DENTAL NECESSITY Sample Clauses

DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member.
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DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by BCBSRI, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member’s family or dentist of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service that can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action. Please see Appeals in Section 5 for details. We may review dental necessity on a case-by-case basis. We determine dental necessity solely for purposes of claims payment based on our dental policies and related guidelines under this plan.
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DENTAL NECESSITY. (DENTALLY NECESSARY) means that the dental services provided by a dentist to identify or treat your dental or oral health condition, upon review by Blue Cross & Blue Shield of Rhode Island, are: • consistent with the symptoms and appropriate and effective for the diagnosis, treatment, or care of the oral condition, disease, or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of dental practice within the dental community or scientific evidence; • not primarily for the convenience of the member, the member's family or dentist of such member; AND • the most appropriate in terms of type, amount, frequency, setting, duration, and level of service which can safely be provided to the member. We will make a determination whether a dental service is dentally necessary based on our dental policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may review dental necessity on a case-by-case basis. WE DETERMINE DENTAL NECESSITY SOLELY FOR PURPOSES OF CLAIMS PAYMENT IN ACCORDANCE WITH OUR DENTAL POLICIES AND RELATED GUIDELINES UNDER THIS AGREEMENT. PREDETERMINATION is an administrative procedure whereby your dentist sends to us your treatment plan before treatment is rendered. Pre-determinations are an estimate, not a guarantee of payment. The pre-determination estimates are based on your eligibility status and benefits at the time the request is processed. It is subject to change. Obtaining predetermination is NOT a requirement in order for planned covered dental service to be covered. However, if you decide to have the dental service when the predetermination is that the service is not covered, you will be responsible for the cost of the dental service. This is true whether you have the service rendered by a network or non-network dentist. You have the right to appeal or to take legal action as described in Section 7.0. Network dentists may get pre-determination for all covered dental services. This includes, but is not limited to, multiple restorations, periodontics (treatment of gums), prosthodontics (bridges and dentures) and orthodontics. When your dentist is non-network, you or the non-network dentist may obtain a predetermination. You may inquire about pre- determinations by calling us at (000) 000-0000 or 0-000-000-0000.
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Related to DENTAL NECESSITY

  • Health Plans A. The health plans offered and benefits provided by those plans shall be those recommended by the JLMBC, approved by the City Council, and administered by the Personnel Department in accordance with LAAC Section 4.

  • Medical and Dental Coverage The County and Union agree that this Memorandum of Understanding shall be reopened at the County's request to meet and confer to discuss and mutually agree upon changes related to the Medical and Dental Plans, benefits, and contribution rates.

  • Medical Plan ‌ Eligible employees and dependants shall be covered by the British Columbia Medical Services Plan or carrier approved by the British Columbia Medical Services Commission. The Employer shall pay one hundred percent (100%) of the premium. An eligible employee who wishes to have coverage for other than dependants may do so provided the Medical Plan is agreeable and the extra premium is paid by the employee through payroll deduction. Membership shall be a condition of employment for eligible employees who shall be enrolled for coverage following the completion of three (3) months’ employment or upon the initial date of employment for those employees with portable service as outlined in Article 14.12.

  • Dental Care Plan The Welfare Plan will include a Dental Care Plan which will reimburse members for expenses incurred in respect of the coverages summarized in Appendix "1". The Plan will not duplicate benefits provided now or which may be provided in the future by any government program.

  • Health and Dental Coverage A dependent child is an eligible employee’s child to age twenty-six (26).

  • Dental Care a. Dental Care for Members over age 19 is limited to the following: i. care and stabilization treatment rendered within 62 days of an Accidental Dental Injury provided such services are for the treatment of damage to Sound Natural Teeth; ii. extraction of teeth required prior to radiation therapy when you have a diagnosis of cancer of the head or neck. b. General anesthesia and hospitalization services are covered when required to assure the safe delivery of necessary dental treatment or surgery for a dental Condition which, if left untreated, is likely to result in a medical Condition if: i. a Member has one or more medical Conditions that would create significant or undue medical risk for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or Ambulatory Surgery Center; or ii. a Covered Dependent child is under eight years of age and it is determined by a licensed dentist and the Covered Dependent’s Attending Physician that dental treatment or surgery in a Hospital or Ambulatory Surgery Center is necessary due to a significantly complex dental Condition, or a developmental disability in which patient management in the dental office has proven to be ineffective.

  • Leave for Medical and Dental Care (a) Where it is not possible to schedule medical and/or dental appointments or appointments with a registered midwife outside regularly scheduled working hours, reasonable time off for such appointments for employees or for dependent children shall be permitted, but where any such absence exceeds two hours, the full-time absence shall be charged to the entitlement described in Clause 20.12. "Medical, dental and/or registered midwife appointments" include only those services covered by the BC Medical Services Plan, the Public Service Dental Plan, the Extended Health Benefit Plan and assessment appointments with the Employee and Family Assistance Program. (b) Employees in areas where adequate medical and dental facilities are not available shall be allowed to deduct from their credit described in Clause 20.12 the necessary time including travel and treatment time up to a maximum of three days to receive medical and dental care at the nearest medical centre for the employee, their spouse, dependent child and a dependent parent permanently residing in the employee's household or with whom the employee permanently resides. The Employer may request a certificate of a qualified medical or dental practitioner, as the case may be, stating that treatment could not be provided by facilities or services available at the employee's place of residence. An employee on leave provided by this clause shall be entitled to reimbursement of reasonable receipted expenses for accommodation and travel to a maximum of $510 effective April 1, 2019, $520 effective April 1, 2020, and $530 effective April 1, 2021 per calendar year. (c) An employee otherwise entitled to leave pursuant to (b) above who chooses to travel on a vacation day or a day of rest or to remain at work and not accompany their spouse, dependent child or dependent parent, as provided in (b) above, may claim the reimbursement of receipted expenses under the conditions stipulated. (d) Employees in receipt of STIIP benefits who would otherwise qualify for leave under this clause shall be eligible to claim expenses in the manner described above. (e) Where leave pursuant to (b) above would be reduced, the Employer may approve airfare payment for the employee in lieu of the $510 effective April 1, 2019, $520 effective April 1, 2020, and $530 effective April 1, 2021 reimbursement, once per calendar year. (f) For the purpose of this clause, "child" includes a child over the age of 18 residing in the employee's household who is permanently dependent on the employee due to mental or physical impairment.

  • Medical Plans The Employer will maintain the current health (including vision) and dental insurance programs and practices. For Calendar Years 2022 — 2023, the Employer shall contribute 80% of the premium charge for PPO plans, 85% of premium for the EPO plan, 85% of premium for the IHM plan, 80% for the prescription drug plan and 50% for the dental plan.

  • Health Plan An appropriately licensed entity that has entered into a contract with Subcontractor, either directly or indirectly, under which Subcontractor provides certain administrative services for Health Plan pursuant to the State Contract. For purposes of this Appendix, Health Plan refers to UnitedHealthcare Insurance Company.

  • Medical and Dental Benefits If Executive’s employment is subject to a Termination, then to the extent that Executive or any of Executive’s dependents may be covered under the terms of any medical or dental plans of the Company (or an Affiliate) for active employees immediately prior to the Termination Date, then, provided Executive is eligible for and elects coverage under the health care continuation rules of COBRA, the Company shall provide Executive and those dependents with coverage equivalent to the coverage in effect immediately prior to the Termination. For a period of twelve (12) months (18 months for a Termination during a Covered Period), Executive shall be required to pay the same amount as Executive would pay if Executive continued in employment with the Company during such period and thereafter Executive shall be responsible for the full cost of such continued coverage; provided, however, that such coverage shall be provided only to the extent that it does not result in any additional tax or other penalty being imposed on the Company (or an Affiliate) or violate any nondiscrimination requirements then applicable with respect to the applicable plans. The coverages under this Section 4(e) may be procured directly by the Company (or an Affiliate, if appropriate) apart from, and outside of the terms of the respective plans, provided that Executive and Executive’s dependents comply with all of the terms of the substitute medical or dental plans, and provided, further, that the cost to the Company and its Affiliates shall not exceed the cost for continued COBRA coverage under the Company’s (or an Affiliate’s) plans, as set forth in the immediately preceding sentence. In the event Executive or any of Executive’s dependents is or becomes eligible for coverage under the terms of any other medical and/or dental plan of a subsequent employer with plan benefits that are comparable to Company (or Affiliate) plan benefits, the Company’s and its Affiliates’ obligations under this Section 4(e) shall cease with respect to the eligible Executive and/or dependent. Executive and Executive’s dependents must notify the Company of any subsequent employment and provide information regarding medical and/or dental coverage available.

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