BENEFITS mean those dental services which are provided under the terms of the Group Dental Service Contract and described in this booklet.
CLIENT means the applicant contracting to obtain Benefits.
CONTRACT DENTIST means a Dentist who provides services in general dentistry, and has agreed to provide Benefits to Enrollees under this Program.
CONTRACT ORTHODONTIST means a Dentist who specializes in orthodontics, and has agreed to provide Benefits to Enrollees under this Program.
CONTRACT SPECIALIST means a Dentist who provides Specialist Services, and has agreed to provide Benefits to Enrollees under this Program.
COPAYMENT means the amount charged to an Enrollee by a Contract Dentist 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, together with the Eligible Member, has 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 an Eligible Member who is eligible for Benefits as described in this booklet.
ELIGIBLE MEMBER means any Costco Executive member who is eligible for Benefits as described in this booklet.
EMERGENCY SERVICES means care provided by a Dentist to treat a dental condition that manifests as a symptom of sufficient severity, including severe pain, such that the absence of immediate attention could reasonably be expected by the Enrollee to result in either: (i) placing the Enrollee's dental health in serious jeopardy, or (ii) serious impairment to dental functions.
ENROLLEE means an Eligible Member ("Primary Enrollee") or an Eligible Dependent ("Dependent Enrollee") enrolled to receive Benefits.
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 this Program.
PREAUTHORIZATION means the process by which Delta Dental determines if a procedure or treatment is a referable Benefit under the Enrollee's plan.
PREMIUM means the amount payable as provided in this booklet.
REASONABLE means that an Enrollee exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact his/her Contract Dentist to obtain Emergency Services and, in the event the Dentist is not available, makes at least one attempt to contact Delta Dental for assistance before seeking care from another Dentist.
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 mean services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics or pediatric dentistry, and which must be preauthorized in writing by Delta Dental.
TREATMENT IN PROGRESS means any single dental procedure, as defined by the CDT Code, that has been started while the Enrollee was eligible to receive Benefits, and for which multiple appointments are necessary to complete the procedure whether or not the Enrollee continues to be eligible for Benefits under the DeltaCare USA plan. Examples include: teeth that have been prepared for crowns, root canals where a working length has been established, full or partial dentures for which an impression has been taken and orthodontics when bands have been placed and tooth movement has begun.
WE, US or OUR means Delta Dental of California.