|
|
 |
|
| SPECIALIST SERVICES |
|
| |
Treatment for covered procedures which requires a Dentist to provide Specialist Services for oral surgery, endodontics, periodontics or pediatric dentistry, must be
- referred by the assigned Contract Dentist, and
- preauthorized in writing by us.
You pay the specified Copayment. (Refer to Schedule A.)
IF YOU REQUIRE SPECIALIST SERVICES AND THERE IS
NO CONTRACT DENTIST TO PROVIDE THESE SERVICES
WITHIN 35 MILES OF YOUR HOME ADDRESS, YOUR ASSIGNED CONTRACT DENTIST MUST RECEIVE WRITTEN PRE-AUTHORIZATION FROM DELTA DENTAL TO REFER YOU TO AN OUT-OF-NETWORK DENTIST TO PROVIDE THE SPECIALIST SERVICES. SPECIALIST SERVICES PERFORMED BY AN OUT-OF-NETWORK DENTIST THAT ARE NOT PREAUTHORIZED BY DELTA DENTAL MAY NOT BE COVERED.
If the services of a Contract Orthodontist are needed, please refer to Section XI, Orthodontics, in Schedule A, Description of Benefits and Copayments and Schedule B, Orthodontic Limitations and Exclusions, to determine coverage under this Program.
If you are referred to a dental school clinic for Specialist Services, those services may be provided by a Dentist, a dental student, a clinician or a dental instructor. Services provided by a health care professional not listed within this section are not covered. |
| |
| |
|
HIPAA Notice of Privacy Practices | Web Site Privacy Notice
© 2008 Delta Dental |
|
