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| SPECIALIST SERVICES |
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The Administrator relies on the professional judgment of the general dentist to diagnose the appropriate, efficient and prudent solution to your dental needs based on the plan Benefits. Specialist Services for oral surgery, endodontics, periodontics or pediatric dentistry, must be
- referred by the assigned Contract Dentist, and
- preauthorized by us.
You pay the specified Copayment. (See Schedule A.)
All approved Specialist Services claims will be paid by us, less any applicable Copayments. A Contract Dentist may provide services either personally, or through associated dentists, or the other technicians or hygienists who may lawfully perform the services.
We will authorize continuing care from a specialist if your Contract Dentist determines that you have a life-threatening, degenerative, chronic or disabling dental condition or dental disease that requires specialized dental care, and the Contract Specialist has expertise in treating the life-threatening degenerative, chronic or disabling disease or condition. This standing referral shall be made in accordance with a written treatment plan for a covered service developed by the Contract Dentist, the Contract Specialist and you. If we do not have a specialist with the professional training and expertise in treating the particular dental disease or condition, or such Contract Specialist cannot be reached without unreasonable delay or travel, then we will authorize treatment to be performed by a specialist outside the network.
If the assigned Contract Dentist refers you to a specialist who is not a Contract Specialist for covered dental services, we will be responsible for payment of the specialist's charges that exceed the Copayment specified in Schedule A. You will only be liable for the same fees and/or Copayments that you would pay to a Contract Specialist for the same treatment.
If the services of a Contract Orthodontist are needed, please refer to Section XI, Orthodontics, in Schedule A, and Schedule B, Orthodontic Limitations and Exclusions, to determine Benefits. |
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