Medically Necessary Orthodontic Benefits - Exclusions and Limitations Sample Clauses

Medically Necessary Orthodontic Benefits - Exclusions and Limitations. If the fee for a procedure or service is “Disallowed”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee. • If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan. 1. For Medically Necessary Orthodontic treatment commenced while a Pediatric Enrollee is eligible for orthodontic benefits under this policy, Delta Dental will initiate payment of its liability once bands or orthodontic devices are placed. Delta Dental requires a dental consultant’s review to determine if orthodontic treatment is medically necessary. 2. For Medically Necessary Orthodontic treatment commenced prior to becoming eligible under this policy, Delta Dental will pro-rate its liability based on the number of remaining months of active treatment compared to the total number of months of active treatment. Delta Dental requires dental consultant review to determine if orthodontic treatment was medically necessary at the start of treatment. 3. Active treatment includes procedures undertaken and appliances used with those procedures for the purpose of bringing teeth into proper position and alignment. Active treatment does not include space maintainers, palate expanders or other devices used to prepare the patient for services to position and align teeth. 4. Delta Dental will make one (1) payment of twenty-five percent (25%) of the allowed charge at the start of treatment followed by monthly payments throughout the length of treatment up to a maximum of thirty-six (36) months for its total liability. “Start of treatment” means the date of initial banding or a segment thereof, or a device is placed in the patient’s mouth. Periodic monthly payments will continue based upon the continuing eligibility of the Pediatric Enrollee. 5. Cephalometric images, oral/facial photographic images and diagnostic models are a covered benefit with Medically Necessary Orthodontic treatment only. 6. The replacement of an orthodontic appliance is a covered benefit once per arch in a lifetime. 7. The repair of an orthodontic appliance is not a covered benefit. The patient is financially responsible. 8. Rebonding or recementation of a fixed retainer is a covered benefit once in a lifetime per patient if performed by a different Dentist than the Dentist who placed the appliance. Rebondin...

Medically Necessary Orthodontic Benefits - Exclusions and Limitations.  If the fee for a procedure or service is “Not Billable to the Patient”, it is not payable by Delta Dental, nor collectable from the patient by a Participating Dentist. Participating Dentists agree not to charge a separate fee.  If the fee for a procedure or service is “Denied”, it is not payable by Delta Dental, but is chargeable to the patient as the procedure or service is not a benefit of the patient’s plan. 1. For Medically Necessary Orthodontic treatment commenced while a Pediatric Enrollee is eligible for orthodontic benefits under this policy, Delta Dental will initiate payment of its liability once bands or orthodontic devices are placed. Delta Dental requires a dental consultant’s review to determine if orthodontic treatment is medically necessary.