Combined Evidence of Coverage and Disclosure Form
www.deltadentalins.com
Group Dental Plan for
Retired Members of
COUNTY OF SACRAMENTO
Group Number: 4063
Effective Date: January 1, 2009
I.D. CARD PAGE
(include the following)
IDENTIFICATION
During your first visit with the Dentist, it is very important to advise your Dentist of the following
information:
Delta Dental Group Number: 4063
Name of Group: County of Sacramento
Retiree’s ID Number:
SPOUSES/DOMESTIC PARTNERS and DEPENDENT CHILDREN MUST also use the RETIREE’S ID Number.
1
USING THIS BOOKLET
This booklet has been written with you in mind. It is designed to help you make the most of your Delta
Dental plan. This combined Evidence of Coverage/Disclosure form discloses the terms and conditions of
your coverage.
The Combined Evidence of Coverage/Disclosure form should be read completely and carefully and
individuals with special health care needs should read carefully those sections that apply to them (see
CHOICE OF DENTISTS AND PROVIDERS section). You have a right to review it prior to your enrollment.
Please read the “DEFINITIONS” section. It will explain to you any words that have special or technical
meanings under your group Contract. A copy of the Contract will be furnished upon request.
Please read this summary of your dental Benefits carefully. Keep in mind that YOU means the ENROLLEES
whom Delta Dental covers. WE, US and OUR always refers to Delta Dental of California (Delta Dental).
Retirees check in with the Employee Benefits Office and with Delta Dental when you have dental questions
about dental coverage that are not answered in the Evidence of Coverage/Certificate booklet.
DELTA DENTAL OF CALIFORNIA
100 First Street
San Francisco, CA 94105
For claims, eligibility and benefits inquiries, or additional information, call Delta Dental’s Customer Service
department toll-free at: 800-765-6003 or contact us on our web site: www.deltadentalins.com.
A STATEMENT DESCRIBING OUR POLICIES AND PROCEDURES FOR PRESERVING THE
CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO
YOU UPON REQUEST.
This Combined Evidence of Coverage/Disclosure Form constitutes only a
summary of the dental plan. The dental Contract must be consulted to
determine the exact terms and conditions of coverage.
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TABLE OF CONTENTS
DEFINITIONS .............................................................................................................................. 3
WHO IS COVERED?...................................................................................................................... 4
WHO ARE YOUR ELIGIBLE DEPENDENTS?........................................................................................ 4
ENROLLING YOUR SPOUSE/DOMESTIC PARTNER.............................................................................. 5
ENROLLING YOUR DEPENDENT CHILDREN....................................................................................... 5
COVERAGE COSTS....................................................................................................................... 5
WHEN YOU ARE NO LONGER COVERED........................................................................................... 5
CANCELING THIS PLAN................................................................................................................. 5
YOUR BENEFITS .......................................................................................................................... 6
TABLE OF ALLOWANCES PROVIDED BY YOUR DENTAL PLAN .............................................................. 7
LIMITATIONS .............................................................................................................................. 8
EXCLUSIONS/SERVICES WE DO NOT COVER ................................................................................... 9
DEDUCTIBLES........................................................................................................................... 10
COVERED FEES ......................................................................................................................... 10
CHOICE OF DENTISTS AND PROVIDERS........................................................................................ 11
CONTINUITY OF CARE ................................................................................................................ 11
PUBLIC POLICY PARTICIPATION BY ENROLLEES ............................................................................. 12
SAVING MONEY ON YOUR DENTAL BILLS ...................................................................................... 12
YOUR FIRST APPOINTMENT......................................................................................................... 12
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE ............................................ 13
PREDETERMINATIONS ................................................................................................................ 13
REIMBURSEMENT PROVISIONS.................................................................................................... 13
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST................................... 14
SECOND OPINIONS.................................................................................................................... 14
ORGAN AND TISSUE DONATION .................................................................................................. 15
GRIEVANCE PROCEDURE AND CLAIMS APPEAL............................................................................... 15
IF YOU HAVE ADDITIONAL COVERAGE.......................................................................................... 16
PLAN ADMINISTRATOR............................................................................................................... 17
FUNDING POLICY AND PAYMENT OF PREMIUMS ............................................................................. 17
OPTIONAL CONTINUATION OF COVERAGE (COBRA)........................................................................ 17
NOTICE OF PRIVACY PRACTICES: CONFIDENTIALITY OF YOUR HEALTHCARE INFORMATION ................ 20
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DEFINITIONS
Certain words that you will see in this booklet have specific meanings. These definitions should make your
dental plan easier to understand.
Allowance – the maximum amount paid for a covered Single Procedure. Any difference between the
Allowance and the dentist’s fee is the responsibility of the Enrollee.
Benefits - those Covered Services listed on the Table of Allowances.
Contract - the written agreement between the County of Sacramento and Delta Dental to provide dental
Benefits. The Contract, together with this booklet, forms the terms and conditions of the Benefits you are
provided.
Covered Services - those dental services to which Delta Dental will apply Benefit payments, according to
the Contract.
Deductible - the amount you must pay for dental care each year before Delta Dental’s Benefits begin.
Delta Dental Dentist - a Dentist who has signed an agreement with Delta Dental or a Participating Plan,
agreeing to provide services under the terms and conditions established by Delta Dental or the
Participating Plan.
Dependent – the spouse or domestic partner or dependent child of a retiree who is eligible to enroll for
Benefits in accordance with the conditions of eligibility outlined in this booklet.
Domestic Partner – a domestic partner and a spouse have the same meaning as defined in Section 297
of the California Family Code.
Effective Date - the date this plan starts.
Enrollee - a Primary Enrollee or Dependent enrolled to receive Benefits or a person who chooses to pay
for OPTIONAL CONTINUATION OF COVERAGE.
Maximum - the greatest dollar amount Delta Dental will pay for covered procedures in a calendar year.
Participating Plan - Delta Dental and any other member of the Delta Dental Plans Association with
whom Delta Dental contracts for assistance in administering your Benefits.
Premiums - the money paid to Delta Dental each month for you and your Dependents’ dental coverage.
Primary Enrollee - any group member or retiree who is eligible to enroll for Benefits in accordance with
the conditions of eligibility outlined in this booklet.
Retirement System – the group for whose retirees dental Benefits are being provided.
Single Procedure – a dental procedure to which a separate Procedure Number has been assigned by the
American Dental Association in the current version of Common Dental Terminology (CDT).
Spouse – the spouse of a retiree who is eligible to enroll for Benefits in accordance with the conditions of
eligibility outlined in this booklet.
Surviving Spouse/Domestic Partner – the spouse or domestic partner of an active employee who dies
or a retiree who dies; who is receiving a continuing monthly retirement allowance; and who is eligible to
enroll for Benefits in accordance with the conditions of eligibility outlined in this booklet.
4
Usual, Customary and Reasonable (UCR) -
A Usual fee is the amount which an individual dentist regularly charges and receives for a given service or
the fee actually charged, whichever is less.
A Customary fee is within the range of usual fees charged and received for a particular service by dentists
of similar training in the same geographic area.
A Reasonable fee schedule is reasonable if it is Usual and Customary. Additionally, a specific fee to a
specific Enrollee is reasonable if it is justifiable considering special circumstances, or extraordinary
difficulty, of the case in question.
WHO IS COVERED?
Retirees and their Dependents will become Enrollees on the first day of the month following retirement
and enrollment. A surviving spouse or surviving domestic partner of a deceased active employee or retiree
is also an Enrollee under this plan.
If both you and your spouse or domestic partner qualify for coverage as Primary Enrollee, neither of you
may enroll as a Dependent of the other. Your children can enroll for coverage as the dependent children of
only one of you.
COBRA Enrollees are eligible for coverage under this plan.
Once enrolled in this plan, you must remain enrolled for 12 months.
WHO ARE YOUR ELIGIBLE DEPENDENTS?
• Your legal spouse or registered domestic partner; or your surviving spouse or surviving domestic
partner.
Domestic partners are defined as same sex partners who are both at least 18 years of age; and
opposite sex partners when at least one partner is over the age of 62.
• Your unmarried dependent children until their 19th birthday;
• Your unmarried dependent children until their 24th birthday if enrolled full-time in an accredited
school, college or university;
• An unmarried dependent child aged 19 or older who is incapable of self-support because of a
physical or mental handicap that occurred before he or she turned 19, if the child is mostly
dependent on you for support. Proof of this handicap must be given to Delta Dental or your
employer within 31 days, if it is requested. Proof will not be required more than once a year after
the child has reached age 21.
“Dependent children” also means stepchildren, children of a domestic partner, adopted children, children
placed for adoption and foster children, provided that they are dependent upon you for support and
maintenance.
Dependent coverage is also extended to any child who is recognized under a Qualified Medical Child
Support Order (QMCSO).
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ENROLLING YOUR SPOUSE/DOMESTIC PARTNER
Your spouse or domestic partner must be enrolled when you enroll.
If you marry or register a domestic partner after retirement, your new spouse or domestic partner must
enroll within 30 days of the date of the marriage or domestic partnership registration.
Once enrolled in this plan, you must remain enrolled for 12 months.
ENROLLING YOUR DEPENDENT CHILDREN
Your Dependents must be enrolled when you first become eligible or on the first day of the month after
they become Dependents. However, Dependents who are covered under another group dental plan are not
required to enroll under this Delta Dental plan. If the other coverage ends, the Dependents may enroll
under this plan within 30 days of the loss of the other coverage. Proof of prior coverage is required.
Dependent children up to four years of age may be enrolled at the beginning of any Contract year
including the Contract year immediately following their fourth birthday.
Once enrolled in this plan, you must remain enrolled for 12 months.
COVERAGE COSTS
County of Sacramento pays Delta Dental a monthly Premium for coverage of you and your enrolled
Dependents. You do not pay for your own coverage, but you are responsible for the cost of coverage for
your enrolled Dependents. The County of Sacramento can tell you how much you must contribute for the
cost of Dependent coverage.
The amount of the Premium may change at each renewal of the Contract between the County of
Sacramento and Delta Dental. Premiums will not increase during the contract year unless new taxes or tax
rates are imposed upon Delta Dental for this plan or unless there is an agreement between the County of
Sacramento and Delta Dental to change the Premium rate.
WHEN YOU ARE NO LONGER COVERED
1. Your dental coverage will end under this Contract as specified by the Sacramento County
Retirement Board.
2. When the Contract between Delta Dental and the County of Sacramento is discontinued or
canceled, your coverage end immediately.
CANCELING THIS PLAN
Delta Dental may cancel this plan only on an anniversary date (period after the plan first takes effect or at
the end of each renewal period thereafter), or any time if payments required by the Contract are not
made to Delta Dental.
If you believe that this plan has been terminated or not renewed due to your health status or
requirements for health care services (or that of your Dependents), you may request a review by the
California Director of the Department of Managed Health Care.
If the Contract is terminated for any cause, Delta Dental is not required to predetermine services beyond
the termination date or to pay for services provided after the termination date, except for Single
Procedures begun while the Contract was in effect which are otherwise Benefits under the Contract.
6
If this plan is canceled, you and your Dependents have no right to renewal or reinstatement of your
Benefits.
YOUR BENEFITS
Your dental plan covers several categories of Benefits, when the services are provided by a licensed
dentist, and when they are necessary and customary under the generally accepted standards of dental
practice.
After you have satisfied any Deductible requirements, Delta Dental will provide payment for these services
up to the Maximum Allowance indicated on the Table of Allowances, up to a Maximum of $1,500 for each
Enrollee in each calendar year.
Payment for Dental Accident Benefits are limited to a separate $1,000 Maximum per calendar year.
An agreement between the County of Sacramento and Delta Dental is required to change Benefits during
the term of the Contract.
Note: By Report (B/R) procedures are paid up to 80% of the amount for each Single Procedure shown on
the Table of Allowances.
I. DIAGNOSTIC AND PREVENTIVE BENEFITS – up to 100% of the amount for each Single
Procedure shown on the Table of Allowances
Diagnostic - oral examinations; x-rays; diagnostic casts; examination of biopsied tissue; palliative
(emergency) treatment of dental pain; specialist consultation
Preventive - prophylaxis (cleaning); fluoride treatment; space maintainers
Note on additional Benefits during pregnancy. If you are pregnant, Delta Dental will pay for
additional services to help improve your oral health during pregnancy. The additional services each
calendar year while you are eligible in this Delta Dental plan include: one additional oral
examination and either one additional routine cleaning or one additional periodontal scaling and
root planing per quadrant. Written confirmation of your pregnancy must be provided by you or
your dentist when the claim is submitted.
II. BASIC BENEFITS - up to 100% of the amount for each Single Procedure shown on the Table of
Allowances
Oral surgery - extractions and certain other surgical procedures, including pre- and post-operative
care
Restorative - amalgam, silicate or composite (resin) restorations (fillings) for treatment of carious
lesions (visible destruction of hard tooth structure resulting from the process of dental decay)
Endodontic - treatment of the tooth pulp
Periodontic - treatment of gums and bones that support the teeth
Sealants - topically applied acrylic, plastic or composite material used to seal developmental
grooves and pits in teeth for the purpose of preventing dental decay
Adjunctive General Services - general anesthesia; office visit for observation; office visit after
regularly scheduled hours; therapeutic drug injection; treatment of post-surgical complications
(unusual circumstances); limited occlusal adjustment
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III. CROWNS, INLAYS, ONLAYS AND CAST RESTORATION BENEFITS - up to 100% of the amount
for each Single Procedure shown on the Table of Allowances
Crowns, Inlays, Onlays and Cast Restorations are Benefits only if they are provided to treat cavities
which cannot be restored with amalgam, silicate or direct composite (resin) restorations.
IV. PROSTHODONTIC BENEFITS - up to 100% of the amount for each Single Procedure shown on
the Table of Allowances
Construction or repair of fixed bridges, partial dentures and complete dentures are Benefits if
provided to replace missing, natural teeth.
TABLE OF ALLOWANCES PROVIDED BY YOUR DENTAL PLAN
This is not a fee schedule. Delta Dental shall pay or otherwise discharge the lesser of the dentist’s Usual,
Customary, and Reasonable fees or the fees actually charged, up to the amount for each Single Procedure
shown on the Table of Allowances.
By Report (B/R) procedures are paid at 80%. Delta Dental shall determine the Allowances based on the
nature and extent of the services performed. A dental procedure of an equivalent gravity and severity
listed in the Table of Allowances shall be used as the basis for Delta Dental’s determination.
Code Procedure Allowance
D0100-D0999 DIAGNOSTIC
Clinical oral evaluations
D0120 Periodic oral evaluation ............................................................................................................... 18.00
D0140 Limited oral evaluation – problem focused ................................................................................. 18.00
D0150 Comprehensive oral evaluation – new or established patient .................................................... 18.00
D0160 Detailed and extensive oral evaluation, problem focused .......................................................... 18.00
D0170 Reevaluation limited problem focused (established patient; not post operative visit) ................ 18.00
D0180 Comprehensive periodontal evaluation – new or established patient ........................................ 18.00
Radiographs/diagnostic imaging (including interpretation)
D0210 Intraoral – complete series including bitewings .......................................................................... 47.00
D0220 Intraoral periapical – first film ...................................................................................................... 13.00
D0230 Intraoral periapical – each additional film ................................................................................... 5.00
D0240 Intraoral – occlusal film ............................................................................................................... 16.00
D0250 Extraoral – first film ..................................................................................................................... 28.00
D0260 Extraoral – each additional film ................................................................................................... 12.00
D0270 Bitewing – single film .................................................................................................................. 13.00
D0272 Bitewings – two films ................................................................................................................... 21.00
D0274 Bitewings – four films .................................................................................................................. 25.00
D0277 Vertical bitewings – 7 to 8 films .................................................................................................. 47.00
D0290 Posterior – anterior or lateral skull and facial bone survey film .................................................. 28.00
D0330 Panoramic film ............................................................................................................................ 43.00
D0340 Cephalometric film ...................................................................................................................... 29.00
Tests and examinations
D0470 Diagnostic casts .......................................................................................................................... 51.00
Oral pathology laboratory
D0472 Accession of tissue, gross exam, preparation and transmission of written report ...................... 76.00
D0473 Accession of tissue, gross & microscopic exam, preparation and transmission of written report 76.00
D0474 Accession of tissue, gross & micro exam, assessment of surgical margins for presence of
disease, preparation and transmission of written report .............................................................
76.00
D0502 Other oral pathology procedures ................................................................................................ 76.00
D1000-D1999 PREVENTIVE
Dental prophylaxis
D1110 Prophylaxis – adult ...................................................................................................................... 37.00
D1120 Prophylaxis – child through age 13…………………………………………………………………… 28.00
Topical fluoride treatment
D1203 Topical application of fluoride (prophylaxis not included) – child through age 13……………….. 12.00
D1204 Topical application of fluoride (prophylaxis not included) – adult…………………………………. 17.00
D1205 Topical application of fluoride (including prophylaxis) – adult .................................................... 41.00
1
Code Procedure Allowance
Space maintenance (passive appliances) (including all adjustments within six months following installation).
D1510 Space maintainer – fixed – unilateral .......................................................................................... 176.00
D1515 Space maintainer – fixed – bilateral ............................................................................................ 228.00
D1520 Space maintainer – removable – unilateral ................................................................................ 248.00
D1525 Space maintainer – removable – bilateral .................................................................................. 248.00
D2000-D2999 RESTORATIVE
Amalgam restorations (including polishing)
D2140 Amalgam – one surface, primary or permanent ......................................................................... 39.00
D2150 Amalgam – two surfaces, primary or permanent ........................................................................ 50.00
D2160 Amalgam – three surfaces, primary or permanent ..................................................................... 61.00
D2161 Amalgam – four or more surfaces, primary or permanent .......................................................... 70.00
Resin – based composite restorations – direct
D2330 Resin-based composite – one surface, anterior ......................................................................... 52.00
D2331 Resin-based composite – two surfaces, anterior ........................................................................ 52.00
D2332 Resin-based composite – three surfaces, anterior ..................................................................... 52.00
D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior) ................ 80.00
D2390 Resin-based composite crown, anterior ..................................................................................... 132.00
D2391 Resin-based composite – one surface, posterior ....................................................................... 80.00
D2392 Resin-based composite – two surfaces, posterior ...................................................................... 112.00
D2393 Resin-based composite – three surfaces, posterior ................................................................... 140.00
D2394 Resin-based composite – four or more surfaces, posterior ........................................................ 140.00
D2410 Gold foil – one surface................................................................................................................. 183.00
D2420 Gold foil – two surfaces................................................................................................................ 280.00
D2430 Gold foil – three or more surfaces ............................................................................................... 320.00
Inlay/onlay restorations
D2510 Inlay – metallic – one surface ..................................................................................................... 183.00
D2520 Inlay – metallic – two surfaces .................................................................................................... 280.00
D2530 Inlay – metallic – three or more surfaces .................................................................................... 320.00
D2542 Onlay – metallic – two surfaces .................................................................................................. 403.00
D2543 Onlay – metallic – three surfaces ............................................................................................... 403.00
D2544 Onlay – metallic – four or more surfaces .................................................................................... 403.00
Crowns – single restoration only
D2710 Crown - resin-based composite (indirect) ................................................................................... 239.00
D2712 Crown - 3/4 resin-based composite (indirect) ............................................................................. 239.00
D2720 Crown – resin with high noble metal ........................................................................................... 394.00
D2721 Crown – resin with predominantly base metal ............................................................................ 436.00
D2722 Crown – resin with noble metal ................................................................................................... 456.00
D2740 Crown – porcelain/ceramic substrate ......................................................................................... 394.00
D2750 Crown – porcelain fused to high noble metal .............................................................................. 394.00
D2751 Crown – porcelain fused to predominantly base metal ............................................................... 436.00
D2752 Crown – porcelain fused to noble metal ..................................................................................... 456.00
D2780 Crown – ¾ cast high noble metal ............................................................................................... 400.00
D2781 Crown – ¾ cast predominantly base metal ................................................................................. 400.00
D2782 Crown – ¾ cast noble metal ....................................................................................................... 400.00
D2783 Crown – ¾ porcelain/ceramic ...................................................................................................... 400.00
D2790 Crown – full cast high noble metal .............................................................................................. 394.00
D2791 Crown – full cast predominantly base metal ............................................................................... 420.00
D2792 Crown – full cast noble metal ...................................................................................................... 441.60
D2794 Crown – titanium ......................................................................................................................... 394.00
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Code Procedure Allowance
Other restorative services
D2910 Recement inlay, onlay, or partial coverage restoration .............................................................. 39.00
D2915 Recement cast or prefabricated post and core ........................................................................... 39.00
D2920 Recement crown ......................................................................................................................... 39.00
D2930 Prefabricated stainless steel crown – primary tooth ................................................................... 75.00
D2931 Prefabricated stainless steel crown – permanent tooth .............................................................. 82.00
D2932 Prefabricated resin crown ........................................................................................................... 82.00
D2933 Prefabricated stainless steel crown with resin window ............................................................... 134.00
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth ........................................... 134.00
D2950 Core buildup, including any pins ................................................................................................. 75.00
D2951 Pin Retention – per tooth, in addition to restoration ................................................................... 36.00
D2952 Cast post and core in addition to crown ...................................................................................... 122.00
D2954 Prefabricated post and core in addition to crown ....................................................................... 93.00
D2957 Each additional prefabricated post – same tooth......................................................................... 93.00
D2960 Labial veneer (resin laminate) – chairside .................................................................................. 106.00
D2961 Labial veneer (resin laminate) – laboratory ................................................................................ 259.00
D2962 Labial veneer (porcelain laminate) – laboratory .......................................................................... 260.00
D2980 Crown repair, by report ............................................................................................................... BR
D3000-D3999 ENDODONTICS
Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the
dentinocemental junction and application of medicament ..........................................................
47.00
D3221 Pulpal debridement, primary and permanent teeth ..................................................................... 64.00
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) ........... 47.00
D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) ......... 47.00
Procedures D3310 through D3450 include all test x-rays taken as part of the complete root canal
procedure.
Endodontic therapy (including treatment plan, clinical procedures, and follow-up care).
D3310 Anterior (excluding final restoration) ........................................................................................... 228.00
D3320 Bicuspid (excluding final restoration) .......................................................................................... 289.00
D3330 Molar (excluding final restoration) ............................................................................................... 355.00
D3333 Internal root repair of perforation defects..................................................................................... 120.00
D3346 Retreatment of previous root canal therapy – anterior ............................................................... 228.00
D3347 Retreatment of previous root canal therapy – bicuspid .............................................................. 289.00
D3348 Retreatment of previous root canal therapy – molar .................................................................. 355.00
D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root
resorption, etc.) ...........................................................................................................................
120.00
D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of
perforations, root resorption, etc.) ...............................................................................................
120.00
D3353 Apexification/recalcification – final visit (includes completed root canal therapy – apical
closure/calcific repair of perforations, root resorption, etc.) ........................................................
120.00
Apicoectomy/periradicular services
D3410 Apicoectomy/periradicular surgery – anterior ............................................................................. 289.00
D3421 Apicoectomy/periradicular surgery – bicuspid (first root) ............................................................ 289.00
D3425 Apicoectomy/periradicular surgery – molar (first root) ................................................................ 289.00
D3430 Retrograde filling – per root ........................................................................................................ 80.00
D3450 Root amputation – per root ......................................................................................................... 236.80
Other endodontic services
D3920 Hemisection (including any root removal), not including root canal therapy .............................. 236.80
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Code Procedure Allowance
D4000-D4999 PERIODONTICS
Surgical services (including usual postoperative services).
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces per
quadrant ......................................................................................................................................
266.00
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per
quadrant ......................................................................................................................................
160.00
D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or bounded
teeth spaces per quadrant ..........................................................................................................
106.50
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth
spaces per quadrant ...................................................................................................................
64.00
D4245 Apically positioned flap ............................................................................................................... 106.50
D4260 Osseous surgery (including flap entry and closure) – four or more contiguous teeth or bounded
teeth spaces per quadrant ..........................................................................................................
389.00
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded
teeth spaces per quadrant ..........................................................................................................
233.00
D4263 Bone replacement graft – first site in quadrant ........................................................................... 195.00
D4264 Bone replacement graft – each additional site in quadrant ........................................................ 195.00
D4266 Guided tissue regeneration – resorbable barrier, per site .......................................................... 97.30
D4267 Guided tissue regeneration – non-resorbable barrier, per site (includes membrane removal) .. 97.30
D4268 Surgical revision procedure, per tooth......................................................................................... 97.30
D4270 Pedicle soft tissue graft procedure ............................................................................................. 30.50
D4271 Free soft tissue graft procedure (including donor site surgery) .................................................. 266.00
D4273 Subepithelial connective tissue graft procedures, per tooth........................................................ 298.00
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical
procedures in the same anatomical area) ..................................................................................
61.00
Non-surgical periodontal service
D4341 Periodontal scaling and root planing - four or more teeth per quadrant ..................................... 71.00
D4342 Periodontal scaling and root planing – one to three teeth, per quadrant .................................... 43.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis ............................ 37.00
Other periodontal services
D4910 Periodontal maintenance (following active therapy) .....................................................................
50.00
D5000-D5999 PROSTHODONTICS, REMOVABLE
Procedures relating to dentures, partial dentures and relines include adjustments for a six month period
following installation. Such procedures do not include specialized techniques involving precision dentures,
personalization or characterizations.
Complete dentures (including routine post-delivery care).
D5110 Complete denture – maxillary ..................................................................................................... 519.00
D5120 Complete denture – mandibular ................................................................................................. 519.00
D5130 Immediate denture – maxillary .................................................................................................... 519.00
D5140 Immediate denture – mandibular ................................................................................................ 519.00
Partial dentures (including routine post-delivery care)
D5211 Maxillary partial denture – resin base (including conventional clasps, rests and teeth) ............. 599.00
D5212 Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) .. 599.00
D5213 Maxillary partial denture – cast metal framework with resin denture bases (including
conventional clasps, rests and teeth) .........................................................................................
600.50
D5214 Mandibular partial denture – cast metal framework with resin denture bases (including
conventional clasps, rests and teeth) .........................................................................................
600.50
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 451.00
D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 451.00
D5281 Removable unilateral partial denture – one piece cast metal (including clasps and teeth) ........ 417.00
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Code Procedure Allowance
Adjustments to dentures
D5410 Adjust complete denture – maxillary ........................................................................................... 26.00
D5411 Adjust complete denture – mandibular ....................................................................................... 26.00
D5421 Adjust partial denture – maxillary ................................................................................................ 26.00
D5422 Adjust partial denture – mandibular ............................................................................................ 26.00
Repairs to complete dentures
D5510 Repair broken complete denture base ........................................................................................ 100.00
D5520 Replace missing or broken teeth – complete denture (each tooth) ............................................ 51.00
Repairs to partial dentures
D5610 Repair resin denture base ........................................................................................................... 100.00
D5630 Repair or replace broken clasp ................................................................................................... 77.00
D5640 Replace broken teeth – per tooth ............................................................................................... 77.00
D5650 Add tooth to existing partial denture ........................................................................................... 49.00
D5660 Add clasp to existing partial denture ........................................................................................... 126.00
Denture rebase procedures
D5710 Rebase complete maxillary denture ........................................................................................... 222.00
D5711 Rebase complete mandibular denture ........................................................................................ 222.00
D5720 Rebase maxillary partial denture ................................................................................................ 222.00
D5721 Rebase mandibular partial denture ............................................................................................. 222.00
Denture reline procedures
D5730 Reline complete maxillary denture (chairside) ............................................................................ 92.00
D5731 Reline complete mandibular denture (chairside) ........................................................................ 92.00
D5740 Reline maxillary partial denture (chairside) ................................................................................. 92.00
D5741 Reline mandibular partial denture (chairside) ............................................................................. 92.00
D5750 Reline complete maxillary denture (laboratory) .......................................................................... 158.00
D5751 Reline complete mandibular denture (laboratory) ...................................................................... 15
8.00
D5760 Reline maxillary partial denture (laboratory) ............................................................................... 158.00
D5761 Reline mandibular partial denture (laboratory) ........................................................................... 158.00
Interim prosthesis
D5820 Interim partial denture (maxillary) ............................................................................................... 204.00
D5821 Interim partial denture (mandibular) ............................................................................................ 204.00
Other removable prosthetic services
D5850 Tissue conditioning, maxillary ..................................................................................................... 53.00
D5851 Tissue conditioning, mandibular ................................................................................................. 53.00
D6200-D6999 PROSTHODONTICS, FIXED
(Each abutment and each pontic constitutes a unit in a fixed partial denture.)
Partial denture pontics
D6210 Pontic – cast high noble metal .................................................................................................... 372.00
D6211 Pontic – cast predominantly base metal ..................................................................................... 420.00
D6212 Pontic – cast noble metal ........................................................................................................... 440.00
D6214 Pontic – titanium ......................................................................................................................... 372.00
D6240 Pontic – porcelain fused to high noble metal .............................................................................. 372.00
D6241 Pontic – porcelain fused to predominantly base metal ............................................................... 428.00
D6242 Pontic – porcelain fused to noble metal ...................................................................................... 448.00
D6250 Pontic – resin with high noble metal ........................................................................................... 372.00
D6251 Pontic – resin with predominantly base metal ............................................................................ 428.00
D6252 Pontic – resin with noble metal ................................................................................................... 448.00
5
Code Procedure Allowance
Fixed partial denture retainers – inlays/onlays
D6545 Retainer – cast metal for resin bonded fixed prosthesis ............................................................. 210.00
D6602 Inlay – cast high noble metal, two surfaces ................................................................................ 280.00
D6603 Inlay – cast high noble metal, three or more surfaces ................................................................ 320.00
D6604 Inlay – cast predominantly base metal, two surfaces ................................................................. 280.00
D6605 Inlay – cast predominantly base metal, three or more surfaces ................................................. 320.00
D6606 Inlay – cast noble metal, two surfaces ........................................................................................ 280.00
D6607 Inlay – cast noble metal, three or more surfaces ........................................................................ 320.00
D6610 Onlay – cast high noble metal, two surfaces ............................................................................... 403.00
D6611 Onlay – cast high noble metal, three or more surfaces .............................................................. 403.00
D6612 Onlay – cast predominantly base metal, two surfaces ................................................................ 403.00
D6613 Onlay – cast predominantly base metal, three or more surfaces ............................................... 403.00
D6614 Onlay – cast noble metal, two surfaces ...................................................................................... 403.00
D6615 Onlay – cast noble metal, three or more surfaces ...................................................................... 403.00
D6624 Inlay – titanium ............................................................................................................................ 320.00
D6634 Onlay – titanium .......................................................................................................................... 403.00
Fixed partial denture retainers – crowns
D6720 Crown – resin with high noble metal ........................................................................................... 394.00
D6721 Crown – resin with predominantly base metal ............................................................................ 436.00
D6722 Crown – resin with noble metal ................................................................................................... 456.00
D6750 Crown – porcelain fused to high noble metal .............................................................................. 394.00
D6751 Crown – porcelain fused to predominantly base metal ............................................................... 436.00
D6752 Crown – porcelain fused to noble metal ...................................................................................... 456.00
D6780 Crown – ¾ cast high noble metal ................................................................................................ 400.00
D6781 Crown – ¾ cast predominantly base metal ................................................................................. 400.00
D6782 Crown – ¾ cast noble metal ........................................................................................................ 400.00
D6783 Crown – ¾ porcelain/ceramic 400.00
D6790 Crown – full cast high noble metal .............................................................................................. 394.00
D6791 Crown – full cast predominantly base metal ............................................................................... 420.00
D6792 Crown – full cast noble metal ...................................................................................................... 441.60
D6794 Crown – titanium ......................................................................................................................... 394.00
Other fixed partial denture services
D6930 Recement fixed partial denture ................................................................................................... 53.00
D6940 Stress breaker ............................................................................................................................. 111.00
D6970 Cast post and core in addition to fixed partial denture retainer ................................................... 122.00
D6971 Cast post as part of fixed partial denture retainer ....................................................................... 122.00
D6972 Prefabricated post and core in addition to fixed partial denture retainer .................................... 93.00
D6973 Core buildup for retainer, including any pins ............................................................................... 75.00
D6976 Each additional cast post – same tooth ....................................................................................... 122.00
D6977 Each additional pre-fabricated – same tooth ............................................................................... 93.00
D6980 Fixed partial denture repair, by report ......................................................................................... BR
D7000-D7999 ORAL AND MAXILLOFACIAL SURGERY
Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7111 Extraction, coronal remnants - deciduous tooth .........................................................................
23.00
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ........................... 46.00
Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care)
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of
bone and/or section of tooth .......................................................................................................
95.00
D7220 Removal of impacted tooth – soft tissue ..................................................................................... 117.00
6
Code Procedure Allowance
D7230 Removal of impacted tooth – partially bony ................................................................................ 167.00
D7240 Removal of impacted tooth – completely bony, with unusual surgical complications ................ 205.00
D7250 Surgical removal of residual tooth roots (cutting procedure) ...................................................... 140.00
Other surgical procedures
D7260 Oroantral fistula closure .............................................................................................................. 400.00
D7261 Primary closure of a sinus perforation ........................................................................................ 400.00
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth ................. 256.00
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or
stabilization) ................................................................................................................................
268.80
D7280 Surgical access of an unerupted tooth ....................................................................................... 203.20
D7285 Biopsy of oral tissue – hard (bone, tooth) ................................................................................... 120.00
D7286 Biopsy of oral tissue - soft ........................................................................................................... 120.00
Alveoloplasty – surgical preparation of ridge for dentures
D7310 Alveoloplasty in conjunction with extractions – per quadrant ..................................................... 75.00
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
.....................................................................................................................................................
45.00
D7320 Alveoloplasty not in conjunction with extractions – per quadrant ............................................... 87.00
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant ......................................................................................................................................
53.00
Vestibuloplasty
D7350 Vestibuloplasty – ridge extension (including soft tissue graft, muscle reattachment, revision of
soft tissue attachment and management of hypertrophied and hyperplastic tissue) .................
460.00
Surgical excision of soft tissue lesions
D7411 Excision of benign lesion greater than 1.25 cm .......................................................................... 400.00
D7465 Destruction of lesion(s) by physical or chemical method, by report ........................................... 181.60
Surgical excision of intra-osseous lesions
D7440 Excision of malignant tumor – lesion diameter up to 1.25 cm ....................................................
D7441 Excision of malignant tumor – lesion diameter greater than 1.25 cm .........................................
D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm ........................ 181.60
D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm ............ 320.00
D7460 Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm .................. 181.60
D7461 Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm ...... 320.00
Excision of bone tissue
D7471 Removal of lateral exostosis (maxilla or mandible) .................................................................... 260.00
D7472 Removal of torus palatinus ......................................................................................................... 260.00
D7473 Removal of torus mandibularis ................................................................................................... 260.00
D7485 Surgical reduction of osseous tuberosity .................................................................................... 260.00
D7490 Radical resection of maxilla or mandible ....................................................................................
Surgical incision
D7510 Incision and drainage of abscess – intraoral soft tissue ............................................................. 92.00
D7520 Incision and drainage of abscess – extraoral soft tissue ............................................................ 160.00
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue .......................... 160.00
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system ................................... 200.00
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone ............................................... 220.00
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body .......................................... 520.00
7
Code Procedure Allowance
Treatment of fractures – simple
D7610 Maxilla – open reduction (teeth immobilized, if present) ............................................................ 2,400.00
D7620 Maxilla – closed reduction (teeth immobilized, if present) .......................................................... 1,600.00
D7630 Mandible – open reduction (teeth immobilized, if present) ......................................................... 3,040.00
D7640 Mandible – closed reduction (teeth immobilized, if present) ....................................................... 1,600.00
D7650 Malar and/or zygomatic arch – open reduction .......................................................................... 2,400.00
D7660 Malar and/or zygomatic arch – closed reduction ........................................................................ 1,656.00
D7670 Alveolus – closed reduction, may include stabilization of teeth .................................................. 256.00
D7680 Facial bones – complicated reduction with fixation and multiple surgical approaches .............. 2,800.00
Treatment of fractures – compound
D7710 Maxilla – open reduction ............................................................................................................. 2,800.00
D7720 Maxilla – closed reduction ........................................................................................................... 2,040.00
D7730 Mandible – open reduction .......................................................................................................... 2,800.00
D7740 Mandible – closed reduction ....................................................................................................... 2,040.00
D7750 Malar and/or zygomatic arch – open reduction .......................................................................... 2,240.00
D7760 Malar and/or zygomatic arch – closed reduction ........................................................................ 2,240.00
D7770 Alveolus – open reduction stabilization of teeth ......................................................................... 3,200.00
D7780 Facial bones – complicated reduction with fixation and multiple surgical approaches .............. 3,200.00
Reduction of dislocation and management of other temporomandibular joint dysfunctions
D7810 Open reduction of dislocation ..................................................................................................... 480.00
D7820 Closed reduction of dislocation ................................................................................................... 220.00
D7830 Manipulation under anesthesia ................................................................................................... 480.00
D7840 Condylectomy .............................................................................................................................. 3,040.00
D7850 Surgical discectomy, with/without implant ................................................................................... 3,200.00
Other repair procedures
D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure ................................................ 176.00
D7970 Excision of hyperplastic tissue – per arch ..............................................................................
.....
D7971 Excision of pericoronal gingival .................................................................................................. 80.00
D7972 Surgical reduction of fibrous tuberosity ....................................................................................... 80.00
D7980 Sialolithotomy .............................................................................................................................. 1,200.00
D7981 Excision of salivary gland, by report ........................................................................................... 1,200.00
D7982 Sialodochoplasty ......................................................................................................................... 160.00
D7983 Closure of salivary fistula ............................................................................................................ 480.00
D9000-D9999 ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
D9110 Palliative (emergency) treatment of dental pain – minor procedure ........................................... 64.00
Anesthesia
D9220 Deep sedation/general anesthesia – first 30 minutes ................................................................. 111.00
D9221 Deep sedation/general anesthesia – each additional 15 minutes .............................................. 46.00
Professional consultation
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner
providing treatment) ....................................................................................................................
120.00
Professional visits
D9430 Office visit for observation (during regularly scheduled hours) - no other services performed .. 27.00
D9440 Office visit – after regularly scheduled hours .............................................................................. 80.00
8
Code Procedure Allowance
Drugs
D9610 Therapeutic drug injection, by report .......................................................................................... BR
Miscellaneous services
D9930 Treatment of complications (postsurgical) – unusual circumstances, by report ......................... 40.00
D9951 Occlusal adjustment – limited ..................................................................................................... 56.00
Note: This table represents codes and nomenclature excerpted from the version of Current Dental
Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the copyright of
the American Dental Association, and have been accepted as the standard for data transmission purposes
under federal Administrative Simplification regulations. For the purposes of this table, Delta Dental’s
administration of Benefits, Limitations and Exclusions under this plan will at all times be based on the
then-current version of CDT whether or not a revised table is provided. Any notes in italic type have been
added by Delta Dental for clarification.
LIMITATIONS
1 An oral examination is a Benefit only twice in a calendar year while you are eligible under any Delta
Dental plan. See Note on additional Benefits during pregnancy.
2 Full-mouth x-rays are a Benefit once in a five-year period while you are eligible under any Delta
Dental plan.
3. Bitewing x-rays are provided on request by the dentist, but no more than twice in a calendar year
while you are eligible under any Delta Dental plan.
4. Only the first two cleanings, fluoride treatments, or Single Procedures which include cleaning, or
combination thereof, in a calendar year are Benefits while you are eligible under any Delta Dental
plan. If you are pregnant during this time, we may pay for an additional cleaning. See Note on
additional Benefits during pregnancy.
Routine prophylaxes are covered as a Diagnostic and Preventive Benefit and periodontal
prophylaxes are covered as a Basic Benefit.
5. Fluoride treatments are covered twice each calendar year under any Delta Dental plan.
6. Periodontal scaling and root planing is a Benefit once for each quadrant each 24-month period. See
note on additional Benefits during pregnancy.
7. Sealant Benefits include the application of sealants only to permanent first molars through age
eight and second molars through age 15 if they are without caries (decay) or restorations on the
occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any
tooth within two years of its application.
8. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five
years, while you are eligible under any Delta Dental plan, unless Delta Dental determines that
replacement is required because the restoration is unsatisfactory as a result of poor quality of care,
or because the tooth involved has experienced extensive loss or changes to tooth structure or
supporting tissues since the replacement of the restoration.
9
9. Prosthodontic appliances are Benefits only once every five years, while you are eligible under any
Delta Dental plan, unless Delta Dental determines that there has been such an extensive loss of
remaining teeth or a change in supporting tissues that the existing appliance cannot be made
satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental plan will
be made if it is unsatisfactory and cannot be made satisfactory.
10. Delta Dental will pay the applicable percentage of the dentist’s fee for a standard partial or
complete denture. A standard partial or complete denture is defined as a removable prosthetic
appliance provided to replace missing natural, permanent teeth made from accepted materials and
by conventional methods.
11. Implants (appliances inserted into bone or soft tissue in the jaw, usually to anchor a denture) are
not covered by your plan. However, if implants are provided along with a covered prosthodontic
appliance, Delta Dental will allow the cost of a standard partial or complete denture toward the cost
of the implants and the prosthodontic appliances when the prosthetic appliance is completed. If
Delta Dental makes such an allowance, we will not pay for any replacement for five years following
the completion of the service.
12. If you select a more expensive plan of treatment than is customarily provided or specialized
techniques, an allowance will be made for the least expensive, professionally acceptable,
alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee for the
customary or standard treatment and you are responsible for the remainder of the dentist’s fee.
For example: a crown where an amalgam filling would restore the tooth; or a precision denture
where a standard denture would suffice.
13. Any services that would be covered under other Benefit categories (subject to the same limitations
and exclusions) are covered instead by your dental accident coverage when they are provided for
conditions caused directly by external, violent and accidental means.
14. Delta Dental will pay Dental Accident Benefits when services are provided within 180 days following
the date of accident and shall not include any services for conditions caused by an accident
occurring before your eligibility date.
EXCLUSIONS/SERVICES WE DO NOT COVER
Delta Dental covers a wide variety of dental care expenses, but there are some services for which we do
not provide Benefits. It is important for you to know what these services are before you visit your dentist.
Delta Dental does not provide benefits for:
1. Services for injuries or conditions that are covered under Workers’ Compensation or Employer’s
Liability Laws.
2. Services which are provided to the Enrollee by any Federal or State Governmental Agency or are
provided without cost to the Enrollee by any municipality, county or other political subdivision,
except Medi-Cal benefits.
3. Services for cosmetic purposes or for conditions that are a result of hereditary or developmental
defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and
teeth that are discolored or lacking enamel.
4. Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or abfraction), for
rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for
stabilizing the teeth. Examples of such treatment are equilibration and periodontal splinting.
10
5. Any Single Procedure, bridge, denture or other prosthodontic service which was started before the
Enrollee was covered by this plan.
6. Prescribed drugs, or applied therapeutic drugs, premedication or analgesia.
7. Experimental procedures.
8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by
the Dentist for treatment in any such facility.
9. Anesthesia, except for general anesthesia given by a dentist for covered oral surgery procedures.
10. Grafting tissues from outside the mouth to tissues inside the mouth (“extraoral grafts”).
11. Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants,
except as provided under LIMITATIONS.
12. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw)
joints or associated muscles, nerves or tissues.
13. Replacement of existing restoration for any purpose other than active tooth decay.
14. Intravenous sedation, occlusal guards and complete occlusal adjustment.
15. Orthodontic services (treatment of mal-alignment of teeth and/or jaws).
16. Procedures not shown on the Table of Allowances.
DEDUCTIBLES
You must pay the first $25 of Covered Services for each Enrollee in each calendar year. The Deductible will
not be applied to Diagnostic and Preventive Benefits, or Dental Accident Benefits.
COVERED FEES
It is to your advantage to select a dentist who is a Delta Dental Dentist, since a lower percentage of the
dentist’s fees may be covered by this plan if you select a dentist who is not a Delta Dental Dentist.
A list of Delta Dental Dentists (see DEFINITIONS) is available in a directory at your group benefits office,
or by calling 800-765-6003.
Payment to a Delta Dental Dentist will be based on the lesser of the Fee Actually Charged, or the accepted
Usual, Customary and Reasonable Fee that the dentist has on file with Delta Dental, or the allowance
shown on the Table of Allowances.
Payment to a dentist outside of California who agrees to be bound by Delta Dental’s rules in the
administration of the plan will be based on the lesser of the Fee Actually Charged or the Customary Fee
for corresponding services for Delta Dental Dentists in California, or the allowance shown on the Table of
Allowances.
Payment to a California dentist, or an out-of-state dentist, who is not a Delta Dental Dentist will be based
on the lesser of the Fee Actually Charged, or the allowance shown on the Table of Allowances.
11
Payment to a dentist located outside the United States will be based on the applicable percentage of the
lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental’s dentists, or the
allowance shown on the Table of Allowances.
CHOICE OF DENTISTS AND PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT
GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Nearly 23,400 dentists in active practice in California are Delta Dental Dentists. You are free to choose any
dentist for treatment, but it is to your advantage to choose a Delta Dental Dentist. This is because his or
her fees are approved in advance by Delta Dental. Delta Dental Dentists have treatment forms on hand
and will complete and submit the forms to Delta Dental free of charge.
If you go to a non-Delta Dental Dentist, Delta Dental cannot assure you what percentage of the charged
fee may be covered. Claims for services from non-Delta Dental Dentists may be submitted to Delta Dental
at P.O. Box 997330, Sacramento, CA 95899-7330.
Dentists located outside the United States are not Delta Dental Dentists. Claims submitted by out-of-
country dentists are translated by Delta Dental staff and the currency is converted to U.S. dollars. Claims
submitted by out-of-country dentists for Enrollees residing in California are referred to Delta Dental’s
Quality Review department for processing. Delta Dental may require a clinical examination to determine
the quality of the services provided, and Delta Dental may decline to reimburse you for Benefits if the
services are found to be unsatisfactory.
A list of Delta Dental Dentists can be obtained by calling 800-765-6003. This list will identify those
dentists who can provide care for individuals who have mobility impairments or have special health care
needs. You can obtain specific information about Delta Dental Dentists by using our web site –
www.deltadentalins.com or calling the Delta Dental Customer Service department at the number shown on
page 1. A printed list of the Delta Dental Dentists in your area is also available by calling 1-800-765-6003.
Services from dental school clinics may be provided by students of dentistry or instructors who are not
licensed by the state of California.
Delta Dental shares the public and professional concern about the possible spread of HIV and other
infectious diseases in the dental office. However, Delta Dental cannot ensure your dentist’s use of
precautions against the spread of such diseases, or compel your dentist to be tested for HIV or to disclose
test results to Delta Dental, or to you. Delta Dental informs its panel dentists about the need for clinical
precautions as recommended by recognized health authorities on this issue. If you should have questions
about your dentist’s health status or use of recommended clinical precautions, you should discuss them
with your dentist.
CONTINUITY OF CARE
Current Enrollees:
Current Enrollees may have the right to the benefit of completion of care with their terminated Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental’s Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental’s Continuity of Care Policy. You must make a specific request to continue under the care of
your terminated Delta Dental Dentist. We are not required to continue your care with that dentist if you
are not eligible under our policy or if we cannot reach agreement with your terminated Delta Dental
Dentist on the terms regarding your care in accordance with California law.
12
New Enrollees:
A new Enrollee may have the right to the qualified benefit of completion of care with their non-Delta
Dental Dentist for certain specified dental conditions. Please call Delta Dental’s Quality Assessment
Department at 415-972-8300 to see if you may be eligible for this benefit. You may request a copy of the
Delta Dental’s Continuity of Care Policy. You must make a specific request to continue under the care of
your current provider. We are not required to continue your care with that dentist if you are not eligible
under our policy or if we cannot reach agreement with your non-Delta Dental Dentist on the terms
regarding your care in accordance with California law. This policy does not apply to new enrollees of an
individual subscriber contract.
PUBLIC POLICY PARTICIPATION BY ENROLLEES
Delta Dental’s Board of Directors includes Enrollees who participate in establishing Delta Dental’s public
policy regarding Enrollees through periodic review of Delta Dental’s Quality Assessment program reports
and communication from Enrollees. Enrollees may submit any suggestions regarding Delta Dental’s public
policy in writing to: Delta Dental of California, Customer Service Department, P. O. Box 997330,
Sacramento, CA 95899-7330.
SAVING MONEY ON YOUR DENTAL BILLS
You can keep your dental expenses down by practicing the following:
1. Compare the fees of different dentists;
2. Use a Delta Dental Dentist;
3. Have your dentist obtain predetermination from Delta Dental for any treatment over $300;
4. Visit your dentist regularly for checkups;
5. Follow your dentist’s advice about regular brushing and flossing;
6. Avoid putting off treatment until you have a major problem; and
7. Learn the facts about overbilling. Under this plan, you must pay the dentist your co-payment share
(see YOUR BENEFITS). You may hear of some dentists who offer to accept insurance payments as
“full payment.” You should know that these dentists may do so by overcharging your plan and may
do more work than you need, thereby increasing plan costs. You can help keep your dental Benefits
intact by avoiding such schemes.
YOUR FIRST APPOINTMENT
During your first appointment, be sure to give your dentist the following information:
1. Your Delta Dental group number (on the front of this booklet);
2. The County of Sacramento’s name;
3. Primary Enrollee’s ID number (which must also be used by your Dependents);
4. Primary Enrollee’s date of birth;
5. Any other dental coverage you may have.
13
ACCESSIBILITY AND SERVICES FOR AFTER-HOURS AND URGENT CARE
If you or a family member has special needs, you should ask your dentist about accessibility to their office
or clinic at the time you call for an appointment. Your dentist will be able to tell you if their office is
accessible taking into consideration the specific requirements of your needs.
Routine or urgent care may be obtained from any licensed dentist during their normal office hours. Delta
Dental does not require prior authorization before seeking treatment for urgent or after-hours care. You
may plan in advance, for treatment for urgent, emergency or after-hours care by asking your dentist how
you can contact the dentist in the event you or a family member may need urgent care treatment or
treatment after normal business hours.
Many dentists have made prior arrangements with other dentists to provide care to you if treatment is
immediately or urgently needed. You may also call the local dental society that is listed in your local
telephone directory if your dentist is not available to refer you to another dentist for urgent, emergency or
after-hours care.
PREDETERMINATIONS
After an examination, your dentist will talk to you about treatment you may need. The cost of treatment is
something you may want to consider. If the service is extensive and involves crowns or bridges, or if the
service will cost more than $300, we encourage you to ask your dentist to request a predetermination.
A predetermination does not guarantee payment. It is an estimate of the amount Delta Dental
will pay if you are eligible and meet all the requirements of your plan at the time the treatment
you have planned is completed.
In order to receive predetermination, your dentist must send a claim form listing the proposed treatment.
Delta Dental will send your dentist a Notice of Predetermination which estimates how much you will have
to pay. After you review the estimate with your dentist and decide to go ahead with the treatment plan,
your dentist returns the form to us for payment when treatment has been completed.
Computations are estimates only and are based on what would be payable on the date the Notice of
Predetermination is issued if the Enrollee is eligible. Payment will depend on the Enrollee’s eligibility and
the remaining annual Maximum when completed services are submitted to Delta Dental.
Predetermining treatment helps prevent any misunderstanding about your financial responsibilities. If you
have any concerns about the predetermination, let us know before treatment begins so your questions can
be answered before you incur any charges.
REIMBURSEMENT PROVISIONS
A Delta Dental Dentist will file the claim for you. You do not have to file a claim or pay Delta Dental’s co-
payment for covered services if provided by a Delta Dental Dentist. Delta Dental of California’s agreement
with our Delta Dental Dentists makes sure that you will not be responsible to the dentist for any money
we owe.
If the covered service is provided by a dentist who is not a Delta Dental Dentist, you are responsible for
filing the claims and paying your dentist. Claims should be filed with Delta Dental of California at P. O. Box
997330, Sacramento, CA 95899-7330 and Delta Dental will reimburse you. However, if for any reason we
fail to pay a dentist who is not a Delta Dental Dentist, you may be liable for that portion of the cost.
Payments made to you are not assignable (in other words, we will not grant requests to pay non-Delta
Dental Dentists directly).
14
Payment for claims exceeding $500 for services provided by dentists located outside the United States
may, at Delta Dental’s option, be conditioned upon a clinical evaluation at Delta Dental’s request (see
Second Opinions). Delta Dental will not pay Benefits for such services if they are found to be
unsatisfactory.
Delta Dental does not pay Delta Dental Dentists any incentive as an inducement to deny, reduce, limit or
delay any appropriate service. If you wish to know more about the method of reimbursement to Delta
Dental Dentists, you may call Delta Dental’s Customer Service department for more information.
Payment for any Single Procedure that is a Covered Service will only be made upon completion of that
procedure. Delta Dental does not make or prorate payments for treatment in progress or incomplete
procedures. The date the procedure is completed governs the calculation of any Deductible (and
determines when a charge is made against any Maximum) under your plan.
If there is a difference between what your dentist is charging you and what Delta Dental says your portion
should be, or if you are not satisfied with the dental work you have received, contact Delta Dental’s
Customer Service department. We may be able to help you resolve the situation.
Delta Dental may deny payment of a claim for services submitted more than 12 months after the date the
services were provided. If a claim is denied due to a Delta Dental Dentist’s failure to make a timely
submission, you shall not be liable to that dentist for the amount which would have been payable by Delta
Dental (unless you failed to advise the dentist of your eligibility at the time of treatment).
The process Delta Dental uses to determine or deny payment for services is distributed to all Delta Dental
Dentists. It describes in detail the dental procedures covered as Benefits, the conditions under which
coverage is provided, and the limitations and exclusions applicable to the plan. Claims are reviewed for
eligibility and are paid according to these processing policies.
Those claims which require additional review are evaluated by Delta Dental’s dentist consultants. If any
claims are not covered, or if limitations or exclusions apply to services you have received from a Delta
Dental Dentist, you will be notified by an adjustment notice on the Notice of Payment or Action. You may
contact Delta Dental’s Customer Service department for more information regarding Delta Dental’s
processing policies.
IF YOU HAVE QUESTIONS ABOUT SERVICES FROM A DELTA DENTAL DENTIST
If you have questions about the services you receive from a Delta Dental Dentist, we recommend that you
first discuss the matter with your dentist. If you continue to have concerns, call our Quality Review
department at 800-765-6003. If appropriate, Delta Dental can arrange for you to be examined by one of
our consulting dentists in your area. If the consultant recommends the work be replaced or corrected,
Delta Dental will intervene with the original dentist to either have the services replaced or corrected at no
additional cost to you or obtain a refund. In the latter case, you are free to choose another dentist to
receive your full Benefit.
SECOND OPINIONS
Delta Dental obtains second opinions through Regional Consultant members of its Quality Review
Committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate
treatment that is proposed or has been provided.
Delta Dental will authorize such an examination prior to treatment when necessary to make a Benefits
determination in response to a request for a Predetermination of treatment cost by a dentist. Delta Dental
will also authorize a second opinion after treatment if an Enrollee has a complaint regarding the quality of
care provided.
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Delta Dental will notify the Enrollee and the treating dentist when a second opinion is necessary and
appropriate, and direct the Enrollee to the Regional Consultant selected by Delta Dental to perform the
clinical examination. When Delta Dental authorizes a second opinion through a Regional Consultant, we
will pay for all charges.
Enrollees may otherwise obtain second opinions about treatment from any dentist they choose, and claims
for the examination may be submitted to Delta Dental for payment. Delta Dental will pay such claims in
accordance with the Benefits of the plan.
This is only a summary of Delta Dental’s policy on second opinions. A copy of Delta Dental’s
formal policy is available from Delta Dental’s Customer Service department upon request.
ORGAN AND TISSUE DONATION
Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of
transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far
exceeds availability. If you are interested in organ donation, please speak to your physician. Organ
donation begins at the hospital when a patient is pronounced brain dead and identified as a potential
organ donor. An organ procurement organization will become involved to coordinate the activities.
GRIEVANCE PROCEDURE AND CLAIMS APPEAL
If you have any questions about the services received from a Delta Dental Dentist, we recommend that
you first discuss the matter with your Dentist. If you continue to have concerns, you may call or write us.
We will provide notifications if any dental services or claims are denied, in whole or part, stating the
specific reason or reasons for denial. Any questions of ineligibility should first be handled directly between
you and your group. If you have any question or complaint regarding the denial of dental services or
claims, the policies, procedures and operations of Delta Dental, or the quality of dental services performed
by a Delta Dental Dentist, you may call us toll-free at 800-765-6003, contact us on our web site at:
www.deltadentalins.com or write us at P. O. Box 997330, Sacramento, CA 95899-7330, Attention:
Customer Service Department.
If your claim has been denied or modified, you may file a request for review (a grievance) with us within
180 days after receipt of the denial or modification. If in writing, the correspondence must include your
group name and number, the Primary Enrollee’s name and ID number, the inquirer’s telephone number
and any additional information that would support the claim for benefits. Your correspondence should also
include a copy of the treatment form, Notice of Payment and any other relevant information. Upon request
and free of charge, we will provide the Enrollee with copies of any pertinent documents that are relevant
to the claim, a copy of any internal rule, guideline, protocol, and/or explanation of the scientific or clinical
judgment if relied upon in denying or modifying the claim.
Our review will take into account all information, regardless of whether such information was submitted or
considered initially. Certain cases may be referred to one of our regional consultants, to a review
committee of the dental society or to the state dental association for evaluation. Our review shall be
conducted by a person who is neither the individual who made the original claim denial, nor the
subordinate of such individual, and we will not give deference to the initial decision. If the review of a
claim denial is based in whole or in part on a lack of medical necessity, experimental treatment, or a
clinical judgment in applying the terms of the contract terms, we shall consult with a dentist who has
appropriate training and experience. The identity of such dental consultant is available upon request.
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We will provide the Enrollee a written acknowledgement within five calendar days of receipt of the request
for review. We will make a written decision within 30 calendar days of receipt of the request for review.
We will respond, within three calendar days of receipt, to complaints involving severe pain and imminent
and serious threat to an Enrollee’s health. You may file a complaint with the Department of Managed
Health Care after you have completed Delta Dental’s grievance procedure or after you have been involved
in Delta Dental’s grievance procedure for 30 calendar days. You may file a complaint with the Department
immediately in an emergency situation, which is one involving severe pain and/or imminent and serious
threat to the Enrollee’s health.
The California Department of Managed Health Care is responsible for regulating health care service plans.
If you have a grievance against Delta Dental, your health plan, you should first telephone Delta Dental at
800-765-6003 and use Delta Dental’s grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.
If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily
resolved by your health plan, or a grievance that has remained unresolved for more than 30 calendar
days, you may call the department for assistance. You may also be eligible for an Independent Medical
Review (IMR).
If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a
health plan related to the medical necessity of a proposed service or treatment, coverage decisions for
treatments that are experimental or investigational in nature and payment disputes for emergency or
urgent medical services. The department also has a toll-free telephone number (888-HMO-2219) and a
TDD line (877-688-9891) for the hearing and speech impaired. The department's Internet Web site
(http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions
online.
IMR has limited application to your dental plan. You may request IMR only if your dental claim concerns a
life-threatening or seriously debilitating condition(s) and is denied or modified because it was deemed an
experimental procedure.
If the group health plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA), the
Enrollee may contact the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) for
further review of the claim or if the Enrollee has questions about the rights under ERISA. The Enrollee may
also bring a civil action under section 502(a) of ERISA. The address of the U.S. Department of Labor is:
U.S. Department of Labor, Employee Benefits Security Administration (EBSA), 200 Constitution Avenue,
N.W. Washington, D.C. 20210.
IF YOU HAVE ADDITIONAL COVERAGE
It is to your advantage to let your dentist and Delta Dental know if you have dental coverage in addition
to this Delta Dental plan. Most dental carriers cooperate with one another to avoid duplicate payments,
but still allow you to make use of both plans - sometimes paying 100% of your dental bill. For example,
you might have some fillings that cost $100. If the primary carrier usually pays 80% for these services, it
would pay $80. The secondary carrier might usually pay 50% for this service. In this case, since payment
is not to exceed the entire fee charged, the secondary carrier pays the remaining $20 only. Since this
method pays 100% of the bill, you have no out-of-pocket expense.
Be sure to advise your dentist of all plans under which you have dental coverage and have him or her
complete the dual coverage portion of the claim form, so that you will receive all benefits to which you are
entitled. For further information, contact the Delta Dental Customer Service department at the number in
the USING THIS BOOKLET section.
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PLAN ADMINISTRATOR
The Plan Administrator (County of Sacramento) is a named fiduciary under this plan and shall be
responsible for the management and control of this plan.
FUNDING POLICY AND PAYMENT OF PREMIUMS
The funding policy and method require the payment of monthly Premiums by the County of Sacramento to
Delta Dental of California as specified in the group dental agreement. If you choose OPTIONAL
CONTINUATION OF COVERAGE (COBRA), you may be charged by the employer, as provided for by law.
OPTIONAL CONTINUATION OF COVERAGE (COBRA)
Please examine your options carefully before declining this coverage. You should be aware
that companies selling individual health insurance typically require a review of your medical
history that could result in a higher premium or you could be denied coverage entirely.
The federal Consolidated Omnibus Budget Reconciliation Act (or COBRA, pertaining to certain employers
having 20 or more employees) and the California Continuation Benefits Replacement Act (or Cal-COBRA,
pertaining to employers with two to 19 employees), both require that continued health care coverage be
made available to “Qualified Beneficiaries” who lose health care coverage under the group plan as a result
of a “Qualifying Event.” You may be entitled to continue coverage under this plan, at your expense, if
certain conditions are met. The period of continued coverage depends on the Qualifying Event and
whether you are covered under federal COBRA or Cal-COBRA.
DEFINITIONS
The meaning of key terms used in this section are shown below and apply to both federal and Cal-COBRA.
Qualified Beneficiary means:
You and/or your Dependents who are enrolled in the Delta Dental plan on the day before the Qualifying
Event.
Qualifying Event means any of the following events which, except for the election of this continued
coverage, would result in a loss of coverage under the dental plan:
Event 1. The termination of employment (other than termination for gross misconduct) or the
reduction in work hours, by your employer;
Event 2. Your death;
Event 3. Your divorce or legal separation from your spouse;
Event 4. Your Dependents’ loss of dependent status under the plan; and
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Event 5. As to your Dependents only, your entitlement to Medicare.
You means the Primary Enrollee.
PERIODS OF CONTINUED COVERAGE UNDER FEDERAL COBRA
Qualified Beneficiaries may continue coverage for 18 months following the month in which Qualifying
Event 1 occurs.
This 18-month period can be extended for a total of 29 months, provided:
1. A determination is made under Title II or Title XVI of the Social Security Act that an individual is
disabled on the date of the Qualifying Event or becomes disabled at any time during the first 60
days of continued coverage; and
2. Notice of the determination is given to the employer during the initial 18 months of continued
coverage and within 60 days of the date of termination.
This period of coverage will end on the first day of the month that begins more than 30 days after the
date of the final determination that the disabled individual is no longer disabled. You must notify your
employer or Delta Dental within 30 days of any such determination.
If, during the 18-month continuation period resulting from Qualifying Event 1, your Dependents, who are
Qualified Beneficiaries, experience Qualifying Events 2, 3, 4 or 5, they may choose to extend coverage for
up to a total of 36 months (inclusive of the period continued under Qualifying Event 1).
Your Dependents, who are Qualified Beneficiaries, may continue coverage for 36 months following the
occurrence of Qualifying Events 2, 3, 4 or 5.
When an employer has filed for bankruptcy under Title II, United States Code, Benefits may be
substantially reduced or eliminated for retired employees and their Dependents, or the surviving spouse of
a deceased retired employee. If this Benefit reduction or elimination occurs within one year before or one
year after filing, it is considered a Qualifying Event. If the Primary Enrollee is a retiree, and has lost
coverage because of this Qualifying Event, he or she may choose to continue coverage until his or her
death. The Primary Enrollee’s Dependents who have lost coverage because of this Qualifying Event may
choose to continue coverage for up to 36 months following the Primary Enrollee’s death.
PERIODS OF CONTINUED COVERAGE UNDER CAL-COBRA (groups of 2 – 19)
In the case of Cal-COBRA, Delta Dental will act as the administrator. Notification and Premium payments
should be made directly to Delta Dental. Notifications and payments should be delivered by first-class
mail, certified mail or other reliable means of delivery.
Individuals who are eligible for coverage under the federal COBRA law are not eligible for coverage under
Cal-COBRA. The employer must notify Delta Dental in writing within 30 days of the date when the
employer becomes subject to COBRA.
Qualified Beneficiaries may continue coverage for 36 months following the month in which Qualifying
Events 1, 2, 3, 4 or 5 occur.
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If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary is
determined under Title II or Title XVI of the Social Security Act to be disabled on the date of the Qualifying
Event or became disabled at any time during the first 60 days of continuation coverage, and notice of the
determination is given to the employer during the initial period of continuation coverage and within 60
days of the date of the social security determination letter, the Qualified Beneficiary may continue
coverage for a total of 36 months following the month in which Qualifying Event 1 occurs.
This period of coverage will end on the first of the month that begins more than 30 days after the date of
the final determination that the disabled individual is no longer disabled. The Qualified Beneficiary must
notify the employer or administrator within 30 days of any such determination.
If, during the 36-month continuation period resulting from Qualifying Event 1, the Qualified Beneficiary
experiences Qualifying Events 2, 3, 4 or 5, he or she must notify the employer within 60 days of the
second Qualifying Event and has a total of 36 months continuation coverage after the date of the first
Qualifying Event.
Delta Dental shall notify the Primary Enrollee of the date his or her continued coverage will terminate. This
termination notification will be sent during the 180-day period prior to the end of coverage.
ELECTION OF CONTINUED COVERAGE
A Qualified Beneficiary will have 60 days from a Qualifying Event to give Delta Dental written notice of the
election to continue coverage.
Upon written notice, Delta Dental will provide a Qualified Beneficiary with the necessary Benefits
information, monthly Premium charge, enrollment forms and instructions to allow election of continued
coverage. Failure to provide this written notice of election to Delta Dental within 60 days will result in the
loss of the right to continue coverage.
A Qualified Beneficiary has 45 days from the written election of continued coverage to pay the initial
Premium to Delta Dental, which includes the Premium for each month since the loss of coverage. Failure
to pay the required Premium within the 45 days will result in the loss of the right to continue coverage,
and any Premiums received after that will be returned to the Qualified Beneficiary.
CONTINUED COVERAGE BENEFITS
The Benefits under the continued coverage will be the same as those provided to active employees and
their Dependents who are still enrolled in the dental plan. If the employer changes the coverage for active
employees, the continued coverage will change as well. Premiums will be adjusted to reflect the changes
made.
TERMINATION OF CONTINUED COVERAGE
A Qualified Beneficiary’s coverage will terminate at the end of the month in which any of the following
events first occur:
1. The allowable number of consecutive months of continued coverage is reached;
2. Failure to pay the required Premiums in a timely manner;
3. The employer ceases to provide any group dental plan to its employees;
4. The individual first obtains coverage for dental Benefits, after the date of the election of continued
coverage, under another group health plan (as an employee or Dependent) which does not contain
or apply any exclusion or limitation with respect to any pre-existing condition of such a person, if
that pre-existing condition is covered under this plan; or
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5. Entitlement to Medicare.
Once continued coverage ends, it cannot be reinstated.
TERMINATION OF THE EMPLOYER’S DENTAL CONTRACT
If the dental contract between the employer and Delta Dental terminates prior to the time that the
continuation coverage would otherwise terminate, the employer shall notify a Qualified Beneficiary either
30 days prior to the termination or when all Enrollees are notified, whichever is later, of the ability to elect
continuation of coverage under the employer’s subsequent dental plan, if any. The continuation coverage
will be provided only for the balance of the period that a Qualified Beneficiary would have remained
covered under the Delta Dental plan had such plan with the former employer not terminated. The
employer shall notify the successor plan in writing of the Qualified Beneficiaries receiving continuation
coverage so they may be notified of how to continue coverage. The continuation coverage will terminate if
a Qualified Beneficiary fails to comply with the requirements pertaining to enrollment in and payment of
Premiums to the new group benefit plan.
OPEN ENROLLMENT CHANGE OF COVERAGE
A Qualified Beneficiary may elect to change continuation coverage during any subsequent open enrollment
period, if the employer has contracted with another plan to provide coverage to its active employees. The
continuation coverage under the other plan will be provided only for the balance of the period that a
Qualified Beneficiary would have remained under the Delta Dental plan.
NOTICE OF PRIVACY PRACTICES: CONFIDENTIALITY OF YOUR HEALTHCARE
INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
This notice is required by law to tell you how Delta Dental and its affiliates ("Delta Dental") protect the
confidentiality of your health care information in our possession. Protected Health Information (PHI) is
defined as any individually identifiable information regarding an Enrollee's healthcare history; mental or
physical condition; or treatment. Some examples of PHI include your name, address, telephone and/or fax
number, electronic mail address, ID number or other identification number, date of birth, date of
treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives, uses and
discloses your PHI to administer your benefit plan or as permitted or required by law. Any other disclosure
of your PHI without your authorization is prohibited.
We must follow the privacy practices that are described in this notice, but also comply with any stricter
requirements under federal or state law that may apply to our administration of your benefits. However,
we may change this notice and make the new notice effective for all of your PHI that we maintain. If we
make any substantive changes to our privacy practices, we will promptly change this notice and
redistribute to you within 60 days of the change to our practices. You may also request a copy of this
notice anytime by contacting the address or phone number at the end of this notice. You should receive a
copy of this notice at the time of enrollment in a Delta Dental plan, and we will notify you of how you can
receive a copy of this notice at least once every three years.
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Permitted Uses and Disclosures of Your PHI
We are permitted to use or disclose your PHI without your prior authorization for the following purposes.
These permitted uses and/or disclosures include disclosures to you, uses and/or disclosures for purposes
of health care treatment, payment of claims, billing of premiums, and other health care operations. If your
benefit plan is sponsored by your employer or another party, we may provide PHI to your employer or
that sponsor for purposes of administering your benefits. We may disclose PHI to third parties that
perform services for Delta Dental in the administration of your benefits. These parties are required by law
to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an
affiliate that performs services for Delta Dental in the administration of your benefits. These affiliates have
implemented privacy policies and procedures and comply with applicable federal and state law.
We are also permitted to use and/or disclose your PHI to comply with a valid authorization, to notify or
assist in notifying a family member, another person, or a personal representative of your condition, to
assist in disaster relief efforts, and to report victims of abuse, neglect, or domestic violence. Other
permitted uses and/or disclosures are for purposes of health oversight by government agencies, judicial,
administrative, or other law enforcement purposes, information about decedents to coroners, medical
examiners and funeral directors, for research purposes, for organ donation purposes, to avert a serious
threat to health or safety, for specialized government functions such as military and veterans activities, for
workers compensation purposes, and for use in creating summary information that can no longer be
traced to you. Additionally, with certain restrictions, we are permitted to use and/or disclose your PHI for
underwriting. We are also permitted to incidentally use and/or disclose your PHI during the course of a
permitted use and/or disclosure, but we must attempt to keep incidental uses and/or disclosures to a
minimum. We use administrative, technical, and physical safeguards to maintain the privacy of your PHI,
and we must limit the use and/or disclosure of your PHI to the minimum amount necessary to accomplish
the purpose of the use and/or disclosure.
Examples of Uses and Disclosures of Your PHI for Treatment, Payment or Healthcare
Operations
Such activities may include but are not limited to: processing your claims, collecting enrollment
information and premiums, reviewing the quality of health care you receive, providing customer service,
resolving your grievances, and sharing payment information with other insurers. Additional examples
include the following.
• Uses and/or disclosures of PHI in facilitating treatment.
For example, Delta Dental may use or disclose your PHI to determine eligibility for services requested
by your provider.
• Uses and/or disclosures of PHI for payment.
For example, Delta Dental may use and disclose your PHI to bill you or your plan sponsor.
• Uses and/or disclosures of PHI for health care operations.
For example, Delta Dental may use and disclose your PHI to review the quality of care provided by our
network of providers.
Disclosures Without an Authorization
We are required to disclose your PHI to you or your authorized personal representative (with certain
exceptions), when required by the U. S. Secretary of Health and Human Services to investigate or
determine our compliance with law, and when otherwise required by law. Delta Dental may disclose your
PHI without your prior authorization in response to the following:
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• Court order;
• Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its
lawful authority;
• Subpoena in a civil action;
• Investigative subpoena of a government board, commission, or agency;
• Subpoena in an arbitration;
• Law enforcement search warrant; or
• Coroner's request during investigations
Disclosures Delta Dental Makes With Your Authorization
Delta Dental will not use or disclose your PHI without your prior authorization if the law requires your
authorization. You can later revoke that authorization in writing to stop any future use and disclosure. The
authorization will be obtained from you by Delta Dental or by a person requesting your PHI from Delta
Dental.
Your Rights Regarding PHI
You have the right to request an inspection of and obtain a copy of your PHI. You may access
your PHI by contacting the appropriate Delta Dental office. You must include (1) your name, address,
telephone number and identification number and (2) the PHI you are requesting. Delta Dental may charge
a reasonable fee for providing you copies of your PHI. Delta Dental will only maintain that PHI that we
obtain or utilize in providing your health care benefits. Most PHI, such as treatment records or X-rays, is
returned by Delta Dental to the dentist after we have completed our review of that information. You may
need to contact your health care provider to obtain PHI that Delta Dental does not possess.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, or PHI that is otherwise not subject to disclosure under federal or
state law. In some circumstances, you may have a right to have this decision reviewed. Please contact the
privacy office as noted below if you have questions about access to your PHI.
You have the right to request a restriction of your PHI. You have the right to ask that we limit how
we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we
accept your request, we will put any limits in writing and abide by them except in emergency situations.
You may not limit the uses and disclosures that we are legally required or allowed to make.
You have the right to correct or update your PHI. This means that you may request an amendment
of PHI about you for as long as we maintain this information. In certain cases we may deny your request
for an amendment. If we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy
of any such rebuttal. If your PHI was sent to us by another, we may refer you to that person to amend
your PHI. For example, we may refer you to your dentist to amend your treatment chart or to your
employer, if applicable, to amend your enrollment information. Please contact the privacy office as noted
below if you have questions about amending your PHI.
You have the right to request or receive confidential communications from us by alternative
means or at a different address. We will agree to a reasonable request if you tell us that disclosure of
your PHI could endanger you. You may be required to provide us with a statement of possible danger, a
different address, another method of contact or information as to how payment will be handled. Please
make this request in writing to the privacy office as noted below.
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You have the right to receive an accounting of certain disclosures we have made, if any, of your
PHI. This right does not apply to disclosures for purposes of treatment, payment, or health care
operations or for information we disclosed after we received a valid authorization from you. Additionally,
we do not need to account for disclosures made to you, to family members or friends involved in your
care, or for notification purposes. We do not need to account for disclosures made for national security
reasons or certain law enforcement purposes, disclosures made as part of a limited data set, incidental
disclosures, or disclosures made prior to April 14, 2003. Please contact the privacy office as noted below if
you would like to receive an accounting of disclosures or if you have questions about this right.
You have the right to get this notice by e-mail. You have the right to get a copy of this notice by e-
mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy
of this notice.
Complaints
You may complain to us or to the U. S. Secretary of Health and Human Services if you believe that Delta
Dental has violated your privacy rights. You may file a complaint with us by notifying the privacy office as
noted below. We will not retaliate against you for filing a complaint.
Contacts
Delta Dental of California offers and administers fee-for-service dental plans for groups headquartered in
the state of California.
You may contact the Privacy Department at the address and telephone number listed below for further
information about the complaint process or any of the information contained in this notice.
Delta Dental Subscriber Services
P.O. Box 997330
Sacramento, CA 95899-7330
(877) 335-8273
This notice is effective on and after July 1, 2006.
