Common use of BENEFIT PAYMENT PROCEDURES Clause in Contracts

BENEFIT PAYMENT PROCEDURES. 1. After Subscriber or eligible Dependent has met any applicable Class I deductible requirement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class I services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment.

BENEFIT PAYMENT PROCEDURES. 1. After Subscriber or eligible Dependent has met any applicable Class I deductible requirement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental PPO Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental PPO Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. In the event a dentist has not signed a Delta Dental PPO Participating Dentist Agreement but has signed a Delta Dental Premier Participating Dentist Agreement, payment for covered Class I services received by the Subscriber or eligible Dependent shall be made by DDPOK to a Delta Dental Premier Participating Dentist at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the maximum allowable amount for Delta Dental Premier Participating Dentists, whichever is less, subject to any maximum benefit payment limitation. Form No. 1000.3 8 of 13 CONFIDENTIAL Appendix B Revised January 2022 In the event a dentist has not signed a Participating Dentist Agreement, payment for covered Class I services rendered to the Subscriber or eligible Dependent by a Nonparticipating Dentist shall be made by DDPOK to the Subscriber, or to other participant or beneficiary if required by law, at the rate of one hundred percent (100%) of the balance of the Dentist’s submitted fee or one hundred percent (100%) of the balance of the amount determined as the prevailing fee, whichever is less, subject to any maximum benefit payment limitation. The Subscriber shall be responsible for paying the Nonparticipating Dentist both the payment received from DDPOK and any portion of the Nonparticipating Dentist’s fee not discharged by such payment.