inc. ❑ Alpha Dental of Arizona
❑ Alpha Dental of Nevada, Inc. ❑ Alpha Dental of New Mexico, Inc.
❑ Alpha Dental of Utah, Inc. ❑ Alpha Dental Programs, Inc.
❑ Delta Dental Insurance Company � Delta Dental of California
❑ Delta Dental of New York, Inc. ❑ Dentegra Insurance Company
❑ Pennsylvania Dental Service Corporation
dba Delta Dental of Pennsylvania
Date: September 4, 2007
r-=�x-�� �
Belinda Mart' ez
Senior Vice President, Sales/Marketing
�'--�.--� � �..___.o._��__^
Kenneth E. Bemardi
Vice President, Underwriting 8�Actuarial
STD BA-GRP 10 Rev 04/2007
Cont:ra�t No. C27650
EXHIBIT A TO HIPAA BUSINESS ASSOCIATE ADDENDUM:
GROUP HEALTH PLAN
Business Associate's Permitted Uses and Disclosures:
Except as otherwise limited in this Business Associate Addendum, Business Associate
shall use and disclose PHI:
A. To perform the functions, activities, or services for, or on behalf of, the Group
Health Plan as specified in this Contract, provided that such use or disclosure would not
violate HIPAA if done by the Group Health Plan.
B. For the Group Health Plan's treatment, payment and health care operations as
defined and permitted under HIPAA with respect to Business Associate's administration
of the applicable dental and/or vision benefits program for the Group Health Plan as
described in this Contract.
C. For Business Associate's treatment, payment and health care operations as
defined and permitted under HIPAA with respect to Business Associate's administration
of the applicable dental and/or vision benefits program for the Group Health Plan as
described in this Contract.
D. To Business Associate's agents or subcontractors as necessary for Business
Associate to perform the services described in this Contract.
E. To the Group Health Plan's or Sponsor/Contractholder's business associate,
agent or subcontractor as requested by the Sponsor/Contractholder.
F. To provide Data Aggregation services to the Group Health Plan if mutually
agreed upon between Group Health Plan and Business Associate.
G. To provide to or obtain de-identification services for the Group Health Plan if
mutually agreed upon between Group Health Plan and Business Associate.
H. As otherwise required or permitted by HIPAA or federal or state law.
I. To report violations of law to appropriate federal or state authorities, consistent
with 45 CFR §164.502 (j) (1).
J. As otherwise requested by the Sponsor/Contractholder or the Group Health Plan
that is not in violation of HIPAA.
STD BA-GRP 11 Rev 04/2007
EXHIBIT B TO HIPAA BUSINESS ASSOCIATE ADDENDUM:
GROUP HEALTH PLAN
Sponsor/Contractholder's Uses and Disclosures
Sponsor/Contractholder shall use and disclose PHI only in compliance with HIPAA and
for the purpose of providing plan administration functions to the Group Health Plan. Plan
administrative functions are defined as administration functions performed by the plan
sponsor of a group health plan on behalf of the group health plan and excludes functions
performed by the plan sponsor in connection with any other benefit or benefit plan of the
plan sponsor.
STD BA-GRP 12 Rev 04/2007