HomeMy WebLinkAboutDELTA DENTALINSU ZFsPSC'-F NOT FiEtlUl6x C
WORK MAY PWCEED
CLERK OF COUNCIL
MAR 0 9 2018
DELTA DENTAL OF CALIFORNIA
(A Not -for -Profit Corporation Incorporated in California
and a Member of the Delta Dental plans Association)
Home Office: 100 First Street, San Francisco, California 94105
(Herein referred to as "Delta Dental")
41S-972-8300
Group Number 00599
A-2018-021
IN CONSIDERATION of the application made by CITY OF SANTA ANA, referred to In this Contract as
"the Contractholder," and IN CONSIDERATION of payment by the Contractholder of the Premiums as
stated in Article 3, Delta Dental agrees to provide the Benefits In Article 4 for a period of two years,
beginning at 12:01 a.m., Standard Time, on the Effective Date, January 1, 2018, and continuing
from year to year thereafter, unless this Contract is terminated in accordance with Article 9,
Premiums are payable by the Contractholder before the Effective Date, and thereafter as stated In
Article 3.
The following document is attached to this Contract and made a part hereof:
Appendix B Current Dental Terminology
This Contract contains the following Articlesi
Article 1
Definitions
Article 2
Eligibility
Article 3
Premium Payments
Article 4
Benefits Provided; Limitations and Exclusions
Article 5
Deductibles & Maximum Amount
Article 6
Coordination of Benefits
Article 7
Conditions Under Which Delta Dental Will Provide Benefits
Article 8
Other Delta Dental Obligations
Article 9
Termination and Renewal
Article 10
Continued Coverage Option
Article 11
General Provisions
EXHIBIT 2
25G-53
ARTICLE 1 - DEFINITIONS
These terms, when used in this Contract, mean the following:
1.1 Administrator - a third party entity designated by Delta Dental to perform administrative
functions described throughout thls Contract, including, but not limited to, the collection of
premium and eligibility,
1.2 Benefits - those dental services that are available under the terms of this Contract as set out
In Article 4,
1.3 Contract - this agreement between Delta Dental and the Contractholder Including the
attached appendices. This Contract Is the entire Contract between the parties,
1.4 Contract Term - the period beginning on the Effective Date and ending on December 31,
2018, and each subsequent yearly period during which this Contract remalns In effect.
1.5 Delta Dental PPOOMI Dentist - a Dentist with whom Delta Dental has a written agreement
to provide services at the in -network level for Enrollees In this Delta Dental PPO Plan.
1.6 Delta Dental PPO Dentist's Fee - the fee that a Delta Dental PPD Dentist has contractually
agreed with Delta Dental to accept for treating Enrollees under this plan, or the Fee Actually
Charged, whichever is less, for a Single Procedure.
1.7 Delta Dental PPO Dentist's Prevailing Fee - the fee for a Single Procedure that satisfies
the majority of Delta Dental PPO Dentists, as determined by, Delta Dental based upon
confidential fee listing accepted by Delta Dental from Delta Dental PPO Dentists,
1.8 Delta Dental Dentist - a Dentist who has signed an agreement with Delta Dental or a.
Participating Plan, agreeing to provide services under the terms and conditions established by
Delta Dental or the Participating Plan.
1.9 Dentist - a duly licensed Dentist legally entitled to practice dentistry when and where
services are provided,
1.10 Dependent - a Primary Enrollee's Dependent who is eligible for Benefits under Article 2 of
this Contract.
1,11 Eligibility Date - the date an Enrollee's eligibility for Benefits becomes effective under the
terms of this Contract.
1.12 Enrollee - a Primary Enrollee or Dependent who Is eligible and enrolls 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 Dental receives the appropriate
monthly payment as set out In Article 3.
1.13 Enrollee Co -payment.- the portion of the Dentist's fees or allowances charged for Benefits
that Is the Enrollee's responsibility.
1.14 Pee Actually Charged - the fee for a particular dental service or procedure that a Dentist
submits to Delta Dental on a claim form, less any portion of such fee that is discounted,
waived or rebated, or which the Dentist does not use good faith efforts to collect.
1.15 Participating Plan - Delta Dental and any other member of the Delta Dental Plans
Association with which Delta Dental contracts to assist it in administering the Benefits of this
Contract.
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1.16 Premiums -the amounts payable by the Contractholder as provided In Article 3,
1.17 Prevailing Fee - an allowance determined by Delta Dental and/or a Participating Plan for
services provided by a dentist who Is not a Delta Dental Dentist.
1,18 Primary Enrollee - an Individual, who by their association with the Contractholder, Is eligible
for Benefits under Article 2 of this Contract.
1.19 Procedure Numbers - the Procedure Numbers shown on Appendix B.
1.20 Single Procedure - a dental procedure to which a separate Procedure Number has been
assigned by the American Dental Association In the current version of Current Dental
Terminology (CDT). Many CDT codes are listed In Appendix B of this Contract.
1.21 For a Dentist who has signed a Delta Dental Dentist Agreement with Delta Dental of
California, his or her "Usual, Customary and Reasonable Fee" for any Single Procedure Is the
fee that the Dentist has filed with Delta Dental and which Delta Dental has accepted. For
these Dentists, the words "Usual, Customary and Reasonable" means the following;
Usual - 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.
Customary - the fee 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 Dental
determines Is statistically relevant.
Reasonable - a fee schedule is reasonable If It Is "usual" and "customary." Additionally, a
specific fee to a specific Enrollee is reasonable If It Is justifiable considering special
circumstances, or extraordinary difficulty, of the case In question.
ARTICLE 2 - ELIGIBILITY
2.1 All regular employees may enroll In this plan and will become eligible to receive WefCts
Immediately following one month from their date of hire.
2.2 Dependents of Primary Enrollees are eligible to enroll under this Contract provided: (1) a
minimum of 50% of employees with Dependents enroll all their Dependents who are not
covered under any other group dental care plan; (2) said Dependents are enrolled at the time
of enrollment of the employee or within 30 days of loss of any other coverage and proof of
prior coverage is provided to the Contractholder; (3) contributions for the enrolled Dependent
continue to be made through payroll deductions until the employee's coverage terminates, or
the Dependent is no longer eligible as defined below, or the employee elects to discontinue
dependent coverage; and (4) new Dependents who qualify for enrollment are enrolled on the
first day of the month next following their eligibility as Dependents, except that dependent
children up to four years of age may be enrolled at the beginning of any Contract Year
Including the Contract Year Immediately following their fourth birthday.
2.3 Once a Primary Enrollee elects to discontinue dependent coverage, Dependents may not be
re-enrolled under this plan, unless the Dependent Is the subject of a Qualified Medical Child
Support Order requiring the Primary Enrollee to provide the Dependent Benefits under this
plan.
2,4 Dependents are the Primary Enrollee's legal spouse and dependent children from birth to age
26, Children Include natural children, stepchildren, adopted children, children placed for
adoption and foster children. The Dependents of Primary Enrollees are eligible to enroll on the
same date that the employee, of whom they are a Dependent, becomes a Primary Enrollee,
Later-acqulred Dependents become'eligible as soon as they acquire dependent status.
2,5 A dependent child may continue eligibility If;
a) He or she is incapable of self-sustaining employment because of a physically or mentally
disabling Injury, Illness or condition that began prior to reaching the limiting age;
b) He or she is chiefly dependent on the eligible employee for support; and
c) Proof of Dependent's disability Is provided within 60 days of request. Such requests will
not be made more than once a year following a two year period after this Dependent
reaches the limiting age. Eligibility will continue as long as the Dependent relies on the
eligible employee for support because of a physically or mentally disabling Injury, illness
or condition that began before he or she reached the limiting age.
2.6 Dependents in military service are not eligible.
2.7 Every enrolled employee and Dependent meeting the preceding conditions of eligibility Is an
Enrollee. However, Delta Dental will not provide Benefits for any employee or his or her
Dependents unless (1) the employee Is Included on the list of Primary Enrollees submitted as
required by this Article (or any revision or correction of such a list), and (2) the appropriate
payments are made as required by Article 3 of this Contract, for the months In which Delta
Dental provides covered dental services,
2.8 The Contractholder agrees to enroll all of Its Primary Enrollees in this plan, All employees of
the Contractholder meeting the eligibility requirements of this Article are "Primary Enrollees"
under this plan unless the Contractholder offers one or more alternate plans of dental
coverage. In that event, Primary Enrollees will continue to be eligible under this plan unless
they file a choice card with the Contractholder electing an alternate plan during an open
enrollment period agreed upon between Delta Dental and the Contractholder,
2.9 The Contractholder will compile and furnish Delta Dental with an Initial report of all Primary
Enrollees, showing their Enrollee ID numbers, their dates of hire and division codes. The
initial report shall be provided to Delta Dental or prior to the Effective Date of this Contract.
The Contractholder also agrees to report all persons electing continued coverage under Article
10, showing their Enrollee ID numbers and date of election.
2.10 The Contractholder may continue to submit subsequent eligibility reports monthly or may
report only additions or deletions to the initial report. If the report is not updated by the
Contractholder or has not arrived or been processed for the current month, Delta Dental will
extend the last report received to process claims. The extension of the eligibility report does
not waive the requirement that the Contractholder provide an updated report to Delta Dental
each month indicating additions or deletions from any previous report, The Contractholder
shall pay, as set forth in Article 3, all Premiums applicable for Primary Enrollees reported in
the updated report.
2.11 Enrollees are not eligible during a period the Primary Enrollee does not report to work on a
regular basis and is not actively employed as determined by the Contractholder. Eligibility
resumes on the first day of the month following the return to active employment If amounts
due to Delta Dental for Enrollees have been paid. Eligibility can continue without Interruption
If the Contractholder continues to report the employee as a Primary Enrollee and the amounts
due to Delta Dental are paid on the employee's behalf,
Coverage Is reinstated on the day employment Is resumed for Enrollees that are members of
the National Guard or a military reserve unit absent from work due to active military duty.
Any waiting period applied as a result of an Enrollee's absence from active employment due
to service in the National Guard or military reserve unit shall be waived.
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2.12 A Primary Enrollee absent from work due to a leave of absence governed by the "Family and
Medical Leave Act of 1993" (P.L. 103-3) will not be subject to Section 2.11.
2.13 A Primary Enrollee absent from work due to a leave of absence governed by the "Uniformed
Services Employment and Re-employment Rights Act of 1994" (P.L. 103-353) will not be
subject to Section 2,11. Such Primary Enrollee shall have the right to continue coverage for
up to 24 months while he or she Is on military leave. If the Primary Enrollee elects this
continued coverage, he or she must submit the Premiums necessary to the Contractholder,
2.14 A Primary Enrollee's eligibility ends on the last day of the month in which his or her full-time
employment ends, unless he or she chooses to continue coverage under Article 10, A
Dependent's ellglblllty ends along with the Primary Enrollee'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.
2.15 The Contractholder agrees to permit Delta Dental, by Its auditors or other authorized
representatives, on reasonable advance written notice, to Inspect the Contractholder's records
In order to verify the accuracy of lists of Primary Enrollees prepared by the Contractholder
and submitted to Delta Dental and to verify the Contractholder's compliance with At -tide 3 of
this Contract.
ARTICLE 3 — PREMIUM PAYMENTS
3.1 Within ten days after receipt of Delta Dental's Invoice, except for the month of January 2018,
the Contractholder agrees to pay the following monthly, billed Premiums to Delta Dental, at the
address shown on the first page of this Contract, for all of Contractholder's Primary Enrollees
and their Dependents who are "Enrollees" as set forth in Article2 of this Contract:
$52.56 for each Primary Enrollee without enrolled Dependents; and
$129.44 for each Primary Enrollee with one or more enrolled Dependents.
Contractholder agrees to pay the invoiced amount. Eligibility adjustments reported to Delta
Dental after the date the Invoice Is prepared will be reflected on the subsequent month's
invoice. Such adjustments are limited to the three-month period prior to the most current
month for which the Contractholder provides eligibility data.
Contractholder agrees to bear the cost or such Premiums without withholding or otherwise
charging Primary Enrollees for their coverage. Primary Enrollees agree to bear the cost of
coverage for their enrolled Dependents.
3.2 The Premium for each person electing continued coverage under the Continued Coverage
Option in Article 10 for himself or herself will be the same as that for a single Primary
Enrollee. The Premium for a person who also elects continued coverage for his or her
Dependents is the same as that for a Primary Enrollee with the same number of Dependents.
The Contractholder may charge persons choosing coverage under Article 10 such amounts as
are permitted by law.
3.3 This Contract Is not in effect until Delta Dental receives the initial Premiums from the
Contractholder.
3.4 If this Contract terminates for any reason, the Contractholder agrees to pay all Premiums
earned by Delta Dental but unpaid by the Contractholder.
266-57
3.5 In addition to the amounts, If any, which Delta Dental withholds from payments to Dentists
as provided In Delta Dental Dentists Rules, the Contractholder authorizes Delta Dental to
deduct from each of Its monthly payments to Delta Dental 15.75% of such amount as
compensation for Delta Dental's administration of this dental plan.
3.6 After the end of each Contract Term, the stabilization shall be calculated by Delta Dental from
the Effective Date of the Contract. The following percentage of any positive amount ("plus
stabilization") may be reflected in the calculation of the renewal rate for the succeeding
Contract Term and/or may be used to offset the additional cost of Increased Benefits for the
succeeding Contract Term,
25% for Contractholders with an average monthly enrollment of 100 to 199 Primary Enrollees
50% for Contractholders with an average monthly enrollment of 200 to 299 Primary
Enrollees.
75% for Contractholder with an average monthly enrollment of 300 to 399 Primary Enrollees.
100% for Contractholders with an average monthly enrollment of 400 or more Primary
Enrollees,
Average monthly enrollment Is based on the 12 -month period preceding each renewal date of
this Contract.
Any negative or positive amount occurring during a Contract Term will be Included in the
calculation of the stabilization during the succeeding Contract Term.
Stabilization means the negative or positive amount of Premiums paid under this plan after
deduction of claims paid, reserves for Incurred but unreported claims and Delta Dental's
administrative charge.
In no event, however, shall the plus stabilization or any part of it be returned to the
Contractholder In a cash transaction and such amounts remaining upon termination of the
Contract shall remain with Delta Dental.
3.7 In the event the Contractholder chooses to convert to a self-funded plan during or at the and
of a Contract Term, the stabilization accumulated under this plan is combined with the
reserves held for incurred but unreported claims, with the balance used to pay for claims and
adminlstratlon without regard to the date of service,
3.9 Except as provided in the next paragraph, an agreement between Delta Dental and the
Contractholder Is required to change the Contractholder's Premium rates during 'a Contract
Term.
3.9 During a Contract Term, If any government agency Imposes any new tax on Delta Dental
based on the amount of Premiums payable or the number of persons covered under this
Contract, or If the rate of any existing tax on the amount of Premiums or the number of
persons covered under this Contract increases, the Premiums stated in this Article will
Increase by the amount of any such new or Increased tax(es):
3.10 Premiums and eligibility may be adjusted retroactively by Delta Dental or the Contractholder,
but such adjustments are limited to the three-month period prior to the most current month
for which the Contractholder provides eligibility data,
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.
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25C-58
4.2 DIAGNOSTIC AND PREVENTIVE BENEFITS. Delta Dental agrees to pay 100% of the Dentist's
Usual, Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or
100% of the Delta Dental PPO Dentist's Fee for the following Diagnostic and Preventive
Benefits:
Diagnostic- oral examinations (including
Initial examinations,
periodic examinations and
emergency examinations)
x-rays
examination of blopsled tissue
palliative (emergency) treatment of dental pain
specialist consultation
Preventive- prophylaxis (cleaning)
topical application of fluoride solution
space maintainers
Note on additional Benefits during pregnancy - When an Enrollee is pregnant, Delta
Dental will pay for additional services to help Improve the oral health of the Enrollee during
the pregnancy. The additional services each calendar year while the Enrollee Is covered under
this Contract Include: one additional oral exam and either one additional routine cleaning or
one additional periodontal scaling and root planing per quadrant. Written confirmation of the
pregnancy must be provided by the Enrollee or her dentist when the claim Is submitted.
4.3 BASIC BENEFITS, Delta Dental agrees to pay 75% of the Dentist's Usual, Customary and
Reasonable fees or the Fee Actually Charged, whichever Is less, or 80% of the Delta Dental
PPO Dentist's Fees for the following Basic Benefits:
Oral Surgery- extractions and certain other surgical procedures, including pre- and post-
operative care
Restorative- amalgam, silicate or composite (resin) restorations (fillings) for treatment of
carious lesions (visible destruction of hard tooth structure resulting from the
process of dental 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
Adjunctive
General
Services- general anesthesia; I.V, sedation; office visit for observation; office visit after
regularly scheduled hours; therapeutic drug injection; treatment of post-
surgical complications (unusual circumstances); occlusal adjustment, limited
4.4 CROWNS, INLAYS, ONLAYS AND CAST RESTORATIONS BENEFITS. Delta Dental agrees to pay
50% of the Dentist's Usual, Customary and Reasonable fees or the Fee Actually Charged,
whichever is less, or 50% of the Delta Dental PPO Dentist's Fee for the treatment of carious
lesions (visible destruction of hard tooth structure resulting from the process of dental decay)
which cannot be restored with amalgam, silicate or direct composite (resin) restorations.
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25C-59
4.5 PROSTHODONTIC BENEFITS, Delta Dental agrees to pay 50% of the Dentist's Usual,
Customary and Reasonable fees or the Fee Actually Charged, whichever is less, or So% of the
Delta Dental PPO Dentist's Fee for the construction or repair of fixed bridges, partial or
complete dentures to replace missing, natural teeth; for Implant surgical placement and
removal; and for Implant supported prosthetics, including Implant repair and recementatlon.
4.6 LIMITATIONS:
(a) Only the first two oral examinations, including office visits for observation and
specialist consultations, or combination thereof, provided to an Enrollee twice In a
calendar year while he or she Is enrolled under any Delta Dental plan are Benefits
under this plan. See Note on additional Benefits during pregnancy.
(b) Delta Dental pays for full -mouth x-rays only after five years have elapsed since any
prior set of full -mouth x-rays was provided under any Delta Dental plan.
Delta Dental pays for a panoramic x-ray provided as an Individual service only after
five years have elapsed since any prior panoramic x-ray was provided under any Delta
Dental plan.
(c) Bitewing x-rays are provided on request by the Dentist, but not more than twice In a
calendar year for children to age 18, or once In a calendar year for adults ages 18 and
over, while the patient is an Enrollee under any Delta Dental plan.
(d) A prophylaxis (cleaning) or Single Procedure that Includes a prophylaxis is a Benefit
twice each calendar year under any Delta Dental plan. See note on additional Benefits
during pregnancy.
Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and
periodontal prophylaxes are covered as a Basic Beneflt.
(e) Periodontal scaling and root planing is a Benefit once for each quadrant each 24 -
month period. See note on additional Benefits during pregnancy.
(f) Fluoride treatment Is a Benefit twice each calendar year under any Delta Dental plan.
(g) Sealant Benefits include the application of sealants only to permanent first molars
through age eight and second molars through age (15) if they are without caries
(decay) or restorations on the occlusal surface. Sealant Benefits do not include the
repair or replacement of a sealant on any tooth within two years of Its application.
(h) Crowns, Inlays, Onlays or Cast Restoration are Benefits on the same tooth only once
every five years while the patient Is an Enrollee under any Delta Dental plan, unless
Delta Dental determines that replacement Is required because the restoration Is
unsatisfactory as a result of poor quality of care, or because the tooth Involved has
experienced extensive loss or changes to tooth structure or supporting tissues since
the replacement of the restoration.
(1) Prosthodontic appliances and implants that were provided under any Delta Dental plan
will be replaced only after five years . have passed, except when Delta Dental
determines that there Is such extensive loss of remaining teeth or change in
supporting tissues that the existing fixed bridge, partial denture or complete denture
cannot be made satisfactory, Replacement of a prosthodontic appliance or Implant
supported prosthesis not provided under a Delta Dental plan will be covered If It Is
unsatisfactory and cannot be made satisfactory, Implant removal Is limited to one for
each tooth during the Enrollee's lifetime whether provided under a Delta Dental or any
other dental care plan,
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(j) Delta Dental will pay the applicable percentage of the Dentist's Fee for a standard cast
chrome or acrylic partial denture or a standard complete denture, (A "standard"
complete or partial denture is defined as a removable prosthetic appliance provided to
replace missing natural, permanent teeth and which Is constructed using accepted and
conventional procedures and materials.)
(k) If an Enrollee selects a more expensive plan of treatment than Is customarily provided,
or specialized techniques, an allowance will be made for the least expensive,
professlonally acceptable alternative treatment plan. Delta Dental will pay the
applicable percentage of the lesser fee and the Enrollee is responsible for the
remainder of the Dentist's fee,
For example: a crown, where an amalgam filling would restore the tooth, or a
precision denture, where a standard denture would suffice.
4.7 EXCLUSIONS - The following services are not Beneflts:
(a) Services for Injuries or conditions that are covered under Workers' Compensation or
Employer's Uabllity Laws.
(b) Services which are provided to the Enrollee by any, Federal or State Government
Agency or are provided without cost to the Enrollee by any municipality, county or
other political subdivision, except as provided In California Health and Safety Code
Section 1373(a).
(c) Services with respect to congenital (hereditary) or developmental (following birth)
malformations or cosmetic surgery or dentistry for purely cosmetic reasons, Including
but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia
(lack of development), fluorosis (a type of discoloration of the teeth) and anodontia
(congenitally missing teeth).
(d) Services for restoring tooth structure lost from wear (abrasion, erosion, attrltlon, or
abfractlon), for rebuilding or maintaining chewing surfaces due to teeth out of
alignment or occlusion, or for stabilizing the teeth. Such services include but are not
limited to equilibration and periodontal splinting,
(e) Prosthodontic services or any Single Procedure started prior to the date the person
became eligible for such services under this Contract.
(f) Prescribed or applied therapeutic drugs, premedication or analgesia.
(g) Experimental procedures.
(h) All hospital costs and any additional fees charged by the Dentist for hospital
treatment.
(1) Charges for anesthesia, other than general anesthesia or LV. sedation administered by
a licensed Dentist In connection with covered oral Surgery services and select
Endodontic and Periodontic procedures.
(j) Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue).
(k) Diagnosis or treatment by any method of any condition related to the
temporomandibular (jaw) joint or associated musculature, nerves and other tissues.
(1) Replacements of existing restorations for any purpose other than active tooth decay.
25d-61
(m) Occlusal guards and complete occlusal adjustment.
(n) Orthodontic services (treatment of mal -alignment of teeth and/or jaws).
(o) Diagnostic casts.
4.8 An agreement between the Contractholder and Delta Dental Is required to change Benefits
during a Contract Term,
ARTICLE; 5 - DEDUCTIBLES & MAXIMUM AMOUNT
5.1 Applicable to services provided by a Delta Dental PPO Dentist: Each Enrollee must pay
the first $25 ("deductible amount") of fees for services that are Benefits received by an
Enrollee during the term of this Contract and otherwise covered by this Contract, such
deductible amount will not exceed $50 for all Enrollees in a single family, consisting of a
Primary Enrollee and his or her Dependents, as defined, Delta Dental will compute these fees
based on the Dentist's Usual, Customary and Reasonable fees,
Applicable to services provided by other dentists: Each Enrollee must pay the first $50
("deductible amount") of fees for services that are Benefits received by an Enrollee during the
term of this Contract and otherwise covered by this Contract. Such deductible amount will not
exceed $100 for all Enrollees in a single Family, consisting of a Primary Enrollee and his or her
Dependents, as defined, Delta Dental will compute these fees based on the Dentist's Usual,
Customary and Reasonable fees.
5.2 Such deductible amounts shall apply once each calendar year or portion thereof during which
the Enrollee Is continuously eligible under this Contract. The deductible does not apply to
Diagnostic and,Preventive Benefits.
5.3 Applicable to services provided by a Delta Dental PPO Dentist: The maximum amount
Delta Dental will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast
Restorations and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,250.
Applicable to services provided by other dentists: The maximum amount Delta Dental
will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast Restorations
and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,000,
ARTICLE 6 - COORDINATION OF BENEFITS
6.1 If'a group insurance policy or any other group health Benefits plan, Including another Delta
Dental plan, entitles a person to receive or be reimbursed for the cost of dental services,
which are also Benefits under this plan, and If this plan Is "primary" under the rules described
below, Delta Dental will provide Benefits as If the other plan did not exist. If the other plan Is
"primary" under these rules, then Delta Dental will coordinate Benefits under this plan with
the primary plan in accordance with California law (California Health and Safety Code
1374.19 (2007).
6.2 If the other plan mainly covers services or expenses other than dental care, this plan is
"primary." Otherwise, Delta Dental will use the following rules to determine which plan is
"primary":
(a) The plan that covers the person as other than a Dependent Is primary over the plan
that covers the person as a Dependent, with the following exception:
If the person is also a Medicare Beneficiary and Medicare is:
(1) secondary to the plan covering the person as a Dependent; and
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26C-62
(II) primary to the plan covering the person as other than a Dependent (for
example, a retired employee),
then the Benefits of the plan covering the person as a Dependent are determined
before the Benefits of the plan covering the person as other than a Dependent.
(b) The plan which covers a child as a Dependent of a parent whose birthday occurs
earlier In a calendar year Is primary over the plan 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:
(1) If the parent with custody has not remarried, the plan that covers the child as a
Dependent of the parent with custody Is primary over the plan which covers the
child as a Dependent of the parent without custody.
(11) If the parent with custody has remarried, the plan which covers the child as a
Dependent of the parent with custody Is primary over the plan which covers the
child as a Dependent of the step-parent, and the plan which covers the child as
a Dependent of the step-parent Is primary over the policy or plan 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 plan, then notwithstanding (1) and (11),
the plan which covers the child as a Dependent of the parent with such
financial responsibility is primary over any other plan which covers the child.
6.3 The Benefits of a plan covering a lald-off or retired employee (or Dependent of such person)
shall be determined after the Benefits of any other plan 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 plan, Benefits order shall be determined as followst
(a) The Benefits of the plan 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 plan cannot be determined by the rules described in this Article 6, the plan that
has covered the person longer shall be primary.
6.6 An Enrollee will provide Delta Dental with any information about the person that Is needed to
administer this Article, and Delta Dental may release any information to or obtain any
Information from any Insurance company or other organization In order to coordinate the
Benefits of an Enrollee. Delta Dental 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 Dental will be Benefits
under this Contract, Delta Dental has the right to recover the value of any Benefits provided
by Delta Dental which exceed Its obligations under the terms of this provision from a Delta
Dental Dentist, Enrollee, Insurance company or other organization, as Delta Dental chooses.
25C-63
ARTICLE 7 - CONDITIONS UNDER WHICH DELTA DENTAL WILL PROVIDE BENEFITS
7.1 Benefits, unless otherwise provided in Article 4, are available from the Eligibility Date of an
Enrollee.
7.2 An Enrollee may choose the services of any licensed Dentist, but neither Delta Dental nor the
Contractholder guarantees the availability of any particular Dentist.
7.3 Before Delta Dental Is obligated to approve and/or satisfy any claims under this Contract,
Delta Dental 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 Enrollee 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 Enrollee be
examined by a dental consultant retained by Delta Dental in or near his or her community or
residence. Delta Dental agrees in every case to hold such Information and records as
confidential.
7.4 The process Delta Dental uses to determine or deny payment for services are distributed to
all Delta Dental Dentists. They describe In detail the dental procedures covered as Benellts,
the conditions under which coverage Is provided and the llmltatlons and exclusions applicable
to the plan. Claims are reviewed for eligibility and are paid according to these processing
policies. Those claims that require additional review are evaluated by Delta Dental's Dentist
consultants. If any claims are net covered or If limitations or exclusions apply to services the
Enrollee has received by a Delta Dental Dentist, the Enrollee will be notified by an adjustment
notice on the Notice of Payment or Action. The Enrollee may contact Delta Dental's Customer
Service department for more Information regarding Delta Dental's processing policies.
7.5 Second Opinions, Delta Dental reserves the right to obtain second opinions through regional
consultant members of its quality review committee. This committee conducts clinical
examinations, prepares objective reports of dental conditions, and evaluates treatment that Is
proposed or has been proposed.
Delta Dental will authorize such an examination prior to treatment when necessary to make a
Benefit determination in response to a request for a predetermination of treatment cost by a
Dentist. Delta Dental will also authorize a second opinion after treatment If an Enrollee has a
complaint regarding the quality of care provided. Delta Dental will notify the Enrollee and the
treating Dentist when a second opinion Is necessary and appropriate, and direct the Enrollee
to the regional consultant selected by Delta Dental to perform the clinical examination. When
Delta Dental authorizes a second opinion through a regional consultant Delta Dental will pay
for all charges.
The Enrollee may otherwise obtain second opinions about treatment from any Dentist they
choose, and claims for the examination may be submitted to Delta Dental for payment. Delta
Dental will pay such claims In accordance with the Beneflts of the plan.
7.6 For services provided by a dentist who is not a Delta Dental PPO Dentist or a Delta Dental
Dentist, Delta Dental will not pay more than the lesser of the fees entered on the claim form
reporting such services to Delta Dental or the Prevailing Fee, multiplied by the applicable
percentage specified in Article 4 for such services. However, If the Dentist discounts, waives,
rebates or does not use good faith efforts to collect some portion of the fees entered on the
claim form from the Enrollee, Delta Dental will not pay more than the applicable percentage
specified In Article 4 of the lesser of (1) the fees entered on the claim form, reduced by the
portion discounted, waived, rebated or not collected, or (2) the Prevailing Fee, reduced by the
portion discounted, waived, rebated or not collected.
26'b-64
7.7 Delta Dental will pay a Delta Dental Dentist directly for services provided by that Dentist.
Contracts between Delta Dental of California and Its Delta Dental Dentists provide that, In the
event Delta Dental falls to pay the Dentist, the Enrollee will not owe the Dentist for any sums
owed by Delta Dental.
7.8 Delta Dental will pay an Enrollee directly for services provided by a Dentist who Is not a Delta
Dental Dentist, and those payments are not assignable. The Enrollee Is liable to the Dentist
for payment to the Dentist for the cost of the service. In addition, Delta Dental will pay for
services from dental school clinics by students of dentistry or Instructors who are not licensed
by the State of California. In the event Delta Dental fails to pay the Dentist who has not
contracted with Delta Dental as a Delta Dental Dentist, the Enrollee may be liable to the
Dentist for the cost of the service.
7.9 Delta Dental is not obligated to pay claims submitted more than 12 months after the date the
service was provided. If a claim is denied because a Delta Dental Dentist failed to make a
timely submission, the Enrollee does not owe the Dentist the amount which would have been
payable by Delta Dental, provided that the Enrollee advised the Dentist of his or her eligibility
for Benefits at the time of treatment.
7.10 Delta Dental, with the assistance of Participating Plans, will give each Delta Dental Dentist,
and any other Dentist or Enrollee 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 service and by the Enrollee (or the Enrollee's
parent or guardian if such Enrollee Is a minor) must be submitted to Delta Dental.
7.11 if an Enrollee has any questions about the services received from a Delta Dental Dentist,
Delta Dental recommends that he or she first discuss the matter with the Dentist. If he or she
continues to have concerns, the Enrollee may call or write Delta Dental. Delta Dental will
provide notifications If any dental services or claims are denied, In whole or part, stating the
specific reason or reasons for denial. Any questions of Ineligibility should first be handled
directly between the Enrollee and the group. If an Enrollee has any question or complaint
regarding the denial of dental services or claims, the policies, procedures and operations of
Delta Dental, or the quality of dental services performed by a Delta Dental Dentist, he or she
may call Delta Dental toll-free at 800-765-6003, contact Delta Dental on the Internet through
the webslte: deltadentalins,com or write Delta Dental at P. 0. Box 997330, Sacramento, CA
95899 Attentlom Customer Service Department.
If an Enrollee's claim has been denied or modified, the Enrollee may file a request for review
(a grievance) with Delta Dental within 180 days after receipt of the denial or modification. If
a request for review Is not made within this 180 -day period, the right to further review of the
claim determination will be lost. If In writing, the correspondence must Include the group
name and number, the Primary Enrollee's name and Enrollee ID number, the inquirer's
telephone number and any additional Information that would support the claim for benefits.
The correspondence should also Include a copy of the treatment form, Notice of Payment and
any other relevant information. Upon request and free of charge, Delta Dental will provide the
Enrollee with copies of any pertinent documents that are relevant to the claim, a copy of any
Internal rule, guideline, protocol, and/or explanation of the scientific or clinical judgment If
relied upon in denying or modifying the claim.
Delta Dental's review will take into account all Information, regardless of whether such
information was submitted or considered initially. Certain cases may be referred to one of
Delta Dental's regional consultants, to a review committee of the dental society or to the
state dental association for evaluation. Delta Dental's review shall be conducted by a person
who Is neither the individual who made the original claim denial, nor the subordinate of such
Individual, and Delta Dental will not give deference to the initial decision.
If the review of a claim denial is based in whole or in part on a lack of medical necessity,
experimental treatment, or a clinical judgment In applying the terms of the contract terms,
Delta Dental shall consult with a dentist who has appropriate training and experience. The
Identity of such dental consultant is available upon request.
Delta Dental will provide the Enrollee a written acknowledgement within five calendar days of
receipt of the request for review. Delta Dental will make a written decision within 30 calendar
days of receipt of the request for review. Delta Dental will respond, within three calendar days
of recelpt, to complaints Involving severe pain and Imminent and serious threat to an
Enrollee's health. An Enrollee may file a complaint with the Department of Managed Health
Care after he or she has completed Delta Dental's grievance procedure or after he or she has
been Involved in Delta Dental's grievance procedure for 30 calendar days. An Enrollee may
file a complaint with the Department Immediately In an emergency sltuatlon, which is one
involving severe pain and/or Imminent and serious threat to the Enrollee's health.
The California Department of Managed Health Care Is responsible for regulating health care
service plans, If an Enrollee has a grievance against Delta Dental or the health plan, the
Enrollee should first telephone Delta Dental at 800-765-6003 and use Delta Dental's
grievance process before contacting the department. Utilizing this grievance procedure does
not prohibit any potential legal rights or remedies that may be available to an Enrollee, If
help is needed with a grievance Involving an emergency, a grievance that has not been
satisfactorily resolved by this health plan, or a grievance that has remained unresolved for
more than thirty (30) calendar days, the Enrollee may call the department for assistance.
An Enrollee may also be eligible for an Independent Medical Review (IMR). If eligible for an
IMR, the IMR process will provide an Impartial review of medical decisions made by a health
plan related to the medical necessity of a proposed service or treatment, coverage decisions
for treatments that are experimental or Investigational in nature and payment disputes for
emergency or urgent medical services, The department also has a toil -free telephone number
(888 -HMO -2219) and a TDD line (877-688-9891) for the hearing and speech Impaired,
The department's Internet Website (httpl//www.hmohelp.ca.gov) has complaint forms,
IMR application forms and instructions online.
If the group health plan is subject to the Employee Retirement Income Security Act of 1974
(ERISA), the Enrollee may contact the U,S, Department of Employee Benefits Security
Administration (EBSA) for further review of the claim or if the Enrollee has questions about
the rights under ERISA. The Enrollee may also bring a civil action under section 502(a) of
ERISA. The address of the U.S. Department of Labor is; U.S. Department of Labor, Employee
Benefits Security Administration (EBSA), 200 Constitution Avenue, N.W. Washington, D.C.
20210.
7.12 The Benefits that Delta Dental provides are limited to the applicable percentages of the
Dentist's fees or allowances specified In Article 4. The Contractholder requires the Enrollee to
pay the balance of any such fee or allowance, known as the "Enrollee Co -payment;' as a
method of sharing the costs of providing dental Benefits between the Contractholder and
Enrollees. If the Dentist discounts, waives or rebates any portion of the Enrollee co -payment
to the Enrollee, Delta Dental only provides as Benefits the Dentist's fees or allowances
reduced by the amount that such fees or allowances are discounted, waived or rebated.
14
26C-66
ARTICLE 8 - OTHER DELTA DENTAL OBLIGATIONS
8.1 Delta Dental shall encourage Delta Dental Dentists to submit a standardized claim form
before providing service, showing the Enrollee's dental needs and the treatment necessary in
the professional judgment of the Dentist.
Delta Dental shall predetermine, from the claim and other data, what would be payable by
Delta Dental and an Enrollee for the proposed service under the terms of this plan as of the
date of predetermination.
Such predetermination shall not constitute a guaranty or autharizatlon of Benefits under this
Contract, and any actual payment by Delta Dental will depend upon the Enrollee's ellglbllity
and remaining annual maximum when completed services are reported to Delta Dental.
Delta Dental shall advise Delta Dental Dentists to notify the Enrollee of all Information
provided by Delta Dental In the predetermination.
8.2 A Dentist may file a statement before treatment, showing the services to be provided to an
Enrollee. Delta Dental will predetermine the amount of Benefits payable under this Contract
for the listed services. A predetermination will become Invalid at the end of the Contract Term
or the date the Enrollee's eligibility ends.
8.3 Delta Dental will not make any payment for services provided to an Enrollee who Is not
reported to Delta Dental as an Enrollee under this Contract when the service Is provided.
Delta Dental shall not be obligated to recover claims paid to a Dentist as a result of
Cc ntracthol der's retroactive eligibility adjustments to eligibility reports. The Contractholder
agrees to reimburse Delta Dental for any erroneous claim payments made by Delta Dental as
a result of Incorrect eligibility reporting by the Contractholder.
8.4 Delta Dental will provide professional review of the adequacy of service provided by Delta
Dental Dentists,
8.5 Delta Dental, with the assistance of Participating Plans, agrees to furnish to the
Contractholder on the effective date, and at reasonable times thereafter, a directory of Delta
Dental Dentists and Delta Dental PPO 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 Dental reserves the right to update the directory without
prior notice to the Contractholder. However, Delta Dental agrees to give notice to the
Contractholder within a reasonable time of any Delta Dental Dentist's termination or breach
of Contract, or inability to perform, which will materially and adversely affect the
Contractholder.
Current information concerning the Delta Dental Dentist status of any Dentist may be
obtained by telephoning the Delta Dental Customer Service department at 800-765-6003.
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 Dental or the Contractholder
be liable for any act or omission by such Dentists, their agents or employees.
8.6 Delta Dental agrees to give to the Contractholder, and the Contractholder agrees to make
available to each Primary Enrollee, an Evidence of Coverage summarizing Benefits to which
the Enrollee 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 Dental
will Issue a corrected Evidence of Coverage, rider or inserts.
26d-67
ARTICLE 9 - TERMINATION AND RENEWAL
9.1 This Contract may be terminated for the following causes:
(a) By Delta Dental, if the Contractholder falls (1) to give Delta Dental a list of all Primary
Enrollees, as required under Article 2, or (2) to permit the inspection of the
Contractholder's records as called for under Article 2, or (3) to pay Premiums, In the
amounts and manner required in Article 3, provided the Contractholder has been duly
notlfled of such failure (and billed for Premiums, If applicable) and at least 15 days
have elapsed since the date of notification.
(b) By either the Contractholder or Delta Dental, upon expiration of a Contract Term.
9,2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta
Dental is released from all further obligations of this Contract, effective the last day of the
month In which written notice of termination Is given. The Contractholder will remain liable to
Delta Dental for the greater of: (1) the unpaid Premiums applicable for the period this
Contract was In effect before termination; or (2) the full amount of all Dentist's statements
paid or otherwise discharged by Delta Dental during the full term of this Contract, plus 25%
of such amount (to compensate Delta Dental for Its administration of the dental plan), less
amounts actually paid by the Contractholder to Delta Dental during the term of such
Contract.
9.3 A party choosing to terminate this Contract at the end of a Contract Term must give at least
60 days written notice of termination to the other party. If Delta Dental wants to change the
Premiums or Benefits effective at the beginning of the next Contract Term, Delta Dental will
give at least 60 days advance written notice of such changes to the Contractholder. Such an
advance notice will have the effect of a notice of termination as of the end of the Contract
Term, unless the Contractholder agrees to the new Contract provisions.
9.4 If the Contractholder notifies Delta Dental 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 Premiums, and such notice will constitute a waiver of notification and billing
required of Delta Dental by paragraph 9.1(a)(3).
9.5 If an Enrollee 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 Director of Managed Health Care under California Health and Safety
Code Section 1365(b). .
9.6 If this Contract Is terminated for any cause, Delta Dental 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 Within 30 days after the and of this Contract, Delta Dental will return to the Contractholder
any Premiums 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 Dental.
9.8 If Delta Dental accepts the proper amount of Premiums after termination of this Contract and
without requiring a new application, that acceptance will reinstate the Contract as though
never terminated, unless Delta Dental within 20 business days after it receives such payment,
either (1) refunds the payment so made or (2) Issues to the Contractholder 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.
9.9 All Benefits end for all Enrollees, when this Contract ends, and Delta Dental will not provide
any right to continuation, renewal or reinstatement of Benefits to such persons In that event.
9.10 Delta Dental must notify the Contractholder In writing of any termination by Delta Dental
under paragraph 9.1, and the Contractholder shall promptly mail a copy of such notice to
each Primary Enrollee and provide Delta Dental with proof of mailing and the date thereof.
ARTICLE 10 - OPTIONAL CONTINUATION OF COVERAGE (COBRA)
10.1 The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain
employers having 20 or more employees) and the California Continuation Benefits
Replacement Act (or Cal -COBRA, pertaining to employers with two to 19 employees), both
require that continued health care coverage be made available to "Qualified Beneficiaries"
who lose health care coverage under the group plan as a result of a "Qualifying Event."
Enrollees may be entitled to continue coverage under this plan, at the Quallfied Beneficiary's
expense, If certain conditions are met. The period of continued coverage depends on the
Qualifying Event and whether the Enrollee is covered under federal COBRA or Cal -COBRA.
10.2 DEFINITIONS
The meaning of key terms used in this Article are shown below and apply to both federal and
Cal -COBRA.
Qualified Beneficiary means:
1. Enrollees who are enrolled In the Delta Dental plan on the day before the Qualifying
Event, or
2. A child who is born to or placed for adoption with the Primary Enrollee during the
period of continued coverage, provided such child Is enrolled within 30 days of birth or
placement for adoption.
Qualifying Event means any of the following events which, except for the election of this
continued coverage, would result In a loss of coverage under the dental plan:
'Event 1: The termination of employment (other than termination for gross misconduct), or
the reduction In work hours, by the Primary Enrollee's employer;
Event 2: The death of the Primary Enrollee;
Event 3: Divorce or legal separation from the Primary Enrollee;
Event 8: A dependent child ceasing to meet the description of dependent child;
Event 5: As to dependents only, a Primary Enrollee becoming entitled to Medicare.
10.3 PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for IS months following the occurrence
Qualifying Event 1.
256-69
This 18 -month period can be extended for a total of 29 months, provided;
1. A determination Is made under Title II or Title XVI of the Social Security Act that an
Individual is disabled on the date of the Qualifying Event or became disabled at any
time during the first 60 days of continued coverage; and
2. Notice of the determination Is given to the employer during the initial 18 months of
continued coverage and within 60 days of the date of the determination.
This period of coverage will end on the first of the month that begins more than 30 days after
the date of the final determination that the disabled individual is no longer disabled. The
Primary Enrollee must notify, the employer/administrator within 30 days of any such
determination.
If, during the 18 month continuation period resulting from Qualifying Event 1, the Primary
Enrollee's dependents experience Qualifying Events 2, 3, 4 or 5, they may choose to extend
coverage for up to a total of 36 months (inclusive of the period continued under Qualifying
Event 1).
The Primary Enrollee's dependents may continue coverage for.36 months following the month
In which Qualifying Events 2, 3, 4 or 5 occur.
Under federal COBRA law only, when an employer has filed for bankruptcy under Title II,
United States Code, beneflts may be substantially reduced or eliminated for retired
employees and their dependents, or the surviving spouse of a deceased retired employee. If
this benefit reduction or elimination occurs within one year before or one year after the filing,
It Is considered a Qualifying Event. If the Primary Enrollee Is a retiree, and has lost coverage
because of this Qualifying Event, he or she may choose to continue coverage until his or her
death. The Primary Enrollee's dependents who have lost coverage because of this Qualifying
Event may choose to continue coverage for up to 36 months following the Primary Enrollee's
death.
10.4 PERIODS OF CONTINUED COVERAGE UNDER CAL -COBRA (groups of 2 - 19)
In the case of Cal -COBRA, Delta Dental will act as the administrator. Notification and
Premium payments should be made directly to Delta Dental. Notifications and payments
should be delivered by first-class mail, certified mail, or other reliable means of delivery,
Individuals who are eligible for coverage under the federal COBRA law are not eligible for
coverage under Cal -COBRA. The employer must notify Delta Dental In writing within 30 days
of the date when the Enrollee becomes subject to COBRA.
Qualified Beneficiaries may continue coverage for 36 months following the month In which
Qualifying Events 1, 2, 3, 4 or 5 occur.
If, during the 36 -month continuation period resulting from Qualifying Event 1, the Qualified
Beneficiary is determined under Title II or Title XVT of the Social Security Act to be disabled
on the date of the Qualifying Event or became disabled at any time during the first 60 days of
continuation coverage; and notice of the determination Is given to the employer during the
initial period of continuation coverage and within 60 days or the date of the social security
determination letter, the Qualified Beneficiary may continue coverage for a total of 36 months
following the month in which Qualifying Event 1 occurs.
18
25C-70
This period of coverage will end on the first of the month that begins more than 30 days after
the date of the final determination that the disabled Individual is no longer disabled. The
Qualified Beneficiary must notify the employer or administrator within 30 days of any such
determination.
If, during the 36 -month continuation period resulting from Qualifying Event 1, the Qualified
Beneficiary experiences Qualifying Events 2, 3, 4 or 5, he or she must notify the employer
within 60 days of the second qualifying event and has a total of 36 months continuation
coverage after the date of the date of the flrst Qualifying Event,
Delta Dental shall notify the Primary Enrollee of the date his or her continued coverage will
terminate. This termination notification will be sent during the 180 -day period prior to the
end of coverage.
10.5 ELECTION OF CONTINUED COVERAGE
The Primary Enrollee's employer shall notify Delta Dental in writing within 30 days of
Qualifying Event 1, A Qualified Beneficiary must notify his or her employer or the
administrator In writing within 60 days of Qualifying Events 2, 3, 4 or 5, or within 60 days of
receiving the election notice from the employer. Otherwise, the option of continued coverage
will be lost.
Within 14 days of receiving notice of a Qualifying Event, the employer or the administrator
will provide a Qualified Beneficiary with the necessary benefits Information, monthly Premium
charge, enrollment forms, and instructions to allow election of continued coverage,
A Qualified Beneflclary'will then have 60 days to give the employer or the administrator
written notice of the election to continue coverage. Failure to provide this written notice of
election to the employer or the administrator within 60 days will result In the loss of the right
to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the
Initial Premium to his or her employer or the administrator, which Includes the Premium for
each month since the loss of coverage. Failure to pay the required Premium within the 45
days will result in loss of the right to continued coverage, and any Premiums received after
that date will be returned to the Qualified Beneflciary.
10.6 CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to active
employees and their dependents who are still enrolled In the dental plan. If the employer
changes the coverage for active employees, the continued coverage will change as well,
Premiums will be adjusted to reflect the changes made.
10,7 TERMINATION OF COVERAGE
A Qualified Beneficiary's coverage will terminate at the end of the month In which any of the
following events first occur:
1. The allowable number of consecutive months of continued coverage is reached;
2. Failure to pay the required Premium in a timely manner;
3. The employer ceases to provide any group dental plan to its employees;
4. The individual moves out of the plan's service area;
X19
25C-% q 1
5. The Individual first obtains coverage for dental benefits, after the date of the election
of continued coverage, under another group health plan (as an employee, or
dependent) which does not contain or apply any exclusion or limitation with respect to
any pre-existing condition of such person, If that pre-existing condition is covered
under this plan;
6. Entitlement to Medicare.
The employer or Primary Enrollee shall notlfy Delta Dental or the administrator within 30 days
of the occurrence of any of the above events. Once continued coverage terminates, It cannot
be reinstated.
10.8 TERMINATION OF THE EMPLOYER'S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the time
that the continuation coverage would otherwise terminate, the employer shall notify a
Qualified Beneficiary (either 30 days prior to the termination or when all Enrollees are notlfied
whichever Is later) of that person's ability to elect continuation coverage under the employer's
subsequent dental plan, If any. The employer must notify the successor plan of the Qualified
Beneficiaries receiving continuation coverage so they may be notlfied of how to continue
coverage under that plan.
The continuation coverage will be provided only for the balance of thea that a Qualified
Beneficiary would have remalned covered under the Delta Dental plan had such plan with the
former employer not terminated. The continuation coverage will terminate if a Qualified
Beneficiary falls to comply with the requirements pertaining to enrollment In, and payment of
Premium to the new group benefit plan within 30 days of receiving notice of the termination
of the Delta Dental plan.
10.9 OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any subsequent
open enrollment period, If the employer has contracted with. another plan to provide coverage
to Its active employees, The continuation coverage under the other plan will be provided only
for the balance of the period that a Qualified Beneficiary would have remained covered under
the Dalte Dental plan.
ARTICLE 11- GENERAL PROVISIONS
11.1 No agent has authority to change this Contract or waive any of Its provisions, Delta Dental
may not change Premium rates, copayments or deductibles, If any, during any of the
following time periods:
(a) after the Contractholder has delivered written acceptance of the Contract,
(b) after the start of an annual open enrollment period, and;
(c) after receipt of the Premium for the first month of the contract term.
Premiums may be changed under the following exceptions:
(a) when authorized or required In the Contract,
(b) when Premiums are subject to execution of a def7nitive agreement, and;
(c) when Delta Dental and the Contractholder mutually agree In writing.
No change In this Contract is valid unless.approved by an executive officer of Delta Dental
and Included In this Contract by written amendment.
zn
25C-72
11.2 The provisions of this Contract are severable, If any portion of this Contract or any
Amendment of It is determined to be Illegal, vold or unenforceable by any arbitrator, court or
other competent authority, all other provisions of this Contract will remain In effect,
11,3 The parties agree that the laws of the State of California, where the Contract was entered Into
and is to be performed, govern all questions regarding the interpretation or enforcement of
this Contract. Delta Dental Is subject to the requirements of Chapter 2.2 of Division 2 of the
California Health and Safety Code and Chapter 1 of Division 1 of Title 28 of the California
Code of Regulations. Any provisions required to be in the Contract by those laws bind Delta
Dental whether or not stated in this Contract.
11.4 Delta Dental and the Contractholder agree to consult each other to the extent reasonably
practical concerning all materials published or distributed relating to this Contract. Neither
Delta Dental nor the Contractholder will publish or distribute materlals that are contrary to
the terms of this Contract.
11.5 Delta Dental and the Contractholder agree to permit and encourage the professional
relationship between Dentist and Enrollee to be maintained without Interference.
11,6 The Contractholder shall designate in writing a representative for purposes of receiving
notices from Delta Dental under this Contract. The Contractholder may change Its
representative at any time on 30 days notice to Delta Dental, Any notice required From Delta
Dental to any Enrollee may be given to the Contractholder's representative, who shall
disseminate such notice to the Enrollee by the next regular communication but in no event
later than 30 days after receipt thereof.
11.7 The Contractholder shall comply In all respects with all applicable federal, state and local laws
and regulations relating to administrative simplification, security and privacy of individually
Identifiable Enrollee Information. The Contractholder agrees that this Contract may be
amended as necessary to comply with federal regulations issued under the Health Insurance
Portability and Accountability Act of 1996 or to comply with any other enacted administrative
simplification, security or privacy laws or regulations.
11.6 Any notice under this Contract will be sufficient If given by either the Contractholder or Delta
Dental to the other or, in the case of employees of the Contractholder, to Its representative at
the addresses below:
For the Contractholder:
City of Santa Ana
20 Civic Center Plaza
Santa Ana, CA 92701-4058
For Delta Dental:
100 First Street
San Francisco, CA 94105
Such notice will be effective 48 hours after deposit in the United States mail with postage
Fully prepaid thereon.,
256-73
CITY OF SANTA ANA
DELTA DENTAL GROUP NUMBER 19209
Printed
FOR;
Delta Dental of California
Lff
Belinda Martinez
Executive Vice President
Chief Sales and Marketing Officer
and
WS
Thomas J. Lelbowltz, FSA, MAAA
Group Vice President and Chief Actuary
Date; January 8, 2018
C 2.2
25 -74
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
r
UmGtr,/( �✓r.,
MARIA HUIZAR
Clerk of the Council
APPROVED AS TO FORINT:
SONIA R. CARVALHO
City Attorney
By:
Laura A. Rossini
Senior Assistant City Attorney
RECOIVIiNIENDED FOR APPROVAL:
LM/15
ELLEN SMI E
Acting Executive Director of Personnel Services
CITY OF SANTA ANA
Raul Godinez, l . �
City Manager
25C-75
APPENDIX B
CODE ON DENTAL PROCEDURES AND NOMENCLATURE
NOTE: All the listed procedures may not be benefits under the terms of your contract, Refer to your
contract for your specific benefits.
00100 - D0999 DIAGNOSTIC
Clinical oral evaluations
D0120 Periodic oral evaluation - established patient
D0140 Limited oral evaluation - problem focused
DO 145 Oral evaluation for a patient under three years of age and counseling with primary
caregiver
D0150 Comprehensive oral evaluation - new or established patient
DO 160 Detailed and extensive oral evaluation - problem focused; by report
D0170 Re-evaluatlon - limited, problem focused (established patient; not post-operative
visit)
D0180 Comprehensive periodontal evaluation - new or established patient
D0190 Screening of a patient
D0191 Assessment of a patient
Radiographs/diagnostic imaging (Including Interpretation)
00210 Intraoral - complete series of radiographic Images
00220 Intraoral - perlapical first radiographic Image
D0230 Intraoral - periapical each additional radiographic Image
D0240 Intraoral - occlusal radiographic Image
D02.50 Extra -oral - 2D projection radiographic image created using a stationary radiation
source, and detector
D0251 Extra -oral posterior dental radiographic image
00270 Bitewing - single radiographic Image. .
D0272 Bitewings - two radiographic Images
D0273 Bitewings - three radiographic images
D0274 Bitewings - four radiographic Images
D0277 Vertical bitewings - 7 to 8 radiographic Images
D0310 Sialography
D0320 Temporomandibular joint arthrogram, Including Injection
D0321 Other temporomandibular joint radiographic images, by report
D0322 Tomographic survey
D0330 Panoramic radiographic image
D0340 2D cephalometric radiographic Image - acquisition, measurement and analysis
D0350 Oral/facial photographic Images obtained Intraorally or extraorally
Tests and examinations
D0411 HbAlc In-offlce point of service testing
D0415 Collection of microorganisms for culture and sensitivity
D0416 Viral culture
D0422 Collection and preparation of genetic sample material for laboratory analysis and
report
D0423 Genetic test for susceptibility to diseases - specimen analysis
D0425 Caries susceptibility tests
D0431 Adjunctive pre -diagnostic test that aids in detection of mucosal abnormalities Including
premalignant and malignant lesions, not to include cytology or biopsy procedures
D0460 Pulp vitality tests
D0470 Diagnostic casts
CDT2018(Eff. 01-01=18)
25C-76
oral pathology laboratory
D0472 Accession of tissue, gross examination, preparatlon and transmission of written report
D0473 Accession of tissue, gross and microscopic examinatlon, preparation and transmission
of written report
D0474 Accession of tissue, gross and microscopic examination, including assessment of
surgical margins for presence of disease, preparation and transmission of written
report
D0475 Decatclflcatlon procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohlstochemical stains
D0479 Tissue In-situ hybridization, Including Interpretation
D0480 Accession of exfollative cytologic smears, microscopic examination, preparation and
transmission of written report
D0481 Electron microscopy - diagnostic
D0482 Direct immunofluorescence
D0483 Indirect Immunofluorescence
D0484 Consultation on slides prepared elsewhere
D0485 Consultation, including preparation of slides from biopsy material supplied by referring
source
D0486 Accession of brush biopsy sample, microscopic examination, preparation and
transmission of written report
D0502 Other oral pathology procedures, by report
D0601 Caries risk assessment and documentation, with a finding of low risk
D0602 Caries risk assessment and documentation, with a finding of moderate risk
D0603 Caries risk assessment and documentation, with a finding of high risk,
D0999 Unspecified diagnostic procedure, by report
D3000 - D1999 PREVENTIVE
Dental prophylaxis
D1110 Prophylaxis - adult
D1120 Prophylaxis - child through age 13
Topical fluoride treatment (office procedure)
D1206 Topical application of fluoride varnish
D1208 - Topical application of fluoride - excluding varnish
Other preventive services
D1310 Nutritional counseling for control of dental disease
D1320 Tobacco counseling for the control and prevention of oral disease
D1330 Oral hygiene Instructions
D1351 Sealant - per tooth
D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent
tooth
D1354 Interim caries arresting medicament application - per tooth
Space maintenance (passive appliances)
D1510
Space maintainer - fixed - unilateral
D1515
Space maintainer - fixed - bilateral
01520
Space maintainer - removable - unilateral
01525
Space malrtainer - removable - bllateral
D1550
Re -cement or re -bond space maintainer
D1555
Removal of fixed space maintalner
D1575
Distal shoe space maintainer - fixed - unilateral
CDT20LS (Eff. 01-01.18)
25C-77
D2000 - D2999 RESTORATIVE
Amalgam restorations (including polishing)
D2140 Amalgam - one surface, primary or permanent
D2150 Amalgam - two surfaces, primary or permanent
D2160 Amalgam - three surfaces, primary or permanent
D2161 Amalgam - four or more surfaces, primary or permanent
Resin -based composite restorations -direct
D2330 Resin -based composite - one surface, anterior
D2331 Resin -based composite -- two surfaces, anterior
D2332 Resin -based composite - three surfaces, anterior
D2335 Resin -based composite - four or more surfaces or Involving Inclsal angle (anterior)
D2390 Resln-based composite crown, anterior
D2391 Resin -based composite - one surface, posterior
D2392 Resin -based composite - two surfaces, posterior
D2393 Resin -based composite - three surfaces, posterior
D2394 Resin -based composite - four or more surfaces, posterior
Gold foil restorations
D2410 Gold foil - one surface
D2420 Gold foil - two surfaces
D2430 Gold foil - three surfaces
Inlay/onlay restorations
D2510 Inlay - metallic - one surface
D2520 Inlay - metallic - two surfaces
02530 Inlay - metallic - three or more surfaces
D2542 Onlay - metallic - two surfaces
D2543 Onlay - metallic - three surfaces
D2544 Onlay - metallic - four or more surfaces
D2610 Inlay - porcelain/ceramic - one surface
D2620 Inlay - porcelain/ceramlc - two surfaces
D2630 Inlay - porcelain/ceramlc - three or more surfaces
D2642 Onlay - porcelain/ceramlc - two surfaces
D2643 Onlay - porcelain/ceramic - three surfaces
D2644 Onlay - porcelain/ceramic - four or more surfaces
D2650 Inlay - resin -based composite - one surface
D2651 Inlay - resin -based composite - two surfaces
D2652 Inlay - resin -based composite - three or more surfaces
D2662 Onlay - resin -based composite - two surfaces
D2663 Onlay - resin -based composite - three surfaces
D2664 Onlay - resin -based composite - four or more surfaces
Crowns -- single restorations only
D2710' Crown - resin -based composite (indirect)
D2712 Crown - 3/4 resin -based composite (Indirect)
D2720 Crown - resin with high noble metal
D2721 Crown - resin with predominantly base metal
D2722 Crown - resin with noble metal
D2740 Crown - porcelain/ceramic
D2750 Crown - porcelain fused to high noble metal
D2751 Crown - porcelain Fused to predominantly base metal
D2752 Crown - porcelain fused to noble metal
D2780 Crown - 3/4 cast high noble metal
D2781 Crown - 3/4 cast predominantly base metal
D2782 Crown - 3/4 cast noble metal
D2783 Crown - 3/4 porcelaln/ceramlc
CDT2018 (Eff. 01-01-18)
25C-7$
D2790 Crown - full cast high noble metal
D2791 Crown - full cast predominantly base metal
D2792 Crown - full cast noble metal
D2794 Crown - titanium
D2799 Provisional crown - further treatment or completion of a diagnosis necessary prior to
final Impression
Other restorative services
D2910 Re -cement or re -bond Inlay, onlay, veneer or partial coverage restorations
D2915 Re -cement or re -bond Indirectly fabricated or prefabricated post and core
D2920 Re -cement or re -band crown
D2921 Reattachment of tooth fragment, Incisal edge or cusp
D2929 Prefabricated porcelain/ceramic crown - primary tooth
02930 Prefabricated stainless steel crown - primary tooth
D2931 Prefabricated stainless steel crown - permanent tooth
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown with resin window
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth
D2940 Sedative fllling
D2941. Interim therapeutic restoration - primary dentition
D2950 Core buildup, Including any pins when required
D2951 Pin retention - per tooth, In addition to restoration
D2952 Post and core In addition to crown, Indirectly fabricated
D2953 Each additional Indirectly fabricated post - same tooth
D2954 Prefabricated post and core In addition to crown
D2955 Post removal
D2957 Each additional prefabricated post - same tooth
D2960 Labial veneer (resin laminate) - chalrslde
D2961 Labial veneer (resin laminate) - laboratory
D2962 Labial veneer (porcelain laminate) - laboratory
D2971 Additional procedures to construct new crown under existing partial denture
framework
D2975 Coping
D2980 Crown repair, necessitated by restorative material failure
D2999 Unspecified restorative procedure, by report
D300O - D3999 ENDODONTICS
Pulp capping
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration)
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the
dentinocemental junction and application of medicament
D3221 Pulpal debridement, primary and permanent teeth
D3222 Partial pulpotomy for apexogenesls-permanent tooth with incomplete root
development
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final
restoration)
D3240 Pulpal.therapy (resorbable filling) = posterior, primary tooth (excluding final
restoration)
Endodontic therapy on primary teeth (including treatment plan, clinical procedures and..
follow-up care)
D3310 Endodontic therapy, anterior tooth (excluding final restoration)
D3320 Endodontic therapy, premolar tooth (excluding final restoration)
D3330 Endodontic therapy, molar tooth (excluding final restoration)
CDT2018 (Eff. 01-01-19)
25C-79
D3331 Treatment of root canal obstruction; non-surgical access
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3333 Internal root repair of perforation defects
Endodontic retreatment
D3346 Retreatment of previous root canal therapy - anterior
D3347 Retreatment of previous root canal therapy - premolar
D3348 Retreatment of previous roof canal therapy - molar
Apexification/recalcification procedures
D3351 Apexiflcatlon/recalcification - Initial visit (aplcai closure/calcific repair of perforations,
root resorption, etc,)
D3352 Apexification/recalcification - Interim medication replacement (apical closure/calcific
repair of perforations, root resorption, pulpal space disinfection, etc,)
D3353 Apex! fication/recaIclMcation - final visit (Includes completed root canal therapy -
apical closure/calcific repair of perforations, root resorption, etc,)
Apicoectomy/periradicular services
D3410 Apicoectomy - anterior
D3421 Apicoectomy - premolar (first root)
D3425 Apicoectomy - molar (first root)
D3426 Apicoectomy (each additional root)
D3427 Perladicular surgery without apicoectomy
D3430 Retrograde filling - per root
D3450 Root amputation - per root
D3460 Endodontic endosseous Implant
D3470 Intentional reimplantation (Including necessary splinting)
Other endodontic procedures,
D3910 Surgical procedure for Isolation of tooth with rubber dam
D3920 Hemisection (including any root removal), not Including root canal therapy
D3950 Canal preparation and fitting of preformed dowel or post
D3999 Unspecified endodontic procedure, by report
D4000 - D4999 PERIODONTICS
Surgical services (including usual post-operative care)
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth
spaces per quadrant
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth
spaces per quadrant
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth
D4230 Anatomical crown exposure - four or more contiguous teeth or bounded tooth spaces
per quadrant
D4231 Anatomical crown exposure - one to three teeth or bounded tooth spaces per quadrant
D4240 Gingival flap procedure, Including root planing - four or more contiguous teeth or
bounded teeth spaces per quadrant
D4241 Gingival flap procedure, Including root planing - one to three contiguous teeth or
bounded teeth spaces per quadrant
D4245 Apically positioned flap
D4249 Clinical crown lengthening - hard tissue
D4260 Osseous surgery (Including elevation of a full thickness flap and closure) - four or
more contiguous teeth or tooth bounded spaces per quadrant
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three
contiguous teeth or tooth bounded spaces per quadrant
D4263 Bone replacement graft - retained natural tooth - flrst site In quadrant
D4264 Bone replacement graft - retained natural tooth - each additional site in quadrant
D4265 Biologic materials to aid in soft and osseous tissue regeneration
CDT2018 (Eff, 01-01-18)
D4266 Guided tissue regeneration - resorbable barrier, per site
D4267 Guided tissue regeneration - nonresorbable barrier, per site (Includes membrane
removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure
D4273 Autogenous connective tissue graft procedure (Including donor and recipient surgical
sites) first tooth, implant, or edentulous tooth position In graft
D4274 Mesial/distal wedge procedure, single tooth (when not performed In conjunction with
surgical procedures in the same anatomical area)
04275 Non -autogenous connective tissue graft (Including recipient site and donor material)
first tooth, implant, or edentulous tooth position in graft
D4276 Combined connective tissue and double pedicle graft, per tooth
D4277 Free soft tissue graft procedure (Including recipient and donor surgical sites), first
tooth, Implant, or edentulous tooth position In graft
D4278 Free soft tissue graft procedure (Including recipient and donor surgical sites), each
additional contiguous tooth, Implant, or edentulous tooth position In same graft site
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical
sites) - each additional contiguous tooth, Implant or edentulous tooth position In same
graft site
D4285 Non -autogenous connective tissue graft procedure (Including recipient surgical site
and donor material) - each additional contiguous tooth, Implant or edentulous tooth
position In same graft site.
Non-surgical periodontal service
D4320 Provisional splinting - Intracoronal
D4321 Provisional splinting - extracoronal
D4341 Periodontal scaling and root planing - four or more teeth per quadrant
D4342 Perlodontal scaling and root planing, - one to three teeth, per quadrant
D4346 Scaling In presence of generalized moderate or severe gingival inflammation
full mouth, after oral evaluation
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis on
subsequent visit
D4381 Localized delivery of antimicrobial agents via controlled release vehicle Into diseased
crevicular tissue, per tooth
Other periodontal services
D4910 Perlodontal maintenance
D4920 Unscheduled dressing change (by someone other than treating dentist or their staff)
D4999 Unspecified perlodontal procedure, by report
135000 - D5899 PROSTHODONTICS (REMOVABLE)
Complete dentures (including routine post -delivery care)
D5110 Complete denture - maxillary
05120 Complete denture - mandibular
D5130 Immediate denture - maxillary
D5140 Immediate denture - mandibular
Partial dentures (including routine post -delivery care)
D5211 Maxillary partial denture - resin base (Including any conventional clasps, rests and
teeth)
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and
teeth)
D5213 Maxillary partial denture - cast'metal framework with resin denture bases (including
any conventional clasps, rests and teeth)
D5214 Mandibular partial denture - cast metal framework with resin denture bases (Including
any conventional clasps, rests and teeth)
D5221 Immediate maxillary partial denture - resin base (Including any conventional clasps,
rests and teeth)
CDT2018 (Eff, 01-01-18)
25C-81
D5222 Immediate mandibular partial denture - resin base (including any conventional clasps,
rests and teeth)
D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases
(Including any conventional clasps, rests and teeth)
D5224 Immediate mandibular partial denture - cast metal framework with resin denture
bases (Including any convertlonal clasps, rests and teeth)
D5225 Maxillary partial denture - flexible base (Including any clasps, rests and teeth)
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth)
D5281 Removable unilateral partial denture - one place cast metal (Including clasps and
teeth)
Adjustments to dentures
D5410 Adjust complete denture - maxlllary
D5411 Adjust complete denture - mandibular
D5421 Adjust partial denture - maxillary
D5422 Adjust partial denture - mandibular
Repairs to complete dentures
D5511 Repair broken complete denture base, mandibular
D5512 Repair broken complete denture base, maxlllary
D5520 Replace missing or broken teeth - complete denture (each tooth)
Repairs to partial dentures
D5611
Repair resin partial denture base, mandibular
D5612
Repair resin partial denture base, maxillary
D5621
Repair cast partial framework, mandibular
D5622
Repair cast partial framework, maxillary
D5630
Repair or replace broken clasp - per tooth
D5640
Replace broken teeth - per tooth
D5650
Add tooth to existing partial denture
D5660
Add clasp to existing partial denture - per tooth
D5670
Replace all teeth and acrylic on cast metal framework (maxillary)
D5671
Replace all teeth and acrylic on cast metal framework (mandibular)
Denture rebase procedures
D5710
Rebase complete maxillary denture
D5711
Rebase complete mandibular denture
D5720
Rebase maxillary partial denture
D5721
Rebase mandibular partial denture
Denture reline procedures
D5730
Reline complete maxillary denture (chairside)
05731
Reline complete mandibular denture (chairside)
D5740
Reline maxillary partial denture (chairside)
D5741
Reline mandibular partial denture (chairside)
D5750
Reline complete maxlllary denture (laboratory)
D5751
Reline complete mandibular denture (laboratory)
D5760
Reline maxillary partial denture (laboratory)
D5761
Reline mandibular partial denture (laboratory)
interim prosthesis
D5810
Interim complete denture (maxillary)
D5811
Interim complete denture (mandibular)
D5820
Interim partial denture (maxillary)
D5821
Interim partial denture (mandibular)
CDT2018 (Erf. 01-01-18)
Other removable prosthetic services
D5850 Tissue conditioning - maxillary
D5851 Tissue conditioning - mandibular
05862 Precision attachment, by report
D5863 Overdenture - complete maxillary
D5864 Overdenture - partial maxillary
D5865 Overdenture - complete mandibular
D5866 Overdenture - partial mandibular
D5867 Replacement of replaceable part of semi -precision or precision attachment (male or
female component)
D587S Modification of removable prosthesis following Implant surgery
D5899 Unspecified removable prosthodontic procedure, by report
D5900 - 05999 MAXILLOFACIAL PROSTHETICS
D5911
Facial moulage (sectional)
D5912
Facial moulage (complete)
D5913
Nasal prosthesis
D5914
Auricular prosthesis
D5915
Orbital prosthesis
D5916
Ocular prosthesis
D5919
Facial prosthesis
D5922
Nasal septal prosthesis
D5923
Ocular prosthesis, Interim
D5924
Cranial prosthesis
D5925
Facial augmentation Implant prosthesis
D5926
Nasal prosthesis, replacement
D5927
Auricular prosthesis, replacement
D5928
Orbital prosthesis, replacement
D5929
Facial prosthesis, replacement
D5931
Obturator prosthesis, surgical
D5932
Obturator prosthesis, definitive
D5933
Obturator prosthesis, modification
D5934
Mandibular resection prosthesis with guide flange
D5935
Mandibular resection prosthesis without guide Flange
D5936
Obturator prosthesis, Interim
D5937
Trismus appliance (not for TMD treatment)
D5951
Feeding aid
05952
Speech aid prosthesis, pediatric
D5953
Speech aid prosthesis, adult
D5954
Palatal augmentation prosthesis
D5955
Palatal lift prosthesis, definitive
D5958
Palatal lift prosthesis, interim
D5959
Palatal lift prosthesis, modification
D5960
Speech aid prosthesis, modification
D5982
Surgical stent
D5983
Radiation carrier
D5984
Radiation shield
D3985
Radiation cone locator
D5986
Fluoride gel carrier
D5987
Commissure splint
D5988
Surgical splint
D5999
Unspecified maxillofacial prosthesis, by report
D6000 - D6199 IMPLANT SERVICES
D6010 Surgical placement of implant body: endosteal implant
D6012 Surgical placement of Interim Implant body for transitional prosthesis; endosteal
Implant
D6013 Surgical placement of mint Implant
CDT2018 (Eff. 01-01.18)
25C-83
D6040 Surgical placement: eposteal Implant
D6050 Surgical placement: transosteal Implant
Implant supported prosthetics
D6055 Dental Implant supported connecting bar
D6056 Prefabricated abutment - Includes modification and placement
D6057 Custom fabricated abutment - Includes placement
D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
06063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble
metal)
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base
metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused. to metal FPD (titanium, titanium alloy,
or high noble metal)
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble
metal)
Other Implant services
D6080 Implant maintenance procedures, Including removal of prosthesis, cleansing of
prosthesis and abutments and reinsertion of prosthesis
D6081 Scaling and debridement in the presence of Inflammation or mucositis of a single
Implant, Including cleaning of the Implant surfaces, without flap entry and closure
D6085 Provisional Implant crown
D6090 Repair implant supported prosthesis, by report
D6091 Replacement of semi-precislon or precision attachment (male or female component) of
implant/abutment supported prosthesis, per attachment
D6092 Re -cement or re -bond Implant/abutment supported crown
D6094 Abutment supported crown - (titanium)
D6095 Repair Implant abutment, by report
D6096 Remove broken Implant retaining screw
D6100 Implant removal, by report
D6101 Debridement of a perilmplant defect or defects surrounding a single Implant, and
surface cleaning of the exposed implant surraces, including flap entry and closure
D6102 Debridement and osseous contouring of a periimplant defect or defects surrounding a
single Implant, and surface cleaning includes surface cleaning of the exposed Implant
surfaces, Including flap entry and closure
D6110 Implant/abutment supported removable denture for edentulous arch- maxillary
D6111 Implant/abutment-supported removable denture for edentulous arch- mandibular
D6112 Implant/abutment supported rem ovabl e. denture for partially edentulous arch -
maxillary
D6113 Implant/abutment supported removable denture for partially edentulous arch -
mandibular
CDT201S(M 01-01-19)
•
06114 Implant/ abutment supported fixed denture for edentulous arch - maxillary
06115 Implant / abutment supported fixed denture for edentulous arch - mandibular
D6116 Implant / abutment supported fixed denture for partially edentulous arch - maxlliary
D6117 Implant / abutment supported fixed denture for partially edentulous arch - mandibular
D6118 Implant/abutment supported interim fixed denture for edentulous arch - mandibular
D6119 Implant/abutment supported Interim fixed denture for edentulous arch - maxillary
06190 Radiographic/surgical implant Index, by Report
D6093 Re -cement or re -bond Implant/abutment supported fixed partial denture
D6194 Abutment supported retainer crown for FPD - (titanium)
D6199 Unspecified Implant procedure, by report
D6200 - D6999 PROSTHODONTICS, FIXED
(Each retainer and each pontic constitutes a unit in a fixed partial denture)
Fixed partial denture pontics
D6205 Pontic - indirect resin based composite
06210 Pontic - cast high noble metal
D6211 Pontic - cast predominantly base metal
D6212 Pontic - cast noble metal
D6214 Pontic - titanium
D6240 Pontic - porcelain fused to high noble metal
D6241 Pontic - porcelain fused to predominantly base metal
D6242 Pontic - porcelain fused to noble metal
D6245 Pontic - porcelain/ceramic
D6250 Pontic - resin with high noble metal
D6251 Pontic - resin with predominantly base metal
D6252 Pontic - resin with noble metal
D6253 Provisional pontic - further treatment or completion of a diagnosis necessary prior to
Impression.
Fixed partial denture retainers - Inlays/ onlays
D6545 Retainer - cast metal for resin bonded fixed prosthesis
D6548 Retainer - porcelain/ceramlc for resin bonded fixed prosthesis
D6549 Resin retainer- for resin bonded fixed prosthesis
06600 Retainer inlay - porcelain/ceramic, two surfaces
D6601 Retainer Inlay - porcelain/ceramic, three or more surfaces
D6602 Retainer inlay - cast high metal, two surfaces
D6603 Retainer inlay - cast high metal, three or more surfaces
D6604 Retainer Inlay - cast predominantly base metal, two surfaces
D6605 Retainer Inlay -, cast predominantly base metal, three or more surfaces
D6606 Retainer inlay - cast noble metal, two surfaces
D6607 Retainer inlay - cast noble metal, three or more surfaces
D6608 Retainer onlay - porcelain/ceramic, two surfaces
D6609 Retainer onlay - porcelain/ceramic, three or more surfaces
D6610 Retainer onlay - cast high noble metal, two surfaces
D6611 Retainer onlay - cast high noble metal, three or more surfaces
D6612 Retainer onlay - cast predominantly base metal, two surfaces
D6613 Retainer onlay - cast predominantly base metal, three or more surfaces
D6614 Retainer onlay - cast noble metal, two surfaces
D6615 Retainer onlay - cast noble metal, three or more surfaces
D6624 Retainer Inlay - titanium
D6634 Retainer onlay - titanium
Fixed partial denture retainers - crowns
D6710
Retainer crown - Indirect resin based composite
D6720
Retainer crown - resin with high noble metal
D6721
Retainer crown - resin with predominantly base metal
D6722
Retainer crown - resin with noble metal
rn}
10 cDT201a (Eff, 01-01-15)
260-86
D6740 Retainer crown - porcelain/ceramic
D6750 Retainer crown - porcelain fused to high noble metal
D6751 Retainer crown - porcelain fused to predominantly base metal
D6752 Retainer crown - porcelain fused to noble metal
D6780 Retainer crown - 3/4 cast high noble metal
D6781 Retainer crown - 3/4 cast predominantly base metal
D6782 Retalner crown - 3/4 cast noble metal
D6783 Retainer crown - 3/4 porcelain/ceramic
D6790 Retalner crown - full cast high noble metal
D6791 Retalner crown - full cast predominantly base metal
D6792 Retalner crown - full cast noble metal
D6793 Provisional retainer crown - further treatment of completion or a diagnosis necessary
prior to Pnal Impression
D6794 Retainer crown - titanium
Other fixed partial denture services
D6920 Connector bar
D6930 Re -cement or re -bond fixed partial denture
D6940 Stress breaker
D6950 Precision attachment
D6980 Fixed partial denture repair necessitated by restorative material
D6985 Pediatric partial denture, Rxed
D6999 Unspecified, fixed prosthodontic procedure, by report
i
D7000 - D7999 ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing, If needed, and routine postoperative care)
D7111 Extractlon, coronal remnants - primary tooth
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical extractions (Includes local anesthesia, suturing, If needed, and routine
postoperative care)
D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and
Including elevation of mucoperiosteal Flap if indicated
D7220 Removal of Impacted tooth - soft tissue
D7230 Removal of Impacted tooth - partially bony
D7240 Removal of impacted tooth - completely bony
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications
D7250 Removal of residual tooth roots (cutting procedure)
Other surgical procedures
D7260 Oroantral flstual closure
D7261. Primary closure of a sinus perforation
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting
and/or stabilization)
D7280 Exposure of an unerupted tooth
D7282 Mobilization of erupted or malposltloned tooth to aid eruption
D7283 Placement of device to facilitate eruption of Impacted tooth
D7285 Inclslonal biopsy of oral tissue - hard (bone, tooth)
D7286 Inclslonal biopsy of oral tissue - soft
D7287 Exfoilative cytological sample collection
D7288 Brush biopsy - transeplthellal sample collection
D7290 Surgical repositioning of teeth
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report
D7292 Placement of temporary anchorage device [screw retained plate] requiring Flap;
Includes device removal
D7293 Placement of temporary anchorage device requiring flap; includes device removal
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D7294 Placement of temporary anchorage device without flap; includes device removal
D7296 Corticotomy - one to three teeth or tooth spaces, per quadrant
D7297 Corticotomy - four or more teeth or tooth spaces, per quadrant
Alveoloplasty - surgical preparation of ridge for dentures
D7310 Alveoloplasty In conjunction with extractions - four or more teeth or tooth spaces, per
quadrant
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant
D7320 Alveoloplasty not In conjunction with extractions - four or more teeth or tooth spaces,
per quadrant
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces,
perquadrant
Vestibuloplasty
D7340 Vestibuloplasty - ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - ridge extension (Including soft tissue grafts, muscle reattachment,
revision of soft tissue attachment and management of hypertrophied and hyperplastic
tissue)
Surgical excision of soft tissue lesions
D7410 Excision of benign lesion up to 1.25 cm
D7411 Excision of benign lesion greater than 1.25 cm
D7412 Excision of benign lesion, complicated
D7413 Excision of malignant lesion up to 1.25 cm
D7414 Excision of malignant lesion greater than 1.25 cm
D7415 Excision of malignant lesion complicated
D7465 Destruction of lesion(s) by physical or chemical method, by report
Surgical excision of intra-osseous lesions
07440 Excision of malignant tumor - lesion diameter up to 1.25 cm
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm
D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25
cm
Excision of bone tissue
D7471 Removal of lateral exostosis (maxilla or mandible)
D7472 Removal of torus palatinus
D7473 Removal of torus manibularis
D7485 Reduction of osseous tuberosity
07490 Radical resection of maxilla or mandible
Surgical incision
D7510 Incision and drainage of abscess - Intraoral soft tissue
D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (Includes
drainage of multiple fasclal spaces)
D7520 Incision and drainage of abscess - extraoral soft tissue
D7521 Incision and drainage of abscess - extraoral soft tissue - ccrripllcated (includes
drainage of multiple fascial spaces)
D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
D7540 Removal of reaction -producing foreign bodies, musculoskeletal system
D7550 Partial ostectomy/sequestrectomy for removal of non-vltal bone
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body
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Treatment of fractures - simple
D7610 Maxilla - open reduction (teeth Immobilized, If present)
D7620 Maxilla - closed reduction (teeth Immobilized, If present)
D7630 Mandible - open reduction (teeth Immobilized, If present)
D7640 Mandible - closed reduction (teeth Immobilized, if present)
D7650 Malar and/or zygomatic arch - open reduction
D7660 Malar and/or zygomatic arch - closed reduction
D7670 Alveolus - closed reduction, may include stabilization of teeth
D7671 Alveolus - open reduction, may include stabilization of teeth
D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches
Treatment of fractures - compound
D7710 Maxilla - open reduction
D7720 Maxilla - closed reduction
D7730 Mandible - open reduction
D7740 Mandible - closed reduction
D7750 Malar and/or zygomatic arch - open reduction
07760 Malar and/or zygomatic arch -closed reduction
D7770 Alveolus - open reduction splinting stabilization of teeth
07771 Alveolus - closed reduction stabilization of teeth
D7780 Facial bones - complicated reduction with fixation and multiple approaches
Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7810 Open reduction of dislocation
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical discectomy, with/without Implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7871 Non -arthroscopic lysis and lavage
D7872 Arthroscopy - diagnosis, with or without biopsy
D7873 Arthroscopy: lavage and lysis of adhesions
D7874 Arthroscopy: disc repositioning and stabilization
D7875 Arthroscopy: synovectomy
D7876 Arthroscopy: discectomy
D7877 Arthroscopy: debridement
D7880 Occlusal orthotic device, by report
D7881 Occlusal orthotic device adjustment
D7899 Unspecified TMD therapy, by report
Repair of traumatic wounds
D7910- Suture of recent small wounds up to 5 cm
Complicated suturing (reconstruction requiring delicate handling of tissues and wide
undermining for meticulous closure)
D7911 Complicated suture - up to 5 cm
D7912 Complicated suture - greater than 5 cm
Other repair procedures
D7920 Skin graft (Identify defect covered, location and type of graft)
D7940 Osteoplasty - for orthognathic deformities
D7941 Osteotomy - mandibular rams
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D7943 Osteotomy - mandibular rami with bone graft; Includes obtaining the graft
07944 Osteotomy - segmented or subapical
D7945 Osteotomy - body of mandible
D7946 LeFort I (maxilla - total)
D7947 LeFort I (maxilla - segmented)
07948 LeFort ii or LeFort III (osteoplasty of
facial bones for midface hypoplasla or retrusion) - without bone graft
D7949 LeFort IT or LeFort III - with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or
nonautogenous, by report
D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach
07952 Sinus augmentation via a vertical approach
07953 Bone replacement graft for ridge preservation - per site
07955 Repair of maxillofacial soft and/or hard tissue defect
D7960 Frenulectomy - also known as frenectcmy or frenotomy - separate procedure not
Incidental to another procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue - per arch
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous tuberosity
D7979 Non-surgical slakolithotonny
D7980 Surgical slalolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
D7991 Coronoldectomy
D7995 Synthetic graft - mandible or facial bones, by report
D7995 Implant - mandible for augmentation purposes (excluding alveolar ridge), by report
D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar
D7998 Intraoral placement of a fixation device not in conjunction with a fracture
D7999 Unspecified oral surgery procedure, by report
08000 - D8999 ORTHODONTICS
Limited orthodontic treatment
D8010 Limited orthodontic treatment of the primary dentition
D8020 Limited orthodontic treatment of the transitional dentition
D6030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentftlon
Interceptive orthodontic treatment
D8050 Interceptive orthodontic treatment of the primary dentition
D8050 Interceptive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive *orthodontic treatment of the adult dentition
Minor treatment to control harmful habits
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
Other orthodontic services
D8660 Pre -orthodontic treatment examination to monitor growth and development
D8670 Periodic orthodontic treatment visit
D8680 Orthodontic retention (removal of appliances, construction and placement of
retalnerls])
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D8681 Removable orthodontic retainer adjustment
D8690 Orthodontic treatment (alternative billing to a contract fee)
D8691 Repair of orthodontic appliance
D8692 Replacement of lost or broken retainer
D8693 Re -bond or re -cement fixed retainer
D8694 Repair of fixed retainers, includes reattachment
D8695 Removal of fixed orthodontic appllance(s) - other than at conclusion of treatment
D8999 Unspecified orthodontic procedure, by report
D9000 - D9999 ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
D9110 Palliative (emergency) treatment of dental pain - minor procedure
D9120 Fixed partial denture sectioning
Anesthesia
09210 Local anesthesia not in conjunction with operative or surgical procedures
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia
D9222 Deep sedation/general anesthesia - first 15 minutes
D9223 Deep sedation/general anesthesia - each subsequent 15 minute Increment
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide
D9239 Intravenous moderate (conscious) sedation/analgesla - first 15 minutes
D9243 Intravenous moderate (conscious) sedatlon/analgesla - each subsequent 15 minute
Increment
D9248 Non -Intravenous conscious sedation
Professional consultation
D9310 Consultation (diagnostic service provided by dentist or physician other than requesting
dentist or physician
Professional visits
D9410 House/extended care facility call
D9420 Hospital call
D9430 Office visit for observation (during regularly scheduled hours) - no other services
performed
D9440 Office visit - after regularly scheduled hours
D9450 Case presentation, detailed and extensive treatment planning
Drugs
09610 Therapeutic parenteral drug, single administration
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
D9630 Drugs or medicaments dispensed in the office for home use
Miscellaneous services
D9910 Application of desensitizing medicament
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post-surgical) - unusual circumstances, by report
D9932 Cleaning and Inspection of removable complete denture, maxillary
D9933 Cleaning and Inspection of removable complete denture, mandibular
D9934 Cleaning and inspection of removable partial denture, maxillary
D9935 Cleaning and inspection of removable partial denture, mandibular
D9940 Occlusal guard, by report
D9941 Fabrication of athletic mouthguard
D9942 Repair and/or reline of occlusal guard
D9943 Occlusal guard adjustment .
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D9950 Occlusion analysts - mounted case
D9951 Occlusal adjustment - iimlted
D9952 Occlusal adjustment - complete
D9970 Enamel mlcroabrasion
D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections
D9972 External bleaching - per arch - performed In office
D9973 External bleaching - per tooth
D9974 Internal bleaching - per tooth
D9995 Teledentlstry - synchronous; real-time encounter
D9996 Teledentlstry - asynchronous; Information stored and forwarded to dentist for
subsequent review
D9999 Unspecified adjunctive procedure, by report
Note; This Appendix represents codes and nomenclature excerpted from the version of Current Dental
Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the
copyright of the American Dental Association, and have been accepted as the standard for data
transmission purposes under federal Administrative SImpilflcatlon regulations. For the purposes of
this Appendix, Delta Dental's administratlon of Beneflts, Limitations and Exclusions under this
Contract will at all times be based on the then -current version of CDT whether or not a revised
Appendix B Is provided.
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