Common use of Exclusions of Benefits for Pediatric Enrollees Clause in Contracts

Exclusions of Benefits for Pediatric Enrollees. Except as specifically provided, the following services, supplies, or charges are not covered: 1) Any dental service or treatment not specifically listed under Schedule A, Description of Benefits and Copayments, as a covered service. 2) Dental services received from any dental facility other than the assigned Contract Dentist or an authorized Contract Specialist (oral surgeon, endodontist, periodontist, pediatric dentist or Contract Orthodontist) except for Emergency Services as described in the Contract. 3) Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, the plan will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law. 4) Any procedure that has a poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or is inconsistent with meeting accepted standards of dental practice. 5) Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA plan. 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. 6) Those incurred after the termination date of the member’s coverage unless otherwise indicated. 7) Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist. (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the Enrollee by a Contract Dentist unless the dentist notifies the Enrollee of his/her liability prior to treatment and the Enrollee chooses to receive the treatment. Contract Dentists should document such notification in their records.) 8) Services or treatment provided by a member of the Enrollee’s immediate family. 9) Those services submitted by a dentist which are for the same services performed on the same date for the same Enrollee by another dentist. 10) Those which are experimental or investigative (deemed unproven). 11) Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association. 12) Consultations or other diagnostic services for non-covered Benefits.

Exclusions of Benefits for Pediatric Enrollees. Except as specifically provided, the following services, supplies, or charges are not covered: 1) Any dental service or treatment not specifically listed under Schedule A, Description of Benefits and CopaymentsCost Share, as a covered service. 2) Dental services received from any dental facility other than the assigned Contract Dentist or an authorized Contract Specialist (oral surgeon, endodontist, periodontist, pediatric dentist or Contract Orthodontist) except for Emergency Services as described in the Contract. 3) Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, the plan will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law. 4) Any procedure that has a poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or is inconsistent with meeting accepted standards of dental practice. 5) Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA plan. 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. 6) Those incurred after the termination date of the member’s coverage unless otherwise indicated. 7) Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist. (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the Enrollee by a Contract Dentist unless the dentist notifies the Enrollee of his/her liability prior to treatment and the Enrollee chooses to receive the treatment. Contract Dentists should document such notification in their records.) 8) Services or treatment provided by a member of the Enrollee’s immediate family. 9) Those services submitted by a dentist which are for the same services performed on the same date for the same Enrollee by another dentist. 10) Those which are experimental or investigative (deemed unproven). 11) Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association. 12) Consultations or other diagnostic services for non-covered Benefits.

Exclusions of Benefits for Pediatric Enrollees. Except as specifically provided, the following services, supplies, or charges are not covered: 1) Any dental service or treatment not specifically listed under Schedule A, Description of Benefits and Copayments, as a covered service. 2) Dental services received from any dental facility other than the assigned Contract Dentist or an authorized Contract Specialist (oral surgeon, endodontist, periodontist, pediatric dentist or Contract Orthodontist) except for Emergency Services as described in the Contract. 3) Those not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, the plan will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law. 4) Any procedure that has a poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or is inconsistent with meeting accepted standards of dental practice. 5) Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA plan. 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. 6) Those incurred after the termination date of the member’s coverage unless otherwise indicated. 7) Those which are not medically or dentally necessary, or which are not recommended or approved by the treating dentist. (Services determined to be unnecessary or which do not meet accepted standards of dental practice are not billable to the Enrollee by a Contract Dentist unless the dentist notifies the Enrollee of his/her liability prior to treatment and the Enrollee chooses to receive the treatment. Contract Dentists should document such notification in their records.) 8) Services or treatment provided by a member of the Enrollee’s immediate family. 9) Those services submitted by a dentist which are for the same services performed on the same date for the same Enrollee by another dentist. 10) Those which are experimental or investigative (deemed unproven). 11) Those which are for unusual procedures and techniques and may not be considered generally accepted practices by the American Dental Association. 12) Consultations or other diagnostic services for non-covered Benefits.