DENTAL CARE AND TREATMENT BENEFITS. After any applicable Dental Waiting Period and payment of any applicable Deductible Amount shown in the Schedule of Benefits, the Claims Administrator will pay the Coinsurance percentage for the Covered Services shown in the Schedule of Benefits, rendered by a Dentist, not to exceed the Allowable Charge, up to the Benefit Period Maximum, if any, as shown in the Schedule of Benefits. Any percentage not covered will be the responsibility of the Member. If shown in the Schedule of Benefits, Benefits under Orthodontics may be limited to the Lifetime Maximum per Plan Participant in the amount shown. Unless otherwise noted in the Schedule of Benefits, payments made under Orthodontics during a Benefit Period are included in the Benefit Period Maximum for Dental Care and Treatment. All applicable Dental Waiting Period, Deductible Amounts, Maximum, and Coinsurance percentages for each service will be disclosed in the Schedule of Dental Benefits. Any applicable Deductible Amount will apply to the Plan Participant's Claims to the Deductible Amount in the order in which Claims are received and processed. It is possible that one Provider may collect the Deductible Amount from the Plan Participant, then when the Plan Participant receives Covered Services from another Provider, that Provider also collects the Plan Participant's Deductible Amount. This generally occurs when the Plan Participant's Claims have not been received and processed by the Claims Administrator. Our system will only show the Deductible Amount applied for Claims that have been processed. Therefore, the Plan Participant may need to pay toward the Deductible Amount until his Claims are submitted and processed, showing that the Deductible Amount has been met. If the Plan Participant overpays his Deductible Amount, the Plan Participant is entitled to receive a refund from the Provider in which the overpayment was made. ANY BENEFIT LISTED IN THIS BENEFIT PLAN, WHICH IS NOT MANDATED BY STATE OR FEDERAL LAW, MAY BE DELETED OR REVISED ON THE SCHEDULE OF BENEFITS. Subject to the above, this Benefit Plan will cover the following Benefits:
DENTAL CARE AND TREATMENT BENEFITS. 13 A. Preventive and Diagnostic Dental Services 13 B. Basic Dental Services 14 C. Major Dental Services 15 D. Orthodontic Services, Treatment, and Appliances 16 ARTICLE V. TRANSFER OF CARE LIMITATIONS 16 ARTICLE VI. LIMITATIONS AND EXCLUSIONS 17 ARTICLE VII. CONTINUATION OF COVERAGE RIGHTS 18 ARTICLE VIII. COORDINATION OF BENEFITS 18 ARTICLE IX. GENERAL PROVISIONS – GROUP AND PLAN PARTICIPANTS 22 ARTICLE X. METHODOLOGY FOR ESTABLISHMENT OF THE DENTAL FEE SCHEDULE 29 ARTICLE XI. COMPLAINT, GRIEVANCE AND APPEAL PROCEDURES 30 ARTICLE XII. MAKING PLAN CHANGES AND FILING CLAIMS 34 ARTICLE XIII. RESPONSIBILITIES OF THE PLAN ADMINISTRATOR 35
DENTAL CARE AND TREATMENT BENEFITS. 14 A. Preventive and Diagnostic Dental Services 15 B. Basic Dental Services 16 C. Major Dental Services 17 D. Orthodontic Services, Treatment and Appliances 18 ARTICLE V. TRANSFER OF CARE LIMITATIONS 18 ARTICLE VI. LIMITATIONS AND EXCLUSIONS 18 ARTICLE VII. CONTINUATION OF COVERAGE RIGHTS 19
