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Bargaining Unit Employees,
click here to access Union Benefits Trust website.


Information provided below is for Exempt Dental benefits effective July 1, 2012.

Click here to see Dental information effective July 1, 2013.

If you are an exempt full-time or part-time permanent employee with one year of continuous state service, the state pays the full cost for you and your eligible dependents to participate in a dental plan.

You can choose to participate in either the Delta Dental PPO or the Delta Dental Premier plan offered through Delta Dental of Ohio. When you participate in either of the dental plans, you can go to the dentist of your choice and receive benefits. However, you will generally pay less when you go to a dentist within the Delta Dental PPO or Delta Dental Premier network. When making your coverage selection, be sure to check with your dentist to determine whether he/she belongs to the Delta Dental PPO or Delta Dental Premier network.
 
Click here to view a complete provider listing and other information from Delta Dental. For first time users log in using your Social Security Number and date of birth.

PPO Plan
Group Number: 9273-0001

Premier Plan
Group Number: 9273-1001

When utilizing participating dentists, the exempt dental plan emphasizes preventive services at no cost by offering:

  • Routine exams
  • Cleanings
  • X-rays

Once you are enrolled in a dental plan, go to the Delta Dental member Web site to:

  • Check eligibility
  • Claims status
  • Benefit availability
  • Print an identification card
  • Locate participating dentists

Click the links below to access the information you need quickly.

Comparing Your Dental Options
What's Covered?
Questions
Eligibility
Enrollment
Claims Process
Disputed Claims Procedure
Disputed Claims Appeal Procedure
Coordination of Benefits
Coordination Disputes
Exclusions & Limitations
Continuation Coverage (COBRA)
Termination of Coverage
Change of Status
Your Rights in The Event of Insolvency
Definitions


Comparing Your Dental Options
The individual yearly deductible is $25; it will be applied to your covered dental expenses once during each benefit year. No deductible will be applied to Class I (preventive) Dental Services or Class IV (orthodontic) Dental Services.

For more information review the 2012 Exempt Dental Plan chart below. 


                                                                                      Click image to enlarge.

Class I Benefits: Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease.

  • Examinations - Initial, periodic and emergency examinations.
  • Prophylaxes - Teeth cleaning and polishing.
  • Fluoride Treatments - Topical application for cavity prevention up to age 19 and age 55 or older.
  • Emergency Palliative Treatment - Emergency treatment to temporarily relieve pain.
  • Radiographs - X-rays as required for routine care or as necessary for the diagnosis of a specific condition.

Class II Benefits: Basic Restorative, Periodontics and Oral Surgery Services

  • Minor Restorative Services, such as amalgam (silver) and resin (white) fillings.
  • Endodontic Services - The treatment of teeth with diseased or damaged nerves (example: root canals).
  • Periodontic Services - The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (periodontal prophylaxis).
  • Sealants - Up to age 19.

Class III Benefits: Major Restorative and Prosthodontic Services
Services and appliances that replace missing natural teeth (such as bridges, partial dentures and complete dentures).

  • Major restorative services, such as crowns, used when teeth cannot be restored with another filling material - one per tooth every 60 months.
  • Relines and repairs to bridges, partial dentures and complete dentures - 60-month replacement limit.
  • Dental implants and abutment placement - lifetime maximum of $1,000 on dental implant services.

Class IV Benefits: Orthodontic Services
Services, treatment and procedures to correct malposed teeth; no age limit.

  • Class IV services have a maximum to the benefits that you can receive in your lifetime. Your benefit amount is dependent upon which dental plan you have and the type of provider you choose.

What's Covered?
Dental expenses are the costs incurred by you or any of your covered dependents. Covered expenses are any charges made by a dentist or dental specialist for services provided in the Schedule of Dental Services. Expenses will only be covered if:

  • The dental service is performed by, or under the direction of, a licensed dentist.
  • The expense is essential for the necessary care of the teeth.
  • The service takes place while you are insured for dental expense benefits.
  • If the dental service is performed on a date other than the date the service was recommended or considered necessary, the dental service will be considered to begin on the date the actual performance of the service begins.

Questions
For questions about dental benefits, please contact Delta Dental 1-800-524-0149 or visit
their Web site at www.deltadentaloh.com.

Eligibility
You are eligible for dental coverage after you have completed one year of continuous state service, and you are a permanent full-time or permanent part-time employee.

Service time for employees classified as student help, college interns or whose appointments are temporary, seasonal or intermittent may count toward one year of continuous state service if such employees are hired on a permanent, full-time basis or permanent part-time basis with no break in service. Please contact your payroll/personnel officer to confirm your eligibility.

Dependents
If you are eligible for dental benefits, your dependents may also be eligible to receive dental benefits under your coverage.

Enrollment
If you are an eligible employee, you will be able to enroll in a dental plan after one year of continuous state service. Prior to the end of your first year of service, you should receive notification that you soon will become eligible for dental coverage.

You must complete a Benefit Enrollment/Change Form (ADM 4717).  Your dental coverage will be effective the first day of your 13th month of state service, as long as you have filled out an enrollment form at least 31 days before your anniversary date. You may enroll up to 31 days after your anniversary date, but your effective date of benefits may be delayed.

If you do not enroll within 31 days of your anniversary date, you must wait until open enrollment to obtain dental care coverage.

Claims Process
Once you are covered by a dental plan, you will be able to receive dental treatments and have a portion of the cost covered by your dental plan. Your Delta Dental dentist will file your claims for you. If you choose to utilize a non-Delta dentist, click here for a claim form.

  • Dental claims should be filed within 12 months of the date of service.
  • All of your benefits will be processed by Delta Dental immediately upon receipt of your claims.
  • If you fail to file a claim within the time specified, you will not receive any payment for your treatment.

If you have any questions about your benefits or a claim payment problem, you should call Delta Dental's toll-free member service unit at 1.800.524.0149, view Delta's Web page at: www.deltadentaloh.com, or send a written inquiry to:

Delta Dental
PO Box 30416
Lansing, MI 48909-7916

Dental claims should be sent to:
Delta Dental
PO Box 9085
Farmington Hill, MI 48333-9085

Disputed Claims Procedure
If you believe Delta Dental incorrectly denied all or part of your claim, here are the steps you can take:

First, you or your dentist should contact Delta Dental's Customer and Claims Services department and ask them to check the claim to make sure it was processed correctly. You may do this by calling the toll-free number, 1.800.524.0149, and speaking with a telephone advisor.

Second, you may also mail your inquiry to the Customer and Claims Services department at the address above. When writing, please enclose a copy of your Explanation of Benefits and describe the problem. Be sure to include your name, telephone number, the date and any information you would like considered regarding your claim.

If your claim is still denied, you can submit your claim for a formal review through the Disputed Claims Procedure. Send your request in writing and mail it as Certified Mail, with a return receipt requested, to:

Dental Director
Delta Dental
PO Box 30416
Lansing, Michigan 48909-7916

Please include your name and address, the Subscriber's Social Security Number, the reason you believe the claim was wrongly denied, and any other information you would like considered regarding the claim.

Delta Dental will review your disputed claim. If your claim is still completely or partially denied, Delta Dental will notify you within 90 days after receiving your letter. Delta Dental's notice will explain why the denial was made and will also give you information about the appeal process.

Disputed Claims Appeal Procedure
If you do not agree with the results of the Disputed Claims Procedure, you may appeal to the Board of Directors of Delta Dental or its delegee.

To do this, you must file a written request for review before the final appeal date listed in the Dental Director's notice denying your disputed claim. If no date is given in this notice, you have up to 150 days from the date you submitted your first letter under the Disputed Claims Procedure to appeal.

Send your written request to the same address, Attention: Board of Directors (or its delegee); it must say why you are requesting a review and why you believe the Dental Director's decision was incorrect. You have the right to review the plan and documents related to it.

In your written request for this review, you may also ask for a hearing with the Board of Directors or its delegee. If the Board of Directors or its delegee decides to convene a hearing, you are entitled - at your own expense - to be represented by legal counsel, to request that a court reporter transcribe the hearing, to present evidence, to request the testimony of witnesses and to cross-examine the witnesses. A decision will be given to you as soon as possible, but not later than 120 days after receiving your written request.

If a hearing is not requested or held, the Board of Directors or its delegee will give you its decision within 60 days after receiving your written request for review. All decisions of the Board of Directors or its delegee will be in writing and will explain why the decision was made.

If you are still not satisfied, you may contact the Ohio Department of Insurance for instructions on filing a consumer complaint by calling 614.644.2673 or 1.800.686.1526. You may also write to the Consumer Service Division of the Ohio Department of Insurance, 2100 Stella Court, Columbus, Ohio 43215-1067.

Coordination of Benefits
You and your family members may have coverage under more than one health plan. Coordination of benefits (COB) is the procedure used to determine the amount of a claim that each plan should pay and to eliminate duplication of payment for services.

  • Under COB, the plan that pays first is the primary plan.
  • The secondary plan pays after the primary plan.
  • When you or your family members are covered by another group plan in addition to this one, Delta Dental will follow Ohio coordination of benefit rules to determine which plan is primary and which is secondary. You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then submit the balance to the secondary plan.

Delta Dental pays for health care only when you follow the rules and procedures. If the rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use.

Plans That Do Not Coordinate
Delta Dental will pay benefits without regard to benefits paid by the following kinds of coverage:

  • Medicaid
  • Group hospital indemnity plans that pay less than $100 per day
  • School accident coverage
  • Some supplemental sickness and accident policies

How Delta Dental Pays As Primary Plan
When Delta Dental is primary, Delta Dental will pay the full benefit allowed by your contract as if you had no other coverage.

How Delta Dental Pays As Secondary Plan
When Delta Dental is secondary, payments will be based on the balance left after the primary plan has paid. In no event will Delta Dental pay more than it would have paid as primary.

For example, if the primary plan pays an amount higher than Delta Dental would have paid, no payment will be made by Delta Dental. If the primary plan pays less than Delta Dental allows, Delta Dental will pay the difference up to Delta Dental's allowed amount.

  • Delta Dental will pay only for health care expenses that are covered by Delta Dental.
  • Delta Dental will pay only if you have followed all of the procedural requirements, including care obtained from or arranged by your Dentist, Predeterminations, etc.
  • Delta Dental will pay no more than the "allowable expenses" for the health care involved. If the allowable expense is lower than the primary plan's, Delta Dental will use the primary plan's allowable expense. That may be less than the actual bill.

Which Plan Is Primary?
To decide which plan is primary, Delta Dental has to consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The primary plan will be determined by the first of the following, which applies:

1. Non-coordinating Plan
If you have another group plan that does not coordinate benefits, it will always be primary.

2. Employee
The plan, which covers you as an employee (neither laid off nor retired), is always primary.

3. Children (Parents Divorced or Separated)
If the court decree makes one parent responsible for health care expenses, that parent's plan is primary.
If the court decree gives joint custody and does not mention health care, Delta Dental follows the birthday rule (see below).

If neither of those rules applies, the order will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.

4. Children and the Birthday Rule
When your children's health care expenses are involved, Delta Dental follows the "birthday rule." The plan of the parent with the first birthday in a calendar year is always primary for the children. If your birthday is in January and your spouse's birthday is in March, your plan will be primary for all of your children.

However, if your spouse's plan has some other coordination rule (for example, a "gender rule" which says the father's plan is always primary), Delta Dental will follow the rules of that plan.

5. Other Situations
For all other situations not described above, the order of benefits will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.

Coordination Disputes
If you believe Delta Dental has not paid a claim properly, you should first attempt to resolve the problem by contacting Delta Dental.

Exclusions & Limitations

Exclusions
No payment will be made by Delta Dental and all charges for the following services will be the responsibility of the subscriber:

1. Services for injuries or conditions payable under Workers' Compensation or Employer's Liability laws. Benefits or services that are available from any government agency, political subdivision, community agency, foundation or similar entity.

NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act, that is, Medicaid.

2. Services, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons.

3. Services or appliances started before an individual became eligible under this plan.

4. Prescription medications, premedications and relative analgesia. General anesthesia and/or intravenous sedation for restorative dentistry or for surgical procedures, unless medically necessary. Charges for hospitalization, laboratory tests and examinations.

5. Preventive control programs including home care items.

6. Charges for failure to keep a scheduled visit with a dentist.

7. Replacement, repair, relines or adjustments of occlusal guards.

8. Charges for completion of forms. A participating dentist may not make these charges to a subscriber/eligible dependent.

9. Inlays.

10. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances.

11. Services for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental in nature as determined by the standards of generally accepted dental practice.

12. Appliances, surgical procedures and restorations for increasing vertical dimension; for restoring occlusion; for replacing tooth structure loss resulting from attrition, abrasion, or erosion. If orthodontic benefits have been selected, this exclusion will not apply to those benefits as limited by the terms and conditions of the plan.

13. Treatment by someone other than a dentist, except for services performed by a licensed dental hygienist under the scope of his or her license.

14. Those benefits excluded by the policies and procedures of Delta Dental including the Processing Policies.

15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.

16. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.

17. Services that are covered under a hospital, surgical/medical or prescription medication program.

18. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).

19. Services that are not within the classes of benefits that have been selected and are not in the contract.

Limitations
The benefits for the following services are limited as follows, unless specified in the Summary of Dental Plan Benefits. All time limitations are measured from the last date of service in any Delta Dental Plan record or, at the request of your group, any dental plan record.

1. Prophylaxes and oral exams are payable twice in a contract period.

2. Bitewing X-rays are payable once in a contract period. Full-mouth X-rays, which include bitewing X-rays, are payable once in any five-year period. A panographic X-ray, including bitewings, is considered a full-mouth X-ray.

3. Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.

4. Cast restorations (including jackets, crowns and onlays) and associated procedures (such as cores and post substructures) on the same tooth are payable once in any five-year period.

5. Porcelain, porcelain substrate and cast restorations are not payable for children less than 12 years of age.

6. Optional treatment: If you select a more expensive service than is customarily provided, or for which Delta Dental does not determine a valid dental need is shown, Delta Dental can make an allowance based on the fee for the customarily-provided service.

7. Benefits for root planing are payable once in any two-year period. Periodontal surgery, including subgingival curettage, is payable once in any three-year period.

8. Prosthodontic (Class III) benefit limitations:

a. One complete upper and one complete lower denture are covered once in any five-year
period for any individual.

b. A partial denture, fixed bridge or removable bridge for any individual can be covered once in
any five-year period unless the loss of additional teeth requires the construction of a new
appliance.

c. Fixed bridges and removable cast partials are not payable for individuals less than 16 years of
age.

d. A reline or the complete replacement of denture base material is limited to once in any three-
year period per appliance.

9. Preventive fluoride treatments are payable for children until their 19th birthday and for adults older than age 55.

10. Orthodontic (Class IV) benefit limitations:

a. Orthodontic benefits are payable at any age of a subscriber/eligible dependent.

b. If the treatment plan is terminated before completion of the case for any reason, Delta Dental's
obligation will cease with payment to the date of termination.

c. The dentist may terminate treatment, with written notification to Delta Dental and to the patient,
for lack of patient interest and cooperation. In those cases, Delta Dental's obligation for
payment of benefits ends on the last day of the month in which the patient was last treated.

d. Any charge for the replacement or repair of an orthodontic appliance furnished under any Delta
Dental Plan will not be paid by Delta Dental and will be the responsibility of the patient.

11. Delta Dental's obligation for payment of benefits ends on the last day of the month in which coverage is terminated.

12. When services in progress are interrupted and completed later by another dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each dentist.

13. Care terminated due to the death of a subscriber or eligible dependent will be paid to the limit of Delta Dental's liability for the services completed or in progress.

14. Maximum Payment:

a. The maximum benefit payable in any one benefit year will be limited to the amount specified
in the Benefit Feature Sheet.

b. Delta Dental's payment for orthodontic (Class IV) benefits will be limited to the lifetime
maximum per person specified in the Benefit Feature Sheet.

15. There is a $25 annual deductible on Class II and Class III services. Delta Dental will not be obligated to pay for, in whole or in part, any service to which the deductible applies until the plan deductible amount is met.

16. Sealants are payable once per tooth per lifetime and only for the occlusal surface of first and second permanent molars for patients up to age 19.

17. Processing Policies may limit treatment.

Continuation Coverage (COBRA)
If you or one of your dependents become ineligible for employer-paid dental coverage, you may be eligible to continue your coverage under the federal COBRA program. Contact your agency for more details.

Termination of Coverage
Your Delta Dental coverage may be automatically terminated:

  • When your employer or organization advises Delta Dental to terminate your coverage; or
  • On the last day of the month for which your employer or organization has failed to pay Delta Dental, or for any other reason stated in the Summary Plan Description.

In no event will eligibility for any person covered under this program continue beyond the date your employer advises Delta Dental or organization to terminate eligibility, except to the extent that COBRA is applicable.

Change of Status
You must notify Delta Dental, through your employer or organization, of any event causing a change in the status of an eligible dependent. Events that can affect the status of an eligible dependent include, but are not limited to, marriage, birth, death, divorce and entrance into military service.

Assignment
Services and/or benefit payments to subscribers and eligible dependents are for the personal benefit of those people and cannot be transferred or assigned.

Subrogation
If Delta Dental pays a claim for which another person or company is liable, Delta Dental has the right to recover its payment from the other person or company.

Obtaining And Releasing Information
While you are covered by Delta Dental, you agree to provide Delta Dental with any information it needs to process your claims and administer your benefits. This includes allowing Delta Dental to have access to your dental records.

Dentist-Patient Relationship
You and your eligible dependents have the freedom to choose any dentist. Each dentist maintains the dentist-patient relationship with the patient and is solely responsible to the patient for dental advice and treatment and any resulting liability.

Loss of Eligibility During Treatment
If you or your eligible dependent lose eligibility while receiving dental treatment, only covered services received while you or your eligible dependent were covered under the plan will be payable.

Certain procedures begun before the loss of eligibility may be covered if the services were completed within a 60-day period measured from the date of termination. In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. The balance of the total fee is your responsibility.

Late Claims Submission
Delta Dental will not honor, and no payment will be made for, services if a claim for those services has not been received by Delta Dental within one year following the year in which the services were completed.

Governing Law
The group contract and/or Certificate will be governed by and interpreted under the laws of the State of Ohio.

Your Rights in The Event of Insolvency
Ohio law requires Delta Dental to make the following statements:

As a licensed health-insuring corporation (HIC) Delta Dental is not a member of a Guarantee Fund. In the event of Delta Dental's insolvency, you are protected only to the extent that the provision in the contracts between Delta Dental and its dentists in which providers agree not to bill members, applies to the dental services you receive.

In addition, in the event of Delta Dental's discontinuance of operations, dentists are required to provide covered dental services that are medically necessary to complete previously initiated treatment, but this is limited to the thirty-day period following discontinuance of operations.

Participating dentists are not required to continue to provide covered dental services past the occurrence of the earliest of the following events.

1. The end of the thirty-day period following the filing of the liquidation order per Ohio law;
2. The end of the member's contract year;
3. The date the member obtains equivalent coverage;
4. The end of the member's period of coverage for a contractual prepayment of premium; or
5. Legal transfer of Delta Dental's obligations.

In the event of Delta Dental becoming insolvent, you may be financially responsible for dental services rendered by a provider or facility that is not under contract with Delta Dental whether or not Delta Dental authorized the use of the provider or health care facility.

In addition, in the event of Delta Dental's discontinuance of operations, as required by Ohio law, Delta Dental is required to submit to the Ohio Superintendent, documentation of an arrangement to provide medically necessary health care services to members until the expiration of the member's contract year. As required by Ohio law, this arrangement to provide medically necessary health care services may be made by using any one, or any combination of the following methods.

1. The maintenance of insolvency coverage;
2. A provision in participating providers' contracts with Delta Dental, provided such provision is not solely relied upon for more than thirty days;
3. In agreement with any other health insuring corporations or insurers, providing members with automatic conversion rights upon the discontinuance of Delta Dental's operations; or
4. Such other methods as approved by the Superintendent of Insurance.
In the event any of the foregoing situations applies to you, please contact Delta Dental at 1.800.524.0149.

Anti-Fraud Toll-Free Hotline
1.800.524.0147

Insurance fraud significantly increases the cost of health care. If you are aware of any false information submitted to Delta Dental, you could help lower these costs by calling the Toll-Free Hotline. Only ANTI-FRAUD calls can be accepted on this line.The following statement is required for this document by Ohio law:

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Definitions

Acrylic
A type of plastic used for dentures and some kinds of crowns.

Amalgam
One of the most common filling materials; usually soft silver that hardens after it is packed into the cavity.

Bitewing X-ray
An X-ray showing exposed portions of the back teeth. Primarily used for early detection of hidden decay between teeth.

Cavity
Portion of a tooth destroyed by decay. Requires filling or sometimes more extensive treatment.

Certificate
This document is the certificate of coverage. Delta Dental will provide benefits as described in this certificate. Any changes in this certificate will be based on changes to the plan.

Completion Dates
Some procedures may require more than one appointment. Treatment is complete:

  • For dentures and partial dentures, on the delivery dates.
  • For crowns and bridgework, on the cementation dates.
  • For root canals and periodontal treatment, on the date of the final procedure that completes treatment.

Control Plan (Delta Dental)
The Delta Dental Plan that contracts with your group. The Control Plan will provide all claims processing, service and administration for a multi-state group. Your Control Plan is Delta Dental Plan of Ohio and is referred to as Delta Dental.

Copayment
The percentage of covered services that you will have to pay toward treatment.

Covered Services
The unique benefits selected in your plan. The Summary of Dental Plan Benefits lists your covered services.

Crown
A dental restoration usually covering the whole exposed portion of a tooth. Most often made of porcelain, gold or acrylic. Frequently used in bridgework or to restore a badly-broken tooth.

Deductible
The amount an individual and/or a family must pay toward covered services before Delta Dental begins paying for services. The Summary of Dental Plan Benefits lists the deductible that applies to you, if any.

Delta Dental Plan
An individual state dental benefit plan that is a member of the Delta Dental Plans Association, a nationwide system of dental health plans offering employers, large and small, custom programs and reporting systems.

Delta Dental's Nonparticipating Dentist Fee
The maximum amount allowed per procedure for services rendered by a nonparticipating dentist.

Delta Dental PPO Point-of-Service
A preferred provider organization program that can reduce your out-of-pocket expenses if you receive care from one of Delta Dental's Dentists. This program has back-up coverage through Delta Dental Premier when treatment is received.

Delta Dental PPO Option Participating Dentist 
A dentist who has entered into a Prudent Purchaser agreement with the Delta Dental Plan in his or her state. The dentist accepts Delta Dental's payment and the patient's payment, if any, as payment in full.

Delta Dental Premier
A national fee-for-service dental benefits program that covers you when you go to a non-PPO dentist.

Delta Dental Premier Participating Dentist
A dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in Delta  Premier. The Delta Premier participating dentist accepts Delta Dental's payment and the patient's payment, if any, as payment in full.

Delta Dental Premier Non-Participating Dentist
A dentist who has not signed an agreement with Delta Dental to participate in Delta Premier. It is the subscriber's responsibility to make full payment to the Delta Premier nonparticipating dentist.

DeltaUSA
A national program with a nationwide network of participating dentists for groups with enrollees in two or more states.

Dentist
A person licensed to practice dentistry in the state or country in which dental services are rendered.

Denture
A removable replacement for a natural tooth or teeth.

Endodontics
Treatments of diseases within the tooth, primarily root canal therapy.

Extraction
The removal of a natural tooth or teeth.

Filling
Material used to fill a cavity that is inserted in a tooth as opposed to one which covers it (crown).

Fixed Bridge
A non-removable replacement for natural tooth or teeth. It is cemented to natural teeth on either side which are used as abutments.

Fluoride
A topically-applied chemical used to prevent tooth decay.

Gingiva
Soft tissue adjacent to your teeth; your gums.

Impaction
A tooth partly- or wholly-buried under the gum by bone or tissue.

Maximum Payment
The maximum dollar amount Delta Dental will pay in any benefit year or lifetime for covered dental services (see the Summary of Dental Plan Benefits).

Occlusion
The contact position of the teeth when the upper and lower jaws are closed, sometimes called "bite."

Oral Surgery
Surgery of the oral mouth cavity, including teeth, tongue and gums. May be dental or non-dental in nature.

Orthodontics
Teeth straightening or repositioning.

Periodontics
Treatment of the gum and tissue around the teeth.

Pontic
An artificial replacement of a missing tooth; part of a fixed bridge.

Predetermination
An estimate of covered services. Dentists may submit their treatment plans and X-rays to Delta Dental before procedures are started. Delta Dental reviews the treatment plan and advises the patient and dentist of what services are covered by your plan and what Delta Dental's payment may be. Delta Dental's payment for predetermined services depends on continued eligibility and the annual or lifetime maximum payment available.

Prophylaxis
Professional cleaning and polishing of the teeth.

Processing Policies
Delta Dental's policies and guidelines used for predetermination and payment of claims. The Processing Policies may be amended from time to time.

Prosthodontics
Artificial replacement of natural teeth (bridges and dentures).

Removable Bridge
A partial denture normally held by clasps to the natural teeth, permitting removal if desired.

Restoration
A filling or crown that restores a natural tooth.

Root Canal Therapy
Treatment of the pulp of the tooth.

Sodium Fluoride Application
A mild decay prevention dental treatment applied to the outer surface of the teeth.

Submitted Amount
The fee the dentist bills to Delta Dental for a specific treatment.

Subscriber
You, when the State of Ohio notifies Delta Dental that you are eligible to receive dental benefits.

Summary of Dental Plan Benefits
A list of the specific provisions of your group dental plan and is a part of the Dental Care Certificate.

Surface
A term which refers to one of the four sides of your tooth or a chewing area of the tooth. A one-surface filling is inserted in only one surface of a tooth; a two-surface filling includes two adjoining surfaces of the same tooth in a single filling.

Usual, Customary, and Reasonable Fees are:

Usual: The usual fee is the lowest fee regularly charged, offered or received by an individual dentist for a dental service. There may be some exceptions for fees charged under preferred provider plans or charitable programs.

Customary: A fee is customary when it is within the range of usual fees charged by dentists of similar training and experience within a specific and limited geographic area.

Reasonable: A fee is reasonable when it meets the above two criteria or it is justifiable considering special circumstances.
 

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