Exhibit 10(m)
DELTA DENTAL PLAN
(A Not-for Profit Corporation Incorporated in California
and a Member of the Delta Dental Plans Association)
Home Office: P.O. Box 7736, San Francisco, California 94
120
(Herein referred to as "Delta")
Group Numbers 5134 and 5135
IN CONSIDERATION of the application made by NORTHROP
GRUMMAN CORPORATION, referred to in this Contract as
"Northrop Grumman Corporation" and IN CONSIDERATION of
payment by Northrop Grumman Corporation as stated in
Article 3, Delta agrees to administer the Benefits in
Article 4 below for a period of three (3) years,
beginning at 12:01 a.m., Standard Time, on July 1, 1995,
and from year to year thereafter, unless this Contract
is terminated in accordance with Article 9.
The following documents are attached to this Contract
and made a part hereof:
Appendix A Benefits
Appendix B Dental Procedure Numbers
Appendix C Orthodontic Benefits Rider
This Contract contains the following Articles:
Article 1 Definitions
Article 2 Eligibility
Article 3 Payments
Article 4 Benefits Provided; Limitations and
Exclusions
Article 5 Deductibles & Maximum Amounts
Article 6 Coordination of Benefits
Article 7 Conditions Under Which Delta Will
Provide Benefits
Article 8 Other Delta Obligations
Article 9 Termination and Renewal
Article 10 Continued Coverage Option
Article 11 General Provisions
ARTICLE -- 1 DEFINITIONS
These terms, when used in this Contract, mean the
following:
1.1 "Attending Dentist's Statement" is the
form completed by the Dentist to request
Delta's payment for dental services or
predetermination for proposed dental
treatment.
1.2 "Benefits" means those dental services
which are available under the terms of this
Contract as set out in Article 4.
1.3 "Contract" means this agreement between
Delta and Northrop Grumman Corporation
including the attached appendices. This
Contract is the entire Contract between the
parties.
1.4 "Contract Term" means the period
beginning on July 1, 1995 and ending on June
30, 1996, and each subsequent yearly period
during which this Contract remains in effect.
1.5 "Dentist" means a duly licensed Dentist
legally entitled to practice dentistry when
and where services are provided.
1.6 "Eligible Dependent" means any of an
employee's dependents who is eligible for
Benefits under Article 2 of this Contract.
1.7 "Eligible Employee" means any employee
who is eligible for Benefits under Article 2
of this Contract.
1.8 "Eligible Person" means an employee or a
dependent who is eligible for Benefits under
Article 2 of this Contract, or a person
ceasing to meet such conditions who chooses
continued coverage as set out in Article 10,
and for whom Delta receives the appropriate
monthly payment set out in Article 3.
1.9 "Eligibility Date" means the date an
employee's eligibility for Benefits becomes
effective under the terms of this Contract.
1.10 "Fee Actually Charged" means the fee for
a particular dental service or procedure which
a Dentist submits to Delta on an Attending
Dentist's Statement, less any portion of such
fee which is discounted, waived, or rebated,
or which the Dentist does not use good faith
efforts to collect.
1.11 "Participating Dentist" means a Dentist
who has signed an agreement with Delta,
agreeing to provide services under the terms
and conditions established by Delta.
1.12 "Participating Plan" means Delta and any
other member of the Delta Dental Plans
Association with which Delta contracts to
assist it in administering the Benefits
described in this Contract.
1.13 "Patient Copayment" means the portion of
the Dentist's fees or allowances charged for
Benefits which is the Eligible Person's
responsibility.
1.14 "Prevailing Fee" is the fee for a Single
Procedure which satisfies the majority of
Dentists in California, as determined by Delta
based upon confidential fee listings accepted
by Delta from Participating Dentists.
1.15 "Procedure Numbers" means the Procedure
Numbers shown on Appendix B.
1.16 "Single Procedure" means a dental
procedure listed in Appendix B to which Delta
has assigned a separate Procedure Number,
e.g., a three-surface amalgam restoration of a
single permanent tooth (Procedure 02160) or a
complete upper denture, including adjustments
for a six month period following installation
(Procedure 05110).
1.17 For a Dentist who has signed a
Participating Dentist Agreement with Delta,
his or her "Usual, Customary, and Reasonable
Fee" for any Single Procedure is the fee which
the Dentist has filed with Delta and which
Delta has accepted. For these Dentists, the
words "Usual, Customary and Reasonable" mean
the following:
USUAL -- A usual fee is the amount which
a Dentist regularly charges and receives for a
given service. If the Dentist charges more
than one fee for a given service, the "Usual"
fee for that service is the lowest fee which
the Dentist regularly charges or offers to
patients.
CUSTOMARY -- A fee is customary when it
is within the range of usual fees charged and
received for a particular service by Dentists
of similar training in the same geographic
area which Delta determines is statistically
relevant.
REASONABLE -- A fee is reasonable if it
is "usual" and "customary", or if Delta agrees
that a fee that falls above customary is
justified by a superior level of care or by
the extraordinary circumstances of the case in
question.
1.18 However, when a nonparticipating Dentist
provides services to an Eligible Person, his
or her "Usual, Customary, and Reasonable" fee
is presumed to be the "Prevailing Fee" for
that procedure.
ARTICLE 2 -- ELIGIBILITY
2.1 All present and future regular Eligible Employees
of Key Executive Group and Supplemental Executive
Plan are eligible for this program. Key Executive
Group shall be in Group #5134. Supplemental
Executive Plan shall be in Group #5135.
2.2 Enrollment for Eligible Employees and their
enrolled dependents will be effective beginning on
July 1, 1995.
2.3 If both husband and wife are eligible, dependent
children may qualify to be enrolled as the Eligible
Dependents of only one of such Eligible Employees.
2.4 Eligible Employees who elect family medical
coverage may only elect family dental coverage.
Eligible Employees who elect single medical
coverage may only elect single dental coverage.
2.5 Eligible Dependents are the employee's legal spouse
and unmarried dependent children from birth to
age 19, or to age 25 if enrolled as full-time
students in an accredited school, college, or
university. Children include step-children,
adopted children, children placed for adoption and
xxxxxx children, provided they depend upon the
employee for support and maintenance. The
dependents of Eligible Employees become Eligible
Dependents on the same date that the employee of
whom they are a dependent becomes an Eligible
Employee. Later-acquired dependents become
Eligible Dependents as soon as they acquire
dependent status.
2.6 An unmarried child, 19 years old or older, may
continue to be an Eligible Dependent even though
not enrolled as a full-time student if they are
incapable of self-support because of physical
handicap or mental incapacity if that handicap or
incapacity began before they reached age 19 and if
they are chiefly dependent upon the Eligible
Employee for support and maintenance. Proof of
such handicap or incapacity and dependency must be
submitted within thirty-one (31) days after request
for such proof from either Northrop Grumman
Corporation or Delta, and subsequently as may be
required by either Northrop Grumman Corporation or
Delta. Neither Delta nor Northrop Grumman
Corporation will request such proof more frequently
than annually after the child in question has
reached age 21.
2.7 Dependents in military service are not eligible.
2.8 Every employee and dependent meeting the preceding
conditions of eligibility is an Eligible Person.
However, Delta will not provide Benefits for any
employee or his or her dependents unless (1) the
employee is included on the list of Eligible
Employees submitted as required by this Article (or
any revision or correction of such a list), and
(2) the appropriate monthly payment is made as
required by Article 3 of this Contract, for the
months in which Delta provides covered dental
services.
2.9 Northrop Grumman Corporation agrees to enroll all
of its "Eligible Persons" in this program. All
employees of Northrop Grumman Corporation meeting
the eligibility requirements of this Article are
"Eligible Employees" under this program unless
Northrop Grumman Corporation offers one or more
alternate programs of dental coverage. In that
event, Eligible Employees will continue to be
eligible under this program unless they file a
choice card with Northrop Grumman Corporation
electing an alternate program during an open
enrollment period agreed upon between Delta and
Northrop Grumman Corporation. Northrop Grumman
Corporation agrees to bear the entire expense of
Dues payments for employees who continue to be
Eligible Persons under this program.
2.10 On or prior to the first day of every month,
commencing on July 1, 1995, Northrop Grumman
Corporation will compile and furnish Delta with a
list of all Eligible Employees, showing their
federally-assigned Social Security numbers, the
dates of hire, and, if applicable, the location
code. Northrop Grumman Corporation also agrees to
include in the list all persons electing continued
coverage under Article 10, showing their federally-
assigned Social Security numbers and dates of
election.
2.11 Northrop Grumman Corporation will offer continued
coverage to employees who are laid off from work.
These employees will have coverage until the end of
the month plus sixty (60) days. These employees
will be terminated and a weekly report will be
issued listing who are eligible and their
reinstatement date and new termination date after
sixty (60) days. This is only for employees who do
not have other group medical coverage. Therefore,
not all terminated and/or laid off employees would
be eligible. Employees on a medical leave will
continue coverage for two (2) years provided they
pay any required payroll deductions. Employees on
personal or educational leave can continue coverage
for one (1) month. Employees on family leave can
continue coverage for four (4) months. Employees
on military leave for six (6) months or less can
continue coverage. If the employee is called to
active military duty, the dental coverage will
stop, but the dependent coverage continues for
twelve (12) months, provided the employees pays for
any required payroll deductions.
2.12 An employee's eligibility ends on the day full-time
service ends, unless they choose to continue
coverage under Article 10. A dependent's
eligibility ends along with the Eligible
Employee's, or sooner if the dependent loses his or
her dependent status, unless continued coverage is
chosen in a timely fashion by or on behalf of the
dependent(s) under Article 10. Eligibility for
such continued coverage will continue for the
period required by the Option. In any event,
eligibility ends immediately when this Contract
ends.
2.13 Northrop Grumman Corporation agrees to permit
Delta, by its auditors or other authorized
representatives, on reasonable advance written
notice, to inspect Northrop Grumman Corporation's
records in order to verify the accuracy of lists of
Eligible Employees prepared by Northrop Grumman
Corporation and submitted to Delta and to verify
Northrop Grumman Corporation's compliance with
Article 3 of this Contract.
ARTICLE 3 -- DUES PAYMENTS
3.1 Northrop Grumman Corporation agrees to pay the
following monthly Dues to Delta, at the address
shown on the first page of this Contract, for all
of Northrop Grumman Corporation's employees and
their dependents who are enrolled "Eligible
Persons" as set forth in Article 2 of this
Contract:
Effective July 1, 1995 through December 31, 1995
for Group #5134:
$86.17 for each Eligible Employee.
Effective July 1, 1995 through December 31, 1995
for Group #5135:
$18.90 for each employee with no dependents; $41.19
for each employee with one or more dependents.
Effective January 1, 1996 through June 30, 1997 for
Group #5134:
$93.61 for each Eligible Employee.
Delta shall use the plus stabilization to subsidize
the sum of $7.79 for each Eligible Employee for a
total rate of $101.40 for each Eligible Employee.
Effective January 1, 1996 through June 30, 1997 for
Group #5135:
$20.53 for each employee with no dependents; $44.75
for each employee with one or more dependents.
Delta shall use the plus stabilization to subsidize
the sum of $1.71 for each employee with no
dependents for a total rate of $22.24 for each
employee with no dependents; the sum of $3.72 for
each employee with one or more dependents for a
total rate of $48.47 for each employee with one or
more dependents.
Northrop Grumman Corporation agrees to bear the
cost of such Dues without withholding or otherwise
charging Eligible Employees for their coverage.
3.2 The Dues for each person electing continued
coverage under the Continued Coverage Option in
Article 10 for himself or herself only will be the
same as for a single Eligible Employee. The Dues
for a person who also elects continued coverage for
his or her dependents will be the same as for an
Eligible Employee with the same number of
dependents. Northrop Grumman Corporation may
charge persons choosing coverage under Article 10
such amounts as are permitted by law.
3.3 In addition to the amounts, if any, which Delta
withholds from payments to Dentists as provided in
Delta Participating Dentists Rules, Northrop
Grumman Corporation authorizes Delta to deduct from
each of its monthly payments to Delta 8.22% as
compensation for Delta's administration of this
dental program.
3.4 After the end of each Contract Term, the excess, if
any, of the total monthly Dues paid by Northrop
Grumman Corporation since July 1, 1995 over the
amounts paid or otherwise discharged by Delta for
Benefits since that date (plus the compensation for
administration deducted under the preceding
paragraph), less a reasonable reserve for incurred
but unreported obligations, shall be held in the
experience stabilization fund, will be relected in
the calculation of the renewal rate for succeeding
Contract Terms and/or may be used to offset the
additional cost of increased Benefits for
succeeding Contract Terms. In no event, however,
shall this excess or any part of it be returned to
Northrop Grumman Corporation in a cash transaction
and any such excess remaining upon termination of
the program shall remain with Delta.
3.5 This Contract is not in effect until Delta receives
the Initial Dues from Northrop Grumman Corporation.
Northrop Grumman Corporation agrees to pay
subsequent Dues to Delta on or before the
tenth (10th) day of each month thereafter.
3.6 If this Contract terminates for any reason,
Northrop Grumman Corporation agrees to pay all Dues
earned by Delta but unpaid by Northrop Grumman
Corporation.
3.7 Except as provided in the next paragraph, an
agreement between Delta and Northrop Grumman
Corporation is required to change Northrop Grumman
Corporation Dues rate during a Contract Term.
3.8 During a Contract Term, if any government agency
imposes any new tax on Delta based on the amount of
Dues payable or the number of persons covered under
this Contract, or if the rate of any existing tax
on the amount of Dues or the number of persons
covered under this Contract increases, the Dues
stated in this Article will increase by the amount
of any such new or increased tax(es).
3.9 If Delta or Northrop Grumman Corporation discover
clerical errors or delays regarding eligibility
data, Dues and eligibility will be adjusted for all
affected months of the current Contract Term.
ARTICLE 4 -- BENEFITS PROVIDED; LIMITATIONS AND
EXCLUSIONS
4.1 Subject to the limitations and exclusions set forth
below, the following services are Benefits when
they are provided by a Dentist and when they are
necessary and customary as determined by the
standards of generally accepted dental practice.
4.2 DIAGNOSTIC AND PREVENTIVE BENEFITS. Delta agrees
to satisfy the applicable percentage shown in
Appendix A of the Dentist's Usual, Customary, and
Reasonable fees or of the Fees Actually Charged,
whichever is less, for the following Diagnostic and
Preventive Benefits:
Diagnostic - oral examinations
x-rays
diagnostic casts
biopsy/tissue
examination
emergency palliative
treatment
specialist
consultation
Preventive - Cleaning
(prophylaxis)
topical application
of fluoride solution
space maintainers
4.3 BASIC BENEFITS. Delta agrees to satisfy the
applicable percentage shown in Appendix A of the
Dentist's Usual, Customary, and Reasonable fees or
of the Fees Actually Charged, whichever is less,
for the following Basic Benefits:
Oral Surgery - extractions
and certain other surgical
procedures, including
preoperative and postoperative
care
Restorative - amalgam,
synthetic porcelain and plastic
restorations (fillings) for
treatment of carious lesions
(visible destruction of hard
tooth structure resulting from
the process of tooth decay)
Endodontic - treatment
of the tooth pulp
Periodontic - treatment
of gums and bones supporting
teeth
Sealants - topically-
applied acrylic, plastic, or
composite material used to seal
developmental grooves and pits
in teeth for the purpose of
preventing dental decay
4.4 LIMITATION ON BASIC BENEFITS:
Procedures for removal of stitches or post-
operative examination are not provided.
4.5 CROWNS, JACKETS, INLAYS, ONLAYS, AND CAST
RESTORATIONS. Delta agrees to satisfy the
applicable percentage shown on Appendix A of the
Dentist's Usual, Customary, and Reasonable fees or
of the Fees Actually Charged, whichever is less,
for the following Crowns, Jackets, Inlays, Onlays,
and Cast Restorations Benefits:
Crowns, Jackets, Inlays, Onlays, and Cast
Restorations for treatment of carious lesions
(visible destruction of hard tooth structure
resulting from the process of dental decay) which
cannot be restored with amalgam, synthetic
porcelain, or plastic restorations.
4.6 PROSTHODONTIC BENEFITS. Delta agrees to satisfy
the applicable percentage shown on Appendix A of
the Dentist's Usual, Customary, and Reasonable fees
or of the Fees Actually Charged, whichever is less,
for the following Prosthodontic Benefits:
Procedures for construction or repair of fixed
bridges, partial or complete dentures.
4.7 LIMITATIONS ON PROSTHODONTIC BENEFITS:
Applicable only to dependents of Executive
employees:
A patient shall be eligible for the replacement of
prosthodontic appliances only following such
patient's continuous enrollment under this Contract
for a period of twelve (12) months. This waiting
period shall be waived for patients who have
satisfied the waiting period under the previous
dental plan.
4.8 ORTHODONTIC BENEFITS. Delta agrees to provide
Orthodontic Benefits in accordance with the
Orthodontic Benefit Rider attached hereto as
Appendix C.
4.9 EXCLUSIONS: The following services are not
Benefits:
(a) Services for injuries or conditions which
are covered under Workers' Compensation or
Employer's Liability Laws.
(b) Services which are provided to the
Eligible Person by any Federal or State
Government Agency or are provided without cost
to the Eligible Person by any municipality,
county or other political subdivision, except
as provided in California Health and Safety
Code Section 1373(a).
(c) Treatment by someone other than a Dentist
or physician, except where performed by a duly
qualified technician under the direction of a
Dentist or physician.
(d) Services or supplies with respect to
cosmetic surgery or dentistry for purely
cosmetic reasons.
(e) Training in or supplies used for dietary
counseling, oral hygiene or plaque control.
(f) Procedures, restorations, and appliances
to increase vertical dimension or to restore
occlusion.
(g) Services and supplies in connection with
injury caused by war whether declared or not,
or by international armed conflict.
(h) Services and supplies furnished in a U.S.
Government hospital; which the person would
not be required to pay if there were no dental
program.
(i) Benefits to which a dependent is entitled
as an employee or former employee of Northrop
Grumman Corporation.
(j) Prosthetic services or any Single
Procedure started prior to the date the person
became eligible for such services under this
program.
(k) Specialized techniques involving
precision attachments, personalization or
characterization and additional charges for
adjustments within 6 months for installation
of prosthetic appliances.
(l) Orthodontic services (treatment of
malalignment of teeth and/or jaws), except
those services provided in accordance with the
Orthodontic Benefit Rider attached hereto as
Appendix C.
4.10 An agreement between Northrop Grumman Corporation
and Delta is required to change Benefits during a
Contract Term.
ARTICLE 5 -- DEDUCTIBLES & MAXIMUM AMOUNTS
5.1 Each Eligible Person must satisfy the amount as
shown in Appendix A ("deductible amount") of fees
for services which are Benefits received by an
Eligible Person during the term of this Contract
and otherwise covered by this Contract. Such
deductible amount will not exceed the amount as
shown in Appendix A for all Eligible Persons in a
single family, consisting of an Eligible Employee
and their Eligible Dependents, as defined. Delta
will compute these fees based on the Dentist's
Usual, Customary, and Reasonable fees.
5.2 Such deductible amounts shall apply once each plan
year (July 1 - June 30) or portion thereof during
which the patient is continuously eligible under
the Contract.
5.3 Eligible husband and wife both covered as Eligible
Employees of Northrop Grumman Corporation will be
allowed to satisfy the deductible as a combined
deductible.
5.4 The maximum amount Delta will pay for Diagnostic
and Preventive, Basic, Crowns, Jackets, Inlays,
Onlays, and Cast Restorations and Prosthodontic
Benefits provided to any one person in any plan
year (July 1 - June 30) shall be the amount shown
in Appendix A.
ARTICLE 6 -- COORDINATION OF BENEFITS:
6.1 If a group insurance policy or any other group
health benefits program, including another Delta
program, entitles a person to receive or be
reimbursed for the cost of dental services which
are also Benefits under this program, and if this
program is "primary" under the rules described
below, Delta will provide Benefits as if the other
program did not exist. If the other program is
"primary" under these rules, then Delta will
provide Benefits under this program only to the
extent that the other program does not fully
provide the dental services.
6.2 If the other program mainly covers services or
expenses other than dental care, this program is
"primary". Otherwise, Delta will use the following
rules to determine which program is "primary":
(a) The program which covers the person as
other than a dependent is primary over the
program which covers the person as a
dependent, with the following exception:
If the person is also a
Medicare Beneficiary and Medicare is:
(i) secondary
to the program covering the
person as a dependent; and
(ii) primary to
the program covering the person
as other than a dependent (for
example, a retired employee),
then the Benefits of the
program covering the person as a
dependent are determined before the
Benefits of the program covering the
person as other than a dependent.
(b) The program which covers a child as a
dependent of a parent whose birthday occurs
earlier in a calendar year is primary over the
program which covers a child as a dependent of
a parent whose birthday occurs later in a
calendar year (except for a dependent child
whose parents are separated or divorced as
described in (c) below).
(c) In the case of a dependent child whose
parents are legally separated or divorced:
(i) If the parent with
custody has not remarried, the
program which covers the child as a
dependent of the parent with custody
is primary over the program which
covers the child as a dependent of
the parent without custody.
(ii) If the parent with
custody has remarried, the program
which covers the child as a
dependent of the parent with custody
is primary over the program which
covers the child as a dependent of
the step-parent, and the program
which covers the child as a
dependent of the step-parent is
primary over the policy or program
which covers the child as a
dependent of the parent without
custody.
(iii) If there is a court
decree that establishes financial
responsibility for dental services
which are Benefits under this
program, then notwithstanding (i)
and (ii), the program which covers
the child as a dependent of the
parent with such financial
responsibility is primary over any
other program which covers the
child.
6.3 The Benefits of a program covering a laid-off or
retired employee (or dependent of such person)
shall be determined after the Benefits of any other
program covering such person as an employee.
6.4 If a person whose coverage is provided under
federal or state law requiring continuation is
covered under more than one program, Benefit order
shall be determined as follows:
(a) The Benefits of the program
covering the person as an employee or
dependent shall be primary.
(b) The Benefits under continuation
coverage shall be secondary.
6.5 If the primary program cannot be determined by the
rules described in this Article 6, the program
which has covered the person longer shall be
primary.
6.6 An Eligible Person will provide Delta with any
information about the person that is needed to
administer this Article, and Delta may release any
information to or obtain any information from any
insurance company or other organization in order to
coordinate the Benefits of an Eligible Person.
Delta in its sole discretion will determine whether
any reimbursement is warranted to an insurance
company or other organization under this provision,
and it is agreed that any such reimbursement paid
by Delta will be Benefits under this Contract.
Delta has the right to recover the value of any
Benefits provided by Delta which exceed its
obligations under the terms of this provision from
a Participating Dentist, Eligible Person, insurance
company or other organization, as Delta chooses.
ARTICLE 7 -- CONDITIONS UNDER WHICH DELTA WILL PROVIDE
BENEFITS
7.1 Benefits, unless otherwise provided in Article 4,
are available from the Eligibility Date of an
Eligible Person.
7.2 An Eligible Person may choose the services of any
licensed Dentist, but neither Delta nor Northrop
Grumman Corporation guarantees the availability of
any particular Dentist.
7.3 Before Delta is obligated to approve and/or satisfy
any claims under this Contract, Delta is entitled
to receive, to such extent as is lawful, such
information and records relating to attendance to
or examination of or treatment provided to an
Eligible Person from any attending or examining
Dentist, or from hospitals in which a Dentist's
care is provided, as may be required in the
administration of such claims, or to require that
an Eligible Person be examined by a dental
consultant retained by Delta in or near his or her
community or residence. Delta agrees in every case
to hold such information and records as
confidential.
7.4 The amounts payable by Delta with respect to
services provided by a Dentist who is not a
Participating Dentist shall not exceed the
applicable percentage herein specified of the fees
charged, or of the Prevailing Fee, whichever is
less.
7.5 Delta will pay a Participating Dentist directly for
services provided by that Dentist. CONTRACTS
BETWEEN DELTA AND ITS PARTICIPATING DENTISTS
PROVIDE THAT, IN THE EVENT DELTA FAILS TO PAY THE
DENTIST, THE ELIGIBLE PERSON WILL NOT OWE THE
DENTIST FOR ANY SUMS OWED BY DELTA.
7.6 Delta will pay an Eligible Person directly for
services provided by a Dentist who is not a
Participating Dentist, and those payments are not
assignable. IN THE EVENT DELTA FAILS TO PAY THE
DENTIST WHO HAS NOT CONTRACTED WITH DELTA AS A
PARTICIPATING DENTIST, THE ELIGIBLE PERSON MAY BE
LIABLE TO THE DENTIST FOR THE COST OF SERVICE.
7.7 Delta is not obligated to pay claims submitted more
than six (6) months after the date the service was
provided. If a claim is denied because a
Participating Dentist failed to make timely
submission, the Eligible Person does not owe that
Dentist the amount which would have been payable by
Delta, provided that the Eligible Person advised
the Dentist of his or her eligibility for Benefits
at the time of treatment.
7.8 Delta, with the assistance of Participating Plans,
will give each Participating Dentist, and any other
Dentist or Eligible Person on request, a standard
form to make a claim for payment for services
covered by this Contract. In order to make a claim
for payment, such form, completed by the Dentist
who provided the services and by the Eligible
Person (or the patient's parent or guardian if such
patient is a minor) must be submitted to Delta at
the address on the form.
7.9 Delta agrees to notify the Eligible Person if any
services submitted on a claim under the preceding
paragraph are denied coverage as Benefits, in whole
or in part, stating the reason(s) for the denial.
Within sixty (60) days after receipt of such
notice, the Eligible Person may make a written
request for review of such denial. Such request
for review must be addressed to Delta, P.O. Box
7736, San Francisco, California 94120, Telephone
(000) 000-0000, Attention: Benefit Services
Department. Such request for review must state the
reason(s) why the Eligible Person believes that the
denial of the claim was in error and must request
any pertinent documents which they wish to review.
Delta's Benefit Services Department will make a
full and fair review of the claim. If the review
involves a determination as to the quality of
services provided or the appropriateness of fees
charged, and the matter cannot be resolved by Delta
to the satisfaction of the claimant, the review
will be referred to a peer review committee of the
appropriate dental society or association which
will accept jurisdiction, and Delta agrees to be
bound by the decision of that peer review
committee. Unless the review is referred to a peer
review committee or other unusual circumstances
arise, Delta agrees to provide a decision on a
request for review to the Eligible Person in
writing within 120 days after Delta receives the
request for review.
7.10 The Benefits which Delta provides are limited to
the applicable percentages of Dentist's fees or
allowances specified in Article 4. Northrop
Grumman Corporation requires the Eligible Person to
pay the balance of any such fee or allowance, known
as the "Patient Copayment", as a method of sharing
the costs of providing dental Benefits between
Northrop Grumman Corporation and Eligible Persons.
If the dentist discounts, waives or rebates any
portion of the Patient Copayment to the Eligible
Person, Delta only provides as Benefits the
applicable percentages of the Dentist's fees or
allowances reduced by the amount that such fees or
allowances are discounted, waived or rebated.
ARTICLE 8 -- OTHER DELTA OBLIGATIONS
8.1 Delta shall encourage Participating Dentists to
submit a standardized Attending Dentist Statement
(ADS) before providing service, showing the
patient's dental needs and the treatment necessary
in the professional judgement of the Dentist.
Delta shall predetermine, from the ADS and other
data, what would be payable by Delta and an
Eligible Person for the proposed services under the
terms of this program as of the date of
predetermination.
Such predetermination shall not constitute a
guaranty or authorization of Benefits under this
Contract, and any actual payments by Delta will
depend on the patient's eligibility and remaining
annual maximum when completed services are reported
by Delta.
Delta shall advise Participating Dentists to notify
the patient of all information provided by Delta in
the predetermination.
8.2 A Dentist may file an Attending Dentist Statement
before treatment, showing the services to be
provided to an Eligible Person. Delta shall
predetermine the amount of Benefits payable under
this Contract for the listed services.
Predeterminations are valid for sixty (60) days
from the date of the predetermination but not
longer than the Contract's term nor beyond the date
the patient's eligibility ends.
8.3 Delta will not make any payment for services
provided to a patient who is not an Eligible Person
under this Contract when the service is provided.
Northrop Grumman Corporation agrees to reimburse
Delta for any erroneous payments made as a result
of incorrect eligibility reporting by Northrop
Grumman Corporation.
8.4 Delta will provide professional review of the
adequacy of service provided by Participating
Dentists.
8.5 Delta agrees to furnish to Northrop Grumman
Corporation on July 1, 1995 and at reasonable times
thereafter, a directory of Participating Dentists
who have agreed to provide the services described
in this Contract. It is understood that the
Dentists listed in that directory may change from
time to time and Delta reserves the right to update
the directory without prior notice to Northrop
Grumman Corporation. However, Delta agrees to give
notice to Northrop Grumman Corporation within a
reasonable time of any Participating Dentist's
termination or breach of contract, or inability to
perform, which will materially and adversely affect
Northrop Grumman Corporation. Current information
concerning the Participating Dentist status of any
Dentist may be obtained by telephoning the Delta
Membership and Fee Listing Department at (415) 972-
8300. The Dentists providing or contracting to
provide dental services under this Contract are
solely responsible for those dental services, and
in no case will Delta or Northrop Grumman
Corporation be liable for any act or omission by
such Dentists, their agents or employees.
8.6 Delta agrees to give to Northrop Grumman
Corporation, and Northrop Grumman Corporation
agrees to make available to each Eligible Employee,
an evidence of coverage summarizing the Benefits to
which the employee is entitled and other provisions
of this Contract. If an amendment to this Contract
materially affects any Benefits described in such
evidence of coverage, Delta will issue a corrected
evidence of coverage, rider or inserts.
ARTICLE 9 -- TERMINATION AND RENEWAL
9.1 This Contract may be terminated for the following
causes:
(a) By Delta, if Northrop Grumman Corporation
fails (1) to give Delta a list of all Eligible
Employees, as required under Article 2, or
(2) to permit the inspection of Northrop
Grumman Corporation's records as called for
under Article 2, or (3) to pay Dues, in the
amounts and manner required in Article 3,
provided Northrop Grumman Corporation has been
duly notified of such failure and at least
fifteen (15) days have elapsed since the date
of notification.
(b) By either Northrop Grumman Corporation or
Delta, upon expiration of a Contract Term.
9.2 If Delta terminates this Contract under paragraph
9.1(a), all Benefits end and Delta is released from
all further obligations of this Contract, effective
the last day of the month in which notice is given.
Northrop Grumman Corporation will remain liable to
Delta for the greater of: (1) the unpaid Dues
applicable for the period this Contract was in
effect before termination; or (2) the full amount
of all Attending Dentist Statements paid or
otherwise discharged by Delta pursuant to this
Contract, plus 8.22% of such amount as provided in
paragraph 3.1, less amounts actually paid by
Northrop Grumman Corporation to Delta.
9.3 A party choosing to terminate this Contract at the
end of a Contract Term must give at least ninety
(90) days written notice of termination to the
other party. If Delta wants to change the
administration or Benefits effective at the
beginning of the next Contract Term, Delta will
give at least ninety (90) days' advance written
notice of such changes to Northrop Grumman
Corporation. Such an advance notice will have the
effect of a notice of termination as of the end of
the Contract Term, unless Northrop Grumman
Corporation agrees to the new Contract provisions.
9.4 If Northrop Grumman Corporation notifies Delta in
writing of its intention to terminate this Contract
as of any date other than the end of the Contract
Term, such notice will be treated as a failure to
pay Dues, and such notice will constitute a waiver
of the notification and billing required of Delta
by Paragraph 9.1(a)(3).
9.5 If an Eligible Person believes that this Contract,
or coverage hereunder, has been terminated or not
renewed due to their health status or requirements
for health care services, they may request a review
by the California Commissioner of Corporations
under California Health and Safety Code Section
1365(b).
9.6 If this Contract is terminated for any cause, Delta
is not required to predetermine services beyond the
termination date or to pay for services provided
after such termination date, except for the
completion of Single Procedures begun while this
Contract was in effect which are otherwise Benefits
under this Contract.
9.7 If at the end of the Contract, Northrop Grumman
Corporation has paid Dues to Delta applicable to a
time period after the termination date, Delta will
return a portion of Dues to Northrop Grumman
Corporation together with the amount due on claims,
if any, less any amounts due to Delta within thirty
(30) days after termination.
9.8 Within 30 days after the end of this Contract,
Delta will return to Northrop Grumman Corporation
any Dues paid which are applicable to a time period
after the termination date, together with amounts
due on claims, if any, less any amounts due to
Delta.
9.9 If Delta accepts the proper amount of Dues, after
termination of this Contract and without requiring
a new application, that acceptance will reinstate
the Contract as though never terminated, unless
Delta, within five (5) business days after it
receives such payment, either (1) refunds the
payment so made or (2) issues to Northrop Grumman
Corporation a new Contract accompanied by written
notice stating clearly those respects in which the
new Contract differs from the terminated Contract
in Benefits, coverage, or otherwise.
9.10 All Benefits end for all Eligible Persons when this
Contract ends, and Delta will not provide
continuation of Benefits to such persons in that
event.
9.11 Delta must notify Northrop Grumman Corporation in
writing of any termination by Delta under paragraph
9.1, and Northrop Grumman Corporation shall
promptly mail a copy of such notice to each
Eligible Employee and provide Delta with proof of
mailing and date thereof.
ARTICLE 10 -- CONTINUED COVERAGE OPTION
10.1 For purposes of this Option, the
following are "Qualifying Events":
(a) Termination of an Eligible
Employee's employment with Northrop
Grumman Corporation (for other than gross
misconduct), or a reduction in the number
of hours worked by the Eligible Employee.
(b) Death of an Eligible Employee.
(c) Divorce or legal separation
from the Eligible Employee.
(d) An Eligible Employee becoming
entitled to Medicare benefits.
(e) A dependent child ceasing to
meet the description of dependent child.
(f) Northrop Grumman Corporation's
federal Chapter 11 bankruptcy proceeding
which (within one year before or one year
after Northrop Grumman Corporation's
bankruptcy filing) causes a substantial
elimination of coverage of a retired
Eligible Employee (who retired on or
before the date of substantial
elimination of coverage), or of the
Eligible Dependents of a retired Eligible
Employee.
10.2 Eligible Persons whose coverage under
this program ends due to Qualifying
Event 10.1(a) may choose to continue coverage
for eighteen (18) months following the month
in which the Qualifying Event occurs.
10.3 If there is a determination that the
Eligible Person was disabled under Title II or
Title XVI of the Social Security Act at the
time Qualifying Event 10.1 (a) occurred, the
Eligible Person may choose to continue
coverage under this program for a total of
twenty-nine (29) months following the month in
which the Qualifying Event occurred. Delta
must receive notice of that determination
during the original eighteen (18) months and
within sixty (60) days after the date of the
determination. This extended coverage based
on disability terminates on the first day of
the month that begins more than thirty (30)
days after the date of the final determination
that the person is no longer disabled.
10.4 Eligible Dependents who choose to
continue their coverage based on Qualifying
Event 10.1(a), described above, and for whom a
second Qualifying Event [but not 10.1(a) or
(f)] occurs within the period of continued
coverage may choose to continue their coverage
for a maximum of thirty-six (36) months
following the month in which the first
Qualifying Event occurred [in the case of a
second Qualifying Event described in 10.1(b),
(c), or (e)], or for a maximum of thirty-six
(36) months following the month in which the
second Qualifying Event occurred [in the case
of the Qualifying Event 10.1(d)].
10.5 Eligible Dependents whose coverage under
this program ends due to Qualifying
Events 10.1(b), (c), (d), or (e), may choose
to continue their coverage for thirty-six
(36) months following the month in which the
Qualifying Event occurs.
10.6 Eligible Persons whose coverage under
this program ends due to Qualifying
Event 10.1(f) may choose to continue their
coverage until death (in the case of a retired
Eligible Employee), or for thirty-six
(36) months after the date of death of the
retired Eligible Employee (in the case of
Eligible Dependents of a retired Eligible
Employee).
10.7 Continued coverage can be chosen only by
notice to Northrop Grumman Corporation, which
must be given no later than sixty (60) days
after a termination of coverage by reason of a
Qualifying Event, or within sixty (60) days
after the Eligible Person receives a notice
from Northrop Grumman Corporation about his or
her rights to continued coverage because of
the particular Qualifying Event, whichever is
later. Persons for whom a Qualifying Event
described in 10.1(c) or (e) occurs must report
it to Northrop Grumman Corporation within
sixty (60) days, or lose their right to choose
continued coverage.
10.8 Continued coverage chosen by a person
under this Article is effective on the first
day of the month following the applicable
Qualifying Event described above. However,
Benefits are not available to a person
choosing continuing coverage until Delta
receives the data about such person as
required hereunder, along with all premiums
then due for such person. Delta will not, in
any event, make Benefits available hereunder
with respect to any person for whom Delta does
not receive such information and Premiums
within sixty (60) days after the date such
person is required under this Option to notify
Northrop Grumman Corporation of his or her
election.
10.9 Continued coverage will be the same as
the coverage for similarly situated Eligible
Persons under this Contract, and if coverage
is modified for such Eligible Persons coverage
for persons having continued coverage will be
modified at the same time and in the same
manner.
10.10 A person's continued coverage chosen under
this Article will end on the last day of the
month in which any of the following events
first occurs:
(a) The period of continued
coverage specified in Paragraphs 10.2,
10.3, 10.4, or 10.5 ends.
(b) This Contract ends.
(c) Northrop Grumman Corporation
fails to pay Dues for the person as
required by Article 3 of this Contract.
(d) The person with continued
coverage becomes covered for dental
Benefits under another group health plan
(as an employee or otherwise) which does
not contain any exclusion or limitation
with respect to any pre-existing
condition of such person covered under
this program.
(e) The person becomes eligible for
Medicare benefits.
10.11 Once continued coverage under this Option
ends, it cannot be reinstated.
ARTICLE 11 -- GENERAL PROVISIONS
11.1 No agent has authority to change this Contract or
waive any of its provisions. No change in this
Contract is valid unless approved by an executive
officer of Delta and included in this Contract by
written amendment.
11.2 Any dispute arising out of or relating to this
Contract or its breach between Northrop Grumman
Corporation, Delta, a Participating Dentist, and an
Eligible Person, or any of them, including any
disagreement with a claim determination made by
Delta after exhaustion of the review procedure
outlined in Article 6 of this Contract, will be
settled by arbitration in accordance with the
Commercial Arbitration Rules of the American
Arbitration Association ("AAA"). Any party to a
dispute, including an Eligible Person, may initiate
arbitration by written notice to each other party
to such dispute, stating the intention to arbitrate
and describing the nature of the dispute, the
amount involved, if any, and the remedy sought, and
by filing two copies of such notice with the
American Arbitration Association Regional Office at
the nearest metropolitan area to the party
initiating arbitration.
11.3 The provisions of this Contract are severable. If
any portion of this Contract or any Amendment of it
is determined to be illegal, void, or unenforceable
by any arbitrator, court, or other competent
authority, all other provisions of this Contract
will remain in effect.
11.4 The parties agree that all questions regarding the
interpretation or enforcement of this Contract are
governed by the laws of the State of California,
where the Contract was entered into and is to be
performed. Delta is subject to the requirements of
Chapter 2.2 of Division 2 of the California Health
and Safety Code and of Subchapter 5.5 of Chapter 3
of Title 10 of the California Administrative Code.
Any provisions required to be in the Contract by
those laws bind Delta whether or not stated in this
Contract.
11.5 Delta and Northrop Grumman Corporation agree to
consult each other to the extent reasonably
practical concerning all materials published or
distributed relating to this Contract. Neither
Delta nor Northrop Grumman Corporation will publish
or distribute materials which are contrary to the
terms of this Contract.
11.6 Delta and Northrop Grumman Corporation agree to
permit and encourage the professional relationship
between Dentist and patient to be maintained
without interference.
11.7 Any notice under this Contract will be sufficient
if given by either Northrop Grumman Corporation or
Delta to the other or, in the case of Northrop
Grumman Corporation, to its Group Representative at
the addresses below:
For the Group:
Benefits Administrator
Xxxxxxx X. Xxxxxx, Incorporated
000 Xxxxx Xxxxxxxx Xxxxxx
Xxx Xxxxxxx, XX 000000
For Delta:
P.O. Box 7736
San Francisco, CA 94120
Such notice will be effective forty-eight (48)
hours after deposit in the United States mail with
postage fully prepaid thereon.
NORTHROP GRUMMAN CORPORATION
BY:______________________
DELTA DENTAL PLAN OF CALIFORNIA
1
BY:
Chairman of the Board
and
2
BY:
Vice President
Underwriting, Actuarial and
Research
DATE: February 12, 1996
Appendix B
PROCEDURE NUMBERS
Procedure Number Procedure
00100-00999 -- DIAGNOSTIC
Clinical oral examinations
00110 Initial oral examination
00120 Periodic oral examination
00130 Emergency oral examination
Radiographs
00210 Intraoral -- complete series (including
bitewings)
00220 Intraoral -- periapical -- first film
00230 Intraoral -- periapical -- each
additional film
00240 Intraoral -- occlusal film
00250 Extraoral -- first film
00260 Extraoral -- each additional film
00270 Bitewings -- single film
00272 Bitewings -- two films
00273 Bitewings -- three films
00274 Bitewings -- four films
00330 Panoramic film
00340 Cephalometric film
Tests and laboratory examinations
00470 Diagnostic casts
00501 Histopathologic examinations
01000-01999 -- PREVENTIVE
Dental prophylaxis
01110 Prophylaxis -- adult
01120 Prophylaxis -- child to age 14
Topical fluoride treatment (office procedure)
01201 Topical application of fluoride
(including prophylaxis) -- child to age 14
01205 Topical application of fluoride
(including prophylaxis) -- adult
01203 Topical application of fluoride
(excluding prophylaxis) -- child to age 14
01204 Topical application of fluoride
(excluding prophylaxis) -- adult
Space maintenance (passive appliances)
01510 Space maintainer -- fixed unilateral
01515 Space maintainer -- fixed bilateral
01520 Space maintainer -- removable unilateral
01525 Space maintainer -- removable bilateral
02000-02999 -- RESTORATIVE
Amalgam restorations (including polishing)
02110 Amalgam -- one surface, primary
02120 Amalgam -- two surfaces, primary
02130 Amalgam -- three surfaces, primary
02131 Amalgam -- four or more surfaces, primary
02140 Amalgam -- one surface, permanent
02150 Amalgam -- two surfaces, permanent
02160 Amalgam -- three surfaces, permanent
02161 Amalgam -- four or more surfaces,
permanent
Silicate restorations
02210 Silicate cement -- per restoration
Filled or unfilled resin restorations
02330 Resin -- anterior
02335 Resin -- four or more surfaces or
involving incisal angle (anterior)
02380 Resin -- one surface, posterior --
primary
02381 Resin -- two surfaces, posterior --
primary
02382 Resin -- three or more
surfaces,posterior, primary
02385 Resin -- one surface, posterior --
permanent
02386 Resin -- two surfaces, posterior --
permanent
02387 Resin -- three or more surfaces,
posterior --permanent
Inlay restorations
02510 Inlay -- metallic -- one surface
02520 Inlay -- metallic -- two surfaces
02530 Inlay -- metallic -- three surfaces
02540 Onlay -- metallic -- per tooth (in
addition to inlay)
02650 Inlay -- composite/resin -- one surface,
(laboratory processed)
02651 Inlay -- composite/resin -- two surfaces,
(laboratory processed)
02652 Inlay -- composite/resin -- three
surfaces, (laboratory processed)
Crowns -- single restoration only
02710 Crown -- resin (laboratory)
02740 Crown -- porcelain/ceramic substrate
02750 Crown -- porcelain fused to high noble
metal
02751 Crown -- porcelain fused to predominantly
base metal
02752 Crown -- porcelain fused to noble metal
02790 Crown -- full cast high noble metal
02791 Crown -- full cast predominantly base
metal
02792 Crown -- full cast noble metal
02810 Crown -- 3/4 cast metallic
Other restorative services
02910 Recement inlay
02920 Recement crown
02930 Prefabricated stainless steel crown --
primary tooth
02931 Prefabricated stainless steel crown --
permanent tooth
02932 Prefabricated resin crown
02933 Prefabricated stainless steel crown with
resin window
02950 Crown buildup (substructure), including
any pins
02951 Pin retention -- per tooth, in addition
to restoration
02952 Cast post and core in addition to crown
02954 Prefabricated post and core in addition
to crown
02960 Labial veneer (laminate) -- chairside
02961 Labial veneer (resin laminate) --
laboratory
02962 Labial veneer (porcelain laminate) --
laboratory
02980 Crown repair, by report
Pulp capping
03110 Pulp cap -- direct (excluding final
restoration)
03120 Pulp cap -- indirect (excluding final
restoration)
03000-03999 -- ENDODONTICS
Pulpotomy
03220 Therapeutic pulpotomy (excluding final
restoration)
Root canal therapy (including treatment plan, clinical
procedures, and follow-up care)
03310 Root canal therapy -- anterior (excluding
final restoration)
03320 Root canal therapy -- bicuspid (excluding
final restoration)
03330 Root canal therapy -- molar (excluding
final restoration)
03350 Apexification/recalcification -- per
treatment visit (includes apical
closure/calcific repair of perforations, root
resorption, etc.)
Periapical services
03410 Apicoectomy/periradicular surgery --
anterior
03421 Apicoectomy/periradicular surgery --
bicuspid (first root)
03425 Apicoectomy/periradicular surgery --
molar (first root)
03426 Apicoectomy/periradicular surgery (each
additional root), by report
03430 Retrograde filling -- per root, in
addition to apicoectomy/ periradicular surgery
03450 Root amputation -- per root
Other endodontic procedures
03920 Hemisection (including any root removal),
not including root canal therapy
04000-04999 -- PERIODONTICS
Surgical services (including usual postoperative
services)
04210 Gingivectomy or gingivoplasty -- per
quadrant
04211 Gingivectomy or gingivoplasty -- single
tooth
04220 Gingival curettage, surgical -- per
quadrant, narrative report required
04240 Gingival flap procedure, including root
planning -- per quadrant
04249 Crown lengthening -- hard and soft
tissue, by report
04250 Mucogingival surgery -- per quadrant
04260 Osseous surgery (including flap entry,
all grafts and closure) -- per quadrant
04268 Guided tissue regeneration, includes
surgery and re-entry, narrative report
required
04270 Pedicle soft tissue graft procedure
04271 Free soft tissue graft procedure
(including donor site)
Adjunctive periodontal services
04341 Periodontal root planing - per quadrant
Other periodontal services
04910 Periodontal maintenance procedures
following active therapy (periodontal
prophylaxis)
04920 Unscheduled dressing change (by someone
other than treating dentist), by report
05000-05899 -- PROSTHODONTICS (REMOVABLE)
Complete dentures (including routine postdelivery care)
05110 Complete denture, upper
05120 Complete denture, lower
05130 Immediate denture, upper
05140 Immediate denture, lower
Partial dentures (including routine postdelivery care)
05211 Upper partial denture -- resin base
(including any conventional clasps, rests and
teeth)
05212 Lower partial denture -- resin base
(including any conventional clasps, rests and
teeth)
05213 Upper partial denture -- metal base with
resin saddles (including any conventional
clasps, rests and teeth)
05214 Lower partial denture -- metal base with
resin saddles (including any conventional
clasps, rests and teeth)
05281 Removable unilateral partial denture --
one piece metal base casting, clasp
attachments -- per unit (including pontics)
Adjustments to dentures
05410 Adjust complete denture -- upper
05411 Adjust complete denture -- lower
05421 Adjust partial denture -- upper
05422 Adjust partial denture -- lower
Repairs to complete dentures
05510 Repair broken complete denture base
05520 Replace missing or broken teeth --
complete denture (each tooth)
Repairs to partial dentures
05610 Repair resin saddle or base
05620 Repair cast framework, by report
05630 Repair or replace broken clasp
05640 Replace broken teeth -- per tooth
05650 Add tooth to existing partial denture
05660 Add clasp to existing partial denture
Denture rebase procedures
05710 Rebase complete upper denture
05711 Rebase complete lower denture
05720 Rebase upper partial denture
05721 Rebase lower partial denture
Denture reline procedures
05730 Reline complete upper denture (chairside)
05731 Reline complete lower denture (chairside)
05740 Reline upper partial denture (chairside)
05741 Reline lower partial denture (chairside)
05750 Reline complete upper denture
(laboratory)
05751 Reline complete lower denture
(laboratory)
05760 Reline upper partial denture (laboratory)
05761 Reline lower partial denture (laboratory)
Other removable prosthetic services
05820 Temporary partial -- stayplate denture
(upper)
05821 Temporary partial -- stayplate denture
(lower)
05850 Tissue conditioning, upper -- denture
05851 Tissue conditioning, lower -- denture
06200-06999 -- PROSTHODONTICS, FIXED
(Each abutment and each pontic constitutes a unit in
bridge)
Bridge pontics
06210 Pontic -- cast high noble metal
06211 Pontic -- cast predominantly base metal
06212 Pontic -- cast noble metal
06240 Pontic -- porcelain fused to high noble
metal
06241 Pontic -- porcelain fused to
predominantly base metal
06242 Pontic -- porcelain fused to noble metal
Retainers
06520 Inlay -- metallic -- two surfaces
06530 Inlay -- metallic -- three or more
surfaces
06540 Onlay -- metallic per tooth in addition
to inlay
06545 Retainer -- cast metal for acid etch
bridge
Bridge retainers -- crowns
06750 Crown -- porcelain fused to high noble
metal
06751 Crown -- porcelain fused to predominantly
base metal
06752 Crown -- porcelain fused to noble metal
06780 Crown -- 3/4 cast high noble metal
06790 Crown -- full cast high noble metal
06791 Crown -- full cast predominantly base
metal
06792 Crown -- full cast noble metal
Other fixed prosthetic services
06930 Recement bridge
06940 Stress breaker
06970 Cast post and core addition to bridge
retainer
06972 Prefabricated post and core in addition
to bridge retainer
06973 Retainer crown buildup (substructure)
including any pins
06980 Bridge repair, by report
07000-07999 -- ORAL SURGERY
Extractions -- includes local anesthesia and routine
postoperative care
07110 Single tooth
07120 Each additional tooth
07130 Root removal -- exposed roots
Surgical extractions -- includes local anesthesia and
routine postoperative care
07210 Surgical removal of erupted tooth
07220 Removal of impacted tooth -- soft tissue
07230 Removal of impacted tooth -- partially
bony
07240 Removal of impacted tooth -- completely
bony
07250 Surgical removal of residual tooth roots
(cutting procedure)
Other surgical procedures
07260 Oral antral fistula closure
07270 Tooth reimplantation and/or stabilization
of accidentally evulsed or displaced tooth
and/or alveolus
07272 Tooth transplantation
07281 Surgical exposure of impacted or
unerupted tooth to aid eruption
07285 Biopsy of oral tissue -- hard
07286 Biopsy of oral tissue -- soft
Alveoloplasty -- surgical preparation of ridge for
dentures
07310 Alveoloplasty in conjunction with
extractions -- per quadrant
07320 Alveoloplasty not in conjunction with
extractions -- per quadrant
Vestibuloplasty
07340 Vestibuloplasty -- ridge extension
(secondary epithelialization)
07350 Vestibuloplasty -- ridge extension
(including soft tissue grafts, muscle
reattachments, revision of soft tissue
attachment and management of hypertrophied and
hyperplastic tissue)
Removal of tumors, cysts and neoplasms
07430 Excision of benign tumor -- lesion
diameter up to 1.25 cm
07431 Excision of benign tumor -- lesion
diameter greater than 1.25 cm
07440 Excision of malignant tumor -- lesion
diameter up to 1.25, by report
07441 Excision of malignant tumor -- lesion
diameter greater than 1.25 cm, by report
07450 Removal of odontogenic cyst or tumor --
lesion diameter up to 1.25 cm
07451 Removal of odontogenic cyst or tumor --
lesion diameter greater than 1.25 cm
07460 Removal of nonodontogenic cyst or tumor -
- lesion diameter up to 1.25 cm
07461 Removal of nonodontogenic cyst or tumor -
- lesion diameter greater than 1.25 cm
07465 Destruction of lesion(s) by physical
methods, by report
Excision of bone tissue
07470 Removal of exostosis -- maxilla or
mandible
07480 Partial ostectomy (guttering or
saucerization), by report
07490 Radical resection of mandible with bone
graft, by report
Surgical incision
07510 Incision and drainage of abscess --
intraoral soft tissue
07520 Incision and drainage of abscess --
extraoral soft tissue
07530 Removal of foreign body, skin or
subcutaneous areolar tissue
07540 Removal of foreign bodies --
musculoskeletal system
07550 Sequestrectomy for osteomyelitis
07560 Maxillary sinusotomy for removal of tooth
fragment or foreign body
Treatment of fractures -- simple
07610 Maxilla -- open reduction (teeth
immobilized if present)
07620 Maxilla -- closed reduction (teeth
immobilized if present)
07630 Mandible -- open reduction (teeth
immobilized if present)
07640 Mandible -- closed reduction (teeth
immobilized if present)
07650 Malar and/or zygomatic arch -- open
reduction, by report
07660 Malar and/or zygomatic arch -- closed
reduction, by report
07670 Alveolus -- stabilization of teeth, open
reduction splinting
07680 Facial bones -- complicated reduction
with fixation and multiple surgical
approaches, by report
Treatment of fractures -- compound
07710 Maxilla -- open reduction
07720 Maxilla -- closed reduction
07730 Mandible -- open reduction
07740 Mandible -- closed reduction
07750 Malar and/or zygomatic arch -- open
reduction, by report
07760 Malar and/or zygomatic arch -- closed
reduction, by report
07770 Alveolus -- stabilization of teeth, open
reduction splinting, by report
07780 Facial bones -- complicated reduction
with fixation and multiple surgical
approaches, by report
Reduction of dislocation and management of other
temporomandibular joint dysfunctions
07810 Open reduction of dislocation, by report
07820 Closed reduction of dislocation
07830 Manipulation under anesthesia
Repair of traumatic wounds
07910 Suture of recent small wounds up to 5 cm,
by report
Complicated suturing (reconstruction requiring delicate
handling of tissues and wide undermining for meticulous
closure)
07911 Suture of complex wounds up to 5cm, by
report
07912 Suture of complex wounds greater than 5
cm, by report
Other repair procedures
07960 Frenulectomy (frenectomy or frenotomy) --
separate procedure
07970 Excision of hyperplastic tissue -- per
arch
07971 Excision of pericoronal gingiva
07980 Sialolithotomy
07981 Excision of salivary gland, by report
07982 Sialodochoplasty
07983 Closure of salivary fistula
09000-09999 -- ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
09110 Palliative (emergency) treatment of
dental pain -- minor procedures
Anesthesia
09211 Regional block anesthesia
09212 Trigeminal division block anesthesia
09220 General anesthesia -- first 30 minutes
09221 General anesthesia -- each additional 15
minutes
Professional consultation
09310 Special consultation (specialist only --
separate fee only if patient not treated by
consultant) Professional visits
09430 Office visit for observation (during
regularly scheduled hours) -- no other
services performed
09440 Office visit -- after regularly scheduled
hours
Drugs
09610 Therapeutic drug injection, by report
Miscellaneous services
09930 Treatment of complications (postsurgical)
-- unusual circumstances, narrative report
required
09951 Occlusal adjustment -- limited
APPENDIX C
ORTHODONTIC BENEFIT RIDER
EFFECTIVE: July 1, 1995
Orthodontic Benefits are available only to persons
enrolled in Group #5134-0014 and the Delta Care Plus
Plan, Group #5134-0301.
In consideration of the payments specified in paragraph
3.1 of the attached Contract, and subject to all of the
terms and conditions thereof, except as herein otherwise
specified, Delta agrees to provide Orthodontic Benefits
to Eligible Persons, as follows:
1. Orthodontics are defined as the procedures
performed by a licensed Dentist, involving surgical
repositioning of the teeth or jaws in whole or in
part and/or the use of an active orthodontic
appliance and post-treatment retentive appliances
for treatment of malalignment of teeth and/or jaws
which significantly interferes with their function.
2. Delta will pay or otherwise discharge 50% of the
lesser of the Usual, Customary and Reasonable fees
or of the fees actually charged for Orthodontics.
3. The lifetime maximum amount payable by Delta for
all Orthodontics rendered to each Eligible Person
shall be $1,000.00 for Group #5134-0014 and
$2,000.00 for Group #5134-0301, and the limitations
on maximum amounts payable during a calendar year,
if any, specified in the attached Agreement, shall
not apply to Orthodontics.
4. EXCLUSIONS AND LIMITATIONS: In addition to
Exclusions and Limitations stated in Article IV to
the attached Contract, the following exclusions and
limitations shall apply to Orthodontic Benefits:
(a) The obligation of Delta to make payments
for an Orthodontic treatment plan begun prior
to the eligibility date of the patient shall
commence with the first payment due following
the patient's eligibility date. The above-
mentioned maximum amount payable will apply
fully to this and subsequent payments.
(b) The obligation of Delta to make payments
for Orthodontics shall terminate on the
payment due date next following the date the
dependent loses eligibility or the employee
loses eligibility, or upon termination of
treatment for any reason prior to completion
of the case, or upon termination of the
Contract, whichever shall occur first.
(c) Delta will not make any payment for
repair or replacement of an Orthodontic
appliance furnished, in whole or in part,
under this Program.
(d) X-rays and extraction procedures incident
to Orthodontics are not covered by Orthodontic
Benefits, but may be covered under the
provisions of the attached Contract, subject
to all of the terms and provisions thereof.
(e) Applicable to Group #5134-0014:
An Eligible Person is eligible for
Orthodontic Benefits only after they have been
continuously enrolled under this Contract for
twelve (12) months.
