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.
- 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.
Major Services (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.
Services, treatment and procedures to correct malposed teeth; no age limit.
- Orthodontic services have a $1,500 lifetime maximum regardless if your dentist is in the Delta Dental PPO network. Delta Dental Premier network or isn't in either network.
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 Diagnostic and Preventive Services or Orthodontic Services.
For information regarding the dental networks, see the Exempt Dental Plan chart below.
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- The dental service must be performed by, or under the direction of, a licensed dentist.
- The expense must be 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.
A type of plastic used for dentures and some kinds of crowns.
One of the most common filling materials; usually soft silver that hardens after it is packed into the cavity.
An X-ray showing exposed portions of the back teeth. Primarily used for early detection of hidden decay between teeth.
Portion of a tooth destroyed by decay. Requires filling or sometimes more extensive treatment.
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.
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.
The percentage of covered services that you will have to pay toward treatment.
The unique benefits selected in your plan. The Summary of Dental Plan Benefits lists your covered services.
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.
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 from a Non-PPO Dentist.
Delta Dental PPO Dentist (“PPO Dentist”) – a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in the Delta Dental PPO. PPO Dentists agree to accept Delta Dental’s payment and your Copayment, if any, as payment in full for Covered Services.
Delta Dental Premier Dentist (“Premier Dentist”) – a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in Delta Dental Premier. Premier Dentists agree to accept Delta Dental’s payment and your Copayment, if any, as payment in full for Covered Services.
Nonparticipating Dentist – a Dentist who has not signed an agreement with any Delta Dental Plan to participate in Delta Dental PPO or Delta Dental Premier.
A person licensed to practice dentistry in the state or country in which dental services are rendered.
A removable replacement for a natural tooth or teeth.
Treatments of diseases within the tooth, primarily root canal therapy.
The removal of a natural tooth or teeth.
Material used to fill a cavity that is inserted in a tooth as opposed to one which covers it (crown).
A non-removable replacement for natural tooth or teeth. It is cemented to natural teeth on either side which are used as abutments.
A topically-applied chemical used to prevent tooth decay.
Soft tissue adjacent to your teeth; your gums.
A tooth partly- or wholly-buried under the gum by bone or tissue.
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).
The contact position of the teeth when the upper and lower jaws are closed, sometimes called "bite."
Surgery of the oral mouth cavity, including teeth, tongue and gums. May be dental or non-dental in nature.
Teeth straightening or repositioning.
Treatment of the gum and tissue around the teeth.
An artificial replacement of a missing tooth; part of a fixed bridge.
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.
Professional cleaning and polishing of the teeth.
Delta Dental's policies and guidelines used for predetermination and payment of claims. The Processing Policies may be amended from time to time.
Artificial replacement of natural teeth (bridges and dentures).
A partial denture normally held by clasps to the natural teeth, permitting removal if desired.
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.
The fee the dentist bills to Delta Dental for a specific treatment.
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.
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.
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. This exclusion does not apply to orthodontic treatment in progress
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.
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 altering, restoring or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction or erosion or for periodontal splinting. 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 or dental professional under the scope of his or her license as permitted by applicable state law.
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.
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 (Major Services) 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 Services 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 Services will be limited to the lifetime maximum per person specified in the Benefit Feature Sheet.
15. There is a $25 annual deductible on Basic Services and Major 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.
For questions about dental benefits, contact Delta Dental at 800-524-0149.
Delta Dental PPO Plan
Group Number: 9273-0001
Visit the Delta Dental website at deltadentaloh.com.
For first time users, log in using your Employee ID number and date of birth.