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ADMINISTRATOR means Delta Dental Insurance Company ("Delta Dental") or other entity designated by Delta Dental of Pennsylvania, operating as an Administrator in the Commonwealth of Pennsylvania. Administrative functions described throughout this Contract and in this booklet may be performed by the Administrator, as designated by Delta Dental of Pennsylvania. The mailing address for Administrator is 12898 Towne Center Drive, Cerritos, California 90703. The Administrator will answer calls directed to (800) 422-4234.
APPLICANT means the individual contracting to obtain dental Benefits as the primary Enrollee. YOU or YOUR refers to the Applicant.
BENEFITS mean those dental services that are provided under the terms of this Contract as described.
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 agreed to provide Benefits under this Program.
CONTRACT ORTHODONTIST means a Dentist who specializes in orthodontics, and who has agreed to provide Benefits under this Program.
CONTRACT SPECIALIST means a Dentist who provides Specialist Services and who has agreed to provide Benefits under this Program.
CONTRACT TERM means the one-year period starting on the Effective Date and each annual renewal period during which the Contract remains in effect.
COPAYMENT means the amount charged to an Enrollee by a Contract Dentist or Contract Specialist for the Benefits provided under this Program.
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 the Administrator.
EFFECTIVE DATE means the first day of the month following our 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 Contract.
EMERGENCY SERVICES mean only those dental services immediately required to alleviate severe pain, swelling or bleeding or immediately required to avoid placing the Enrollee's health in serious danger.
ENROLLEE means a person enrolled to receive Benefits, including the primary Enrollee and Eligible Dependent(s).
FULL-TIME STUDENT means a student who is regularly attending an accredited school with an academic schedule of at least 12 credits.
OUT-OF-NETWORK means treatment by a Dentist who has not signed an agreement with Delta Dental to provide Benefits under the terms 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.
POLICY means the Contract as issued to the Applicant.
PREMIUM means the amount payable as provided in this Contract.
SPECIALIST SERVICES mean services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics, orthodontics or pediatric dentistry.
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 Pennsylvania or the Administrator, as appropriate. |
