Utilization management processes and criteria

Allowances for certain procedures covered under “YOUR BENEFITS” may be subject to limitation or denial based upon professional judgment decisions made by Delta Dental’s licensed dentist consultant staff. The specific clinical or professional criteria upon which allowances may be limited or denied are to be found in Delta Dental’s Evaluation Guidelines for Professional Judgment Decisions. You may obtain a copy of Delta Dental’s Evaluation Guidelines for Professional Judgment Decisions for:

• Basic benefits
• Crowns, inlays, onlays and cast restoration benefits
• Prosthodontic benefits

by sending your request in writing for the specific benefit category or dental procedure
range(s) to Delta Dental at the address below:

Delta Dental of California
Professional Services, MS-5L
100 First Street
San Francisco, CA 94105

The materials provided to you are guidelines used by this Plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.