As used in this Contract:
ADMINISTRATOR means Delta Dental Insurance Company ("Delta Dental"), licensed as a Third Party Administrator in the State of Texas. Administrative functions described in the Contract and in this booklet may be performed by Delta Dental, and designated by ALPHA. The mailing address for Delta Dental is 12898 Towne Center Drive, Cerritos, California 90703-8579. Delta Dental 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 and described in this booklet.
CONTRACT means this agreement between ALPHA 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 to Enrollees under this Program.
CONTRACT ORTHODONTIST means a Dentist who specializes in orthodontics, and who has agreed to provide Benefits to Enrollees under this Program.
CONTRACT SPECIALTY CARE DENTIST means a Dentist who provides Specialized Services and has agreed to provide Benefits to Enrollees 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 amounts charged to an Enrollee by a Contract Dentist, Contract Orthodontist or Contract Specialty Care 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 has, together with the primary Enrollee, affirmed a domestic partnership through an affidavit of domestic partnership provided to ALPHA.
EFFECTIVE DATE means the first day of the month following ALPHA'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 booklet.
EMERGENCY DENTAL SERVICES means procedures administered in a Dentist's facility, emergency dental clinic, or other comparable facility, to evaluate and stabilize dental conditions of a recent onset and severity accompanied by excessive bleeding, severe pain, or acute infection that would lead a prudent layperson possessing an average knowledge of dentistry to believe that immediate care is needed.
ENROLLEE means a person enrolled to receive Benefits including the primary Enrollee and Eligible Dependent(s).
PREAUTHORIZATION means the process by which ALPHA determines if a procedure or treatment is a referable Benefit under the Enrollee's plan.
PREMIUM means the amount payable as provided in this Contract. Refer to How much do I pay?
SERVICE AREA means the State of Texas except for the following counties:
Armstrong, Bailey, Bowie, Brewster, Briscoe, Brown, Carson, Castro, Cochran, Coke, Coleman, Collingsworth, Concho, Crosby, Culberson, Dallam, Deaf Smith, Donely, Edwards, Floyd, Garza, Gray, Hale, Hall, Hansford, Hartley, Hemphill, Hockley, Hutchison, Jasper, Jeff Davis, Kinney, Lamb, Lipscomb, Loving, Lubbock, McCullough, Menard, Moore, Motley, Newton, Ochiltree, Oldham, Parmer, Pecos, Potter, Presidio, Randall, Reeves, Roberts, Runnels, Sabine, San Augustine, Schleicher, Shelby, Sherman, Sutton, Swisher, Terrell, Tom Green, Val Verde, Wheeler, and Willacy.
SPECIALIZED SERVICES means 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 ALPHA or its Administrator, Delta Dental, as appropriate. |
