ALTERNATE BENEFIT means that benefit allowed for the least costly, commonly accepted service or supply that could be used to treat a dental problem for which there are other, more costly treatment options that the covered person selects. (Not all benefit plans offer alternate benefits.)
BENEFITS means those services and supplies covered under the contract. Benefits for all covered services are subject to the limitations and exclusions noted in the Benefit Booklet.
COINSURANCE means the percentage of a covered amount which is payable by Delta Dental. The coinsurance for each type of covered service is shown on the benefits summary. The coinsurance will vary depending on the type of dental service.
COMPLETED means:
For root canal therapy: On the date the canals are permanently filled.
For fixed bridges (fixed partial dentures), crowns, inlays, onlays, and other laboratory prepared restorations: On the date the restoration is cemented in place.
For dentures and partial dentures (removable partial dentures): On the date that the final appliance is first inserted in the mouth.
For all other services, on the date the procedure is started.
For benefit payment purposes, the date completed will be considered as the date when a covered service is incurred.
COPAYMENT means the dollar amount of a covered service that is payable by the covered person.
COVERED AMOUNT means:
For PPO dentists, the lesser of the PPO dentist's allowable fee or the fee actually charged.
For Premier participating dentists, the lesser of the Premier Maximum Plan Allowance, or the fee actually charged.
For all other dentists, the lesser of the non-participating Maximum Plan Allowance, or the fee actually charged.
DEDUCTIBLE means the portion of the covered amount for certain covered services which must be paid in full for each covered person before any benefits are payable. The amount of the deductible is shown on the summary of dental plan benefits. If there is a maximum amount that a family must pay in deductibles.
DENTAL INJURY is an injury to a sound natural tooth (other than a chewing injury) sustained while covered under the contract, which is caused solely by a sudden violent act, or accident that could not be predicted in advance or avoided. A chewing injury is any injury that occurs during the act of biting or chewing regardless of whether the injury is caused by biting food or a foreign object.
DENTIST means an individual licensed to practice dentistry at the time and in the place services are provided.
EMERGENCY TREATMENT or EMERGENCY SERVICE means any necessary service that is rendered as the direct result of an unforeseen occurrence or combination of circumstances that requires immediate, urgent action or remedy.
EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES means those services or supplies that are not generally accepted in the dental community as being safe and effective, as defined by Delta Dental.
FUNCTIONING NATURAL TOOTH: A permanent (adult) natural tooth which is performing its normal role in the mastication (i.e. chewing) process in the covered person's upper or lower arch and which is opposed in the covered person's other arch by another natural tooth or prosthodontic (i.e. artificial) replacement. Third molars are not considered functioning natural teeth.
MAXIMUM PLAN ALLOWANCE means the maximum allowable amount as determined by Delta Dental for a procedure.
NATURAL TOOTH means any tooth or part of a tooth that is organic and formed by the natural development of the body (i.e., not manufactured). Organic portions of a tooth include the crown enamel and dentin, the root cementum and dentin, and the enclosed pulp (nerve).
NECESSARY means a service that is required by, and appropriate for treatment of, the covered person's dental condition according to generally accepted standards of dental care as determined by Delta Dental. SOUND NATURAL TOOTH means a natural tooth that is fully restored to function, does not have any decay, is not more susceptible to injury than a virgin tooth, and is without periodontal disease.
STARTED means:
For full dentures or partial dentures (removable partial dentures): The date the final impression is taken.
For fixed bridges (fixed partial dentures), crowns, inlays, onlays and other laboratory prepared restorations: The date the teeth are first prepared (i.e., drilled down) to receive the restoration.
For root canal therapy: The date the pulp chamber is first opened.
For periodontal surgery: The date the surgery is actually performed.
For all other services: The date the service is performed.
WAITING PERIOD means a period of time starting on a covered person's effective date (the date that person's coverage under the contract began) before benefits for certain services become payable. If a covered service is completed before the waiting period for the service ends, that service is not covered under the contract. If a person's coverage under the contract ended and then the person later becomes covered again, that person's effective date is the most recent effective date unless stated otherwise in the contract. If waiting periods are applicable to coverage, they are noted on the Summary of Dental Plan Benefits.