GLOSSARY
As used in this Disclosure Form/Contract.
APPLICANT means the individual contracting to obtain dental Benefits as the primary Enrollee. YOU or YOUR refers to the Applicant.
BENEFITS means those dental services which are provided under the terms of this Contract and described in this booklet.
CONTRACT means this agreement between Delta Dental and the Applicant including the Enrollment and Payment Authorization Form, the attached schedules, and any appendices, endorsements or riders. This Contract constitutes the entire agreement between the parties.
CONTRACT DENTIST means a Dentist who provides services in general dentistry and who has contracted with Delta Dental to provide Benefits to Enrollees under this Program.
CONTRACT ORTHODONTIST means a Dentist who specializes in orthodontics, and who has contracted with Delta Dental to provide Benefits to Enrollees under this Program.
CONTRACT SPECIALIST means a Dentist who provides Specialist Services and has contracted with Delta Dental to provide Benefits to Enrollees under this Program.
CONTRACT TERM means the one-year period commencing on the Effective Date and each annual renewal period during which the Contract remains in effect.
COPAYMENT means the amounts shown on Schedule A which an Enrollee pays directly to a Dentist for Benefits.
DENTIST means a duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.
DOMESTIC PARTNER means a person who has, together with the primary Enrollee, affirmed a domestic partnership through an affidavit of domestic partnership provided to Delta Dental.
EFFECTIVE DATE means the first day of the month following Delta Dental’s timely receipt of Premium and the Enrollment and Payment Authorization Form.
ELIGIBLE DEPENDENT means any dependent of a primary Enrollee who is eligible for Benefits as described in this Disclosure Form/Contract.
EMERGENCY SERVICES means only those dental services immediately required for alleviation of severe pain, swelling or bleeding or immediately required to avoid placing the Enrollee’s health in serious jeopardy.
ENROLLEE means a person enrolled to receive Benefits under this Program as the primary Enrollee or as an Eligible Dependent.
FULL-TIME STUDENT means a student who is regularly attending an accredited school with an academic schedule of at least 12 credits.
OPTIONAL means any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of this Contract.
PREAUTHORIZATION means the process by which we determine if a procedure or treatment is a referable Benefit under the Enrollee’s plan.
PREMIUM means the amount payable as provided in this Disclosure Form/Contract.
SPECIAL HEALTH CARE NEED means a physical or mental impairment, limitation or condition that substantially interferes with an Enrollee’s ability to obtain Benefits. Examples of such a Special Health Care Need are (1) the Enrollee’s inability to obtain access to the assigned Contract Dentist’s facility because of a physical disability, and (2) the Enrollee’s inability to comply with the Contract Dentist’s instructions during examination or treatment because of physical disability or mental incapacity.
SPECIALIST SERVICES means services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics, orthodontics and pediatric dentistry and which must be preauthorized in writing by Delta Dental.
USUAL FEE means the fee that an individual dentist most frequently charges for a given dental service.
WE, US or OUR means Delta Dental of California. |
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