Laserfiche WebLink
ARTICLE 8 - OTHER DELTA DENTAL OBLIGATIONS <br />8.1 Delta Dental shall encourage Delta Dental Dentists to submit a standardized claim form <br />before providing service, showing the Enrollee's dental needs and the treatment necessary In <br />the professional judgment of the Dentist. <br />Delta Dental shall predetermine, from the claim and other data, what would be payable by <br />Delta Dental and an Enrollee for the proposed service under the terms of this plan as of the <br />date of predetermination. <br />Such predetermination shall not constitute a guaranty or authorization of Benefits under this <br />Contract, and any actual payment by Delta Dental will depend upon the Enrollee's eligibility <br />and remaining annual maximum when completed services are reported to Delta Dental. <br />Delta Dental shall advise Delta Dental Dentists to notify the Enrollee of all Information <br />provided by Delta Dental In the predetermination. <br />8.2 A Dentist may file a statement before treatment, showing the services to be provided to an <br />Enrollee. Delta Dental will predetermine the amount of Benefits payable under this Contract <br />for the listed services. A predetermination will become Invalid at the end of the Contract Term <br />or the date the Enrollee's eligibility ends. <br />8.3 Delta Dental will not make any payment for services provided to an Enrollee who Is not <br />reported to Delta Dental as an Enrollee under this Contract when the service Is provided. <br />Delta Dental shall not be obligated to recover claims paid to a Dentist as a result of <br />Cc ntracthol der's retroactive eligibility adjustments to eligibility reports. The Contractholder <br />agrees to reimburse Delta Dental for any erroneous claim payments made by Delta Dental as <br />a result of Incorrect eligibility reporting by the Contractholder. <br />8.4 Delta Dental will provide professional review of the adequacy of service provided by Delta <br />Dental Dentists. <br />8.5 Delta Dental, with the assistance of Participating Plans, agrees to furnish to the <br />Contractholder on the effective date, and at reasonable times thereafter, a directory of Delta <br />Dental Dentists and Delta Dental PPO Dentists who have agreed to provide the services <br />described in this Contract. It Is understood that the Dentists listed in that directory may <br />change from time to time and Delta Dental reserves the right to update the directory without <br />prior notice to the Contractholder. However, Delta Dental agrees to give notice to the <br />Contractholder within a reasonable time of any Delta Dental Dentist's termination or breach <br />of Contract, or inability to perform, which will materially and adversely affect the <br />Contractholder. <br />Current Information concerning the Delta Dental Dentist status of any Dentist may be <br />obtained by telephoning the Delta Dental Customer Service department at 800-765-6003. <br />The Dentists providing or contracting to provide dental services under this Contract are solely <br />responsible for those dental services, and in no case will Delta Dental or the Contractholder <br />be liable for any act or omission by such Dentists, their agents or employees. <br />8.6 Delta Dental agrees to give to the Contractholder, and the Contractholder agrees to make <br />available to each Primary Enrollee, an Evidence of Coverage summarizing Benefits to which <br />the Enrollee Is entitled and other provisions of this Contract. If an amendment to this <br />Contract materially affects any Benefits described in such Evidence of Coverage, Delta Dental <br />will Issue a corrected Evidence of Coverage, rider or inserts. <br />25d-67 <br />