Benefits, Limitations and Exclusions i. Dental Benefits are payable only for covered services. The dental plan covers several categories of Benefits when a Dental Provider furnishes the services and when they are necessary and within the standards of generally accepted dental practice. Claims will be processed in accordance with the dental plan standard processing policies. Dentists (dental consultants) may be used to review treatment plans, diagnostic materials or prescribed treatments to determine generally accepted dental practices and to determine if treatment has a favorable prognosis. If you receive dental services from a Dental Provider outside the State of Florida, the Provider will be paid according to the dental network payment provisions for said state according to the terms of the Provider’s Contract.
ii. If a primary dental procedure includes component procedures that are performed at the same time as the primary procedure, the component procedures are considered to be part of the primary procedure for purposes of determining the Benefit payable. Even if the Dental Provider bills separately for the primary procedure and each of its component parts, the total Benefit payable for all related charges will be limited to the maximum Benefit payable for the primary procedure.
Benefits, Limitations and Exclusions. This plan provides the Benefits described in the Schedules that are a part of this Contract. Benefits are only available in the state of Florida. The services are performed as deemed appropriate by your attending Contract Dentist.
Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for his or her services or the maximum allowable amount for participating dentists. Participating dentists accept the amount that Delta Dental determines to be the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in Appendix
A. Appendix A defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber or other participant obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant if required by law, and will be based on the dentist’s submitted fee for his or her service or the Prevailing Fee, whichever is less. Each Subscriber or participant is responsible for paying the dentist and for filing their own claims. The complete Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with Appendix A. All claims shall be evaluated, reviewed and paid in accordance with this Plan Agreement and Appendix A, subject to Plan Administrator’s absolute right to review any and all claims decisions (including both payment and denial of claims) and overrule any and all such decisions, on a case− by−case basis, in Plan Administrator’s sole discretion in its role as fiduciary. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in Appendix A.
Benefits, Limitations and Exclusions for additional information. Routine eye exams are limited to one visit per calendar year for children through the end of the month in which they turn 19, and one standard pair of child eyeglasses (lenses, and frames from a pre-selected group of frames).
