Oregon Group Dental Plan - Moda Health
Oregon Group Dental PlanPublic Employees Retirement SystemDelta Dental PPO PlanEffective Date: January 1, 2021Group No. 10004761Dental plans in Oregon provided by Delta Dental Plan of OregonDeltaORLGbk1-1-20211-1-2021 (10004761)(10004761)DeltaORLGbkPPO plan
TABLE OF CONTENTSWELCOME . 1MEMBER RESOURCES . 2CONTACT INFORMATION . 2MEMBERSHIP CARD . 2NETWORK . 2OTHER RESOURCES . 2USING THE PLAN . 3NETWORK INFORMATION . 3In-Network Delta Dental Dentists . 3Out-of-Network Dentists . 3PREDETERMINATION OF BENEFITS . 4BENEFITS AND LIMITATIONS . 5CLASS I:. 6Diagnostic . 6Preventive . 6CLASS II:. 7Restorative . 7Oral Surgery. 7Endodontic . 7Periodontic . 8Anesthesia Services . 8CLASS III:. 8Restorative . 8Prosthodontic . 9Other . 10GENERAL LIMITATION – OPTIONAL SERVICES . 10ORAL HEALTH, TOTAL HEALTH BENEFITS . 11ORAL HEALTH, TOTAL HEALTH BENEFITS . 11Diabetes . 11Pregnancy . 11HOW TO ENROLL . 11HEALTH THROUGH ORAL WELLNESS PROGRAM . 12HOW TO FIND A DENTIST REGISTERED WITH THE HEALTH THROUGH ORAL WELLNESS PROGRAM . 12CLINICAL RISK ASSESSMENT . 12Tooth Decay Risk Assessment . 12Gum Disease Risk Assessment . 13Oral Cancer Risk Assessment . 13DeltaORLGbk 1-1-2021 (10004761)PPO plan
ENHANCED BENEFITS. 13Tooth Decay and Gum Disease Enhanced Benefits . 13Oral Cancer Enhanced Benefits . 13Limitations . 13WHEN ENHANCED BENEFITS END . 14EXCLUSIONS . 15ELIGIBILITY . 18ELIGIBLE PERSONS . 18DEPENDENT CHILDREN . 18DEPENDENT DOMESTIC PARTNERS . 19NEW DEPENDENTS . 19ELIGIBILITY AUDIT . 19ENROLLMENT . 20ENROLLING ELIGIBLE PERSONS. 20New Retiree . 20Medicare Eligibility . 20WHEN COVERAGE BEGINS . 20WHEN COVERAGE ENDS . 21Termination of the Group Plan . 21Termination by Subscriber . 21Subscriber’s Death. 21Loss of Eligibility by Dependent . 21Medicare Eligibility . 22Rescission . 22Continuing Coverage . 22CLAIMS ADMINISTRATION & PAYMENT . 23SUBMISSION AND PAYMENT OF CLAIMS . 23Claim Submission. 23Explanation of Benefits (EOB) . 23Claim Inquiries . 23APPEALS . 23Definitions . 23Time Limit for Submitting Appeals . 24The Review Process . 24First Level Appeals . 24Second Level Appeal . 24BENEFITS AVAILABLE FROM OTHER SOURCES . 25Coordination of Benefits (COB) . 25Third Party Liability . 29Motor Vehicle Accident Recovery . 31DeltaORLGbk 1-1-2021 (10004761)PPO plan
MISCELLANEOUS PROVISIONS . 33RIGHT TO COLLECT AND RELEASE NEEDED INFORMATION . 33CONFIDENTIALITY OF MEMBER INFORMATION . 33TRANSFER OF BENEFITS . 33RECOVERY OF BENEFITS PAID BY MISTAKE . 33CORRECTION OF PAYMENTS . 33CONTRACT PROVISIONS . 34WARRANTIES . 34LIMITATION OF LIABILITY . 34PROVIDER REIMBURSEMENTS . 34INDEPENDENT CONTRACTOR DISCLAIMER . 34NO WAIVER . 35GROUP IS THE AGENT . 35GOVERNING LAW . 35WHERE ANY LEGAL ACTION MUST BE FILED . 35TIME LIMIT FOR FILING A LAWSUIT . 35CONTINUATION OF DENTAL COVERAGE . 36OREGON CONTINUATION FOR SPOUSES & DEPENDENT DOMESTIC PARTNERS* AGE 55 AND OVER. 36Introduction . 36Eligibility . 36Notice and Election Requirements . 36Premiums . 37When Coverage Ends. 37COBRA CONTINUATION COVERAGE . 37Introduction . 37Qualifying Events . 38Other Coverage . 38Notice and Election Requirements . 38COBRA Premiums . 39Length of Continuation Coverage . 39Extending the Length of COBRA Coverage. 40Special Enrollment and Open Enrollment . 41When Continuation Coverage Ends . 41DEFINITIONS . 42TOOTH CHART . 46DeltaORLGbk 1-1-2021 (10004761)PPO plan
WELCOMEDelta Dental Plan of Oregon (abbreviated as Delta Dental), was created in 1955 and is a foundingmember of the Delta Dental Plans Association. Delta Dental Plan of Oregon is the state’s largestdental insurer, offering coverage in the commercial market and administering the Oregon HealthPlan.Delta Dental is pleased to have been chosen by the Group as its dental plan. This handbook isdesigned to provide members with important information about the Plan’s benefits, limitationsand procedures.Members may direct questions to one of the numbers listed in section 2.1 or access tools andresources on Delta Dental’s personalized member website, Member Dashboard, atwww.modahealth.com/pers Member Dashboard is available 24 hours a day, 7 days a weekallowing members to access plan information whenever it is convenient.Delta Dental reserves the right to monitor telephone conversations and email communicationsbetween its employees and its members for legitimate business purposes as determined by DeltaDental.This handbook may be changed or replaced at any time, by the Group or Delta Dental, withoutthe consent of any member. The most current handbook is available on Member Dashboard,accessed through the Delta Dental website. All plan provisions are governed by the Group’s policywith Delta Dental. This handbook may not contain every plan provision.WELCOMEDeltaORLGbk 1-1-2021 (10004761)1PPO plan
MEMBER RESOURCESCONTACT INFORMATIONDelta Dental Website (log in to Member Dashboard)www.modahealth.com/persIncludes many helpful features, such as Find Care (use to find an in-network dentist)Dental Customer Service DepartmentToll-free 844-827-7379Telecommunications Relay Service for the hearing impaired711Delta DentalP.O. Box 40384Portland, Oregon 97240MEMBERSHIP CARDAfter enrolling, members will receive ID (identification) cards that will include the group andidentification numbers. Members will need to present the card each time they receive services.Members may go to Member Dashboard or contact Customer Service for replacement of a lostID card.NETWORKSee Network Information (section 3.1) for details about how networks work.Dental networkDelta Dental Premier NetworkDelta Dental PPO NetworkOTHER RESOURCESAdditional member resources providing general information about the Plan can be found insection 11 and section 14.MEMBER RESOURCESDeltaORLGbk 1-1-2021 (10004761)2PPO plan
USING THE PLANFor questions about the Plan, members should contact Customer Service. This handbookdescribes the benefits of the Plan. It is the member’s responsibility to review this handbookcarefully and to be aware of the Plan’s limitations and exclusions.At a first appointment, members should tell the dentist that they have dental benefits throughDelta Dental. Members will need to provide their subscriber identification number and DeltaDental group number to the dentist. These numbers are located on the ID card.NETWORK INFORMATIONDelta Dental plans are easy to use and cost effective. This plan offers the same annual maximumplan payment limit, deductibles, and coinsurance whether a member sees an in-network dentist(Delta Dental PPO or Delta Dental Premier) or an out-of-network dentist.If members choose an in-network dentist (available on Member Dashboard by using Find Care),all of the paperwork takes place between Delta Dental and the dentist’s office. For membersoutside Oregon, Delta Dental national affiliation with Delta Dental Plans Association providesoffices and/or contacts in every state. Also, dental claims incurred any place in the world may beprocessed in Oregon.Members needing dental care may go to any dental office. However, there are differences inreimbursement by Delta Dental for Delta Dental PPO dentists, Delta Dental Premier dentists andout-of-network dentists. While a member may choose the services of any dentist, Delta Dentaldoes not guarantee the availability of any particular dentist.In-Network Delta Dental DentistsWhen using a Delta Dental PPO dentist or Delta Dental Premier dentist, the dentist may notcharge the member the difference between the plan allowance and the billed amount forcovered services.Payment to a Delta Dental PPO dentist will be the lesser of the PPO fee schedule and the dentist’sactual billed fees.Payment to a Delta Dental Premier dentist will be the lesser of the dentist’s filed or contractedfee with Delta Dental or fees actually charged.Out-of-Network DentistsPayment to an out-of-network dentist or dental care provider is paid at the applicablecoinsurance and limited to the amount in the PPO Fee Schedule. The member may have to paythe difference between the PPO Fee Schedule amount and the billed charge.USING THE PLANDeltaORLGbk 1-1-2021 (10004761)3PPO plan
PREDETERMINATION OF BENEFITSFor expensive treatment plans, Delta Dental provides a predetermination service. The dentistmay submit a predetermination request to get an estimate of what the Plan would pay. Thepredetermination will be processed according to the Plan’s current contract and returned to thedentist. The member and his or her dentist should review the information before beginningtreatment.USING THE PLANDeltaORLGbk 1-1-2021 (10004761)4PPO plan
BENEFITS AND LIMITATIONSBelow is a general list of services the Plan covers when performed by a dentist or dental careprovider (licensed denturist or licensed hygienist), and only when determined to be necessaryand customary by the standards of generally accepted dental practice for the prevention ortreatment of oral disease or for accidental injury. Delta Dental’s dental consultants and dentaldirector shall determine these standards.Payment of covered expenses is always limited to the maximum plan allowance. In no case willbenefits be paid for services provided beyond the scope of a dentist’s or dental care provider’slicense, certificate or registration. Services covered under the medical portion of a member’s planwill not be covered on this Plan except when related to an accident.Covered dental services are outlined in 3 classes that start with preventive care and advance intobasic and major dental procedures. Limitations may apply to these services, and are noted below.See section 7 for exclusions.All annual or per year benefits or cost sharing accrue based on a calendar year (January 1 throughDecember 31) or portion thereof. Frequency limitations are calculated from the previous date ofservice or initial placement, unless otherwise specified.Deductible: 25Per member per year, or portion thereofDeductible applies to covered Class II and Class III servicesAnnual maximum plan payment limit: 1,500Per member per calendar year, or portion thereofAll covered services except class I apply to the annual maximum plan payment limit.Members are responsible for expenses that exceed the annual maximum plan payment limit.Waiting Period: Benefits are not available for oral surgery, restorative, endodontic, periodontic,and prosthodontic services under Class II and Class III services for the first 12 monthsfollowing a member's effective date of coverage.The waiting period will be waived for those members transferring from another group dentalplan with 12 months of continuous coverage.The waiting period does not apply to medicaments covered under the Health through OralWellness program for members who qualify for this benefit.BENEFITS AND LIMITATIONSDeltaORLGbk 1-1-2021 (10004761)5PPO plan
CLASS I:COVERED SERVICES PAID AT 100%.Diagnostica. Diagnostic Services:i. Examinationii. Intra-oral x-rays to assist in determining required dental treatment.b. Diagnostic Limitations:i. Periodic (routine) or comprehensive examinations (including problem focusedcomprehensive examinations) or consultations are covered twice per year.ii. Limited examinations or re-evaluations are covered twice per yeariii. A separate charge for teledentistry is not covered. Teledentistry is included in thefees for overall patient management.iv. Complete series x-rays or a panoramic film is covered once in any 5-year periodv. Supplementary bitewing x-rays are covered once per yearvi. Separate charges for review of a proposed treatment plan or for diagnostic aids suchas study models and certain lab tests are not coveredvii. Only the following x-rays are covered by the Plan: complete series or panoramic,periapical, occlusal and bitewingPreventivea. Preventive Services:i. Prophylaxis (cleanings)ii. Additional cleaning benefit is available for members with diabetes and members intheir third trimester of pregnancy. To be eligible for this additional benefit,members must be enrolled in the Oral Health, Total Health program (see section 5).iii. Periodontal maintenanceiv. Topical application of fluoridev. Sealantsvi. Space maintainersb. Preventive Limitations:i. Prophylaxis (cleaning) or periodontal maintenance is covered twice per year.Additional periodontal maintenance is covered for members with periodontaldisease, up to a total of 2 additional periodontal maintenances per year.ii. Adult prophylaxis is only covered for members age 12 and over. Child prophylaxis iscovered for members under age 12.iii. Topical application of fluoride is covered twice per year for members under age 19.For members age 19 and over, topical application of fluoride is covered twice peryear if there is recent history of periodontal surgery or high risk of decay due tomedical disease or chemotherapy or similar type of treatment (poor diet or oralhygiene does not constitute a medical disease).iv. Sealant benefits are limited to the unrestored occlusal surfaces of permanentmolars. Benefits will be limited to one sealant per tooth during any 5-year period.BENEFITS AND LIMITATIONSDeltaORLGbk 1-1-2021 (10004761)6PPO plan
v. Space maintainers are a benefit once per space for members under age 14. Spacemaintainers for primary anterior teeth, missing permanent teeth or for membersage 14 and over are not covered.CLASS II:COVERED SERVICES PAID AT 80%.Restorativea. Restorative Services:i. Amalgam fillings and composite fillings for the treatment of decayii. Stainless steel crownsb. Restorative Limitations:i. Inlays are considered an optional service. An alternate benefit of an amalgam fillingwill be provided.ii. Fillings on anterior or posterior teeth are limited to once per tooth every 24-monthsiii. Crown buildups are considered to be included in the crown restoration cost. Abuildup will be a benefit only if necessary for tooth retention.iv. Prefabricated and indirectly fabricated post and core in addition to a crown are onlycovered when less than half of the coronal (above the gum) tooth structure remains.v. Replacement of a stainless steel crown by the same dentist within a 2-year periodof placement is not covered. The replacement is included in the charge for theoriginal crown.vi. Additional limitations when teeth are restored with crowns or cast restorations arein section 4.3.1.Oral Surgerya. Oral Surgery Services:i. Extractions (including surgical)ii. Other minor surgical proceduresb. Oral Surgery Limitations:i. A separate, additional charge for alveoloplasty done in conjunction with removal ofteeth is not covered.ii. Surgery on larger lesions or malignant lesions is not considered minor surgery.Endodontica. Endodontic Services:i. Procedures for treatment of teeth with diseased or damaged nerves (for example,pulpal therapy and root canal filling).b. Endodontic Limitations:i. A separate charge for cultures is not covered.ii. A separate charge for pulp removal done with a root canal or root repair is notcovered.BENEFITS AND LIMITATIONSDeltaORLGbk 1-1-2021 (10004761)7PPO plan
iii. A separate charge for pulp capping is not coverediv. Retreatment of the same tooth by the same dentist within a 2-year period of a rootcanal is not eligible for additional coverage. The retreatment is included in thecharge for the original care.Periodontica. Periodontic Services:i. Treatment of diseases of the gums and supporting structures of the teeth and/orimplants.b. Periodontic Limitations:i. Periodontal scaling and root planing is limited to once per quadrant in any 2-yearperiod.ii. Periodontal maintenance is covered under Class I, Preventive.iii. A separate charge for post-operative care done within 3 months followingperiodontal surgery is not covered.iv. Additional periodontal surgical procedures by the same dentist to the same sitewithin a 3-year period of an initial periodontal surgery are not covered.v. Full mouth debridement is limited to once in a 2-year period and, if the member isage 19 or older, only if there has been no cleaning (prophylaxis, periodontalmaintenance) within a 2-year period.Anesthesia Servicesa. General anesthesia or IV sedationCovered only:i. In conjunction with covered surgical procedures performed in a dental officeii. When necessary due to concurrent medical conditionsCLASS III:COVERED SERVICES PAID AT 50%.Restorativea. Restorative Services:i. Cast restorations, such as crowns, onlays or lab veneers, necessary to restoredecayed or broken teeth to a state of functional acceptability.b. Restorative Limitations:i. Cast restorations (including pontics) are covered once in a 7-year period on anytooth. See 4.2.1 for limitations on buildups.ii. Porcelain restorations are considered cosmetic dentistry if placed on the uppersecond or third molars or the lower first, second or third molars. Coverage is limitedto gold without porcelain, and the member is responsible for paying the difference.BENEFITS AND LIMITATIONSDeltaORLGbk 1-1-2021 (10004761)8PPO plan
iii. If a tooth can be restored by an amalgam or composite filling, but another type ofrestoration is selected by the member or dentist, covered expense will be limited toa composite. Crowns are only a benefit if the tooth cannot be restored by a routinefilling.iv. Re-cement or re-bond of a crown, inlay, or veneer, by the same dentist, is limited toonce per lifetime.Prosthodontica. Prosthodontic Services:i. Bridgesii. Partial and complete denturesiii. Denture relinesiv. Repair of an existing prosthetic devicev. Implants and implant maintenancevi. Surgical stent in conjunction with a covered surgical procedureb. Prosthodontic Limitations:i. A bridge or a full or partial denture will be covered once in a 7-year period and onlyif the tooth, tooth site, or teeth involved have not received a cast restoration benefitin the last 7 years.ii. Full, immediate and overdentures: If personalized or specialized techniques areused, the covered amount will be limited to the cost for a standard full denture.Temporary (interim or provisional) complete dentures are not covered.iii. Partial dentures: A temporary (interim) partial denture is only a benefit when placedwithin 2 months of the extraction of an anterior tooth or for missing anteriorpermanent teeth of members age 16 or under. If a specialized or precision device isused, covered expense will be limited to the cost of a standard cast partial denture.No payment is provided for cast restorations for partial denture retainer teethunless the tooth requires a cast restoration due to being decayed or broken.iv. Denture adjustments, repairs and relines: A separate, additional charge for dentureadjustments, repairs and relines done within 6 months after the initial placement isnot covered. Subsequent relines are covered once per denture in a 12-monthperiod. Subsequent adjustments are limited to 2 adjustments per denture in a 12month period.v. Tissue conditioning is covered no more than twice per denture in a 3-year period.vi. Surgical placement and removal of implants are covered. Implant placement andimplant removal are limited to once per lifetime per tooth space. Scaling anddebridement of an implant is covered once in a 2-year period. Implant maintenanceis limited to once every 3 years. The Plan will also cover:A. The final crown and implant abutment over a single implant. This benefitis limited to once per tooth or tooth space over the lifetime of the implant;orB. Provide an alternate benefit per arch of a full or partial denture for thefinal implant-supported full or partial denture prosthetic device when theimplant is placed to support a prosthetic device; orC. The final implant-supported bridge retainer and implant abutment, orpontic. The benefit is limited to once per tooth or tooth space over thelifetime of the implant.BENEFITS AND LIMITATIONSDeltaORLGbk 1-1-2021 (10004761)9PPO plan
D. Implant-supported bridges are not covered if 1 or more of the retainers issupported by a natural tooth.E. These benefits or alternate benefits are not provided if the tooth, implant,or tooth space received a cast restoration or prosthodontic benefit,including a pontic, within the previous 7 years.vii. Fixed bridges or removable
Delta Dental Plan of Oregon (abbreviated as Delta Dental), was created in 1955 and is a founding member of the Delta Dental Plans Association. Delta Dental Plan ofOregon is the state’s largest dental insurer , offering coverage in the com
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DENTAL SCIENCES 1 Chapter 1 I Dental Assisting— The Profession 3 The Career of Dental Assisting 4 Employment for the Dental Assistant 4 The Dental Team 6 Dental Jurisprudence and Ethics 12 Dental Practice Act 12 State Board of Dentistry 12 The Dentist, the Dental Assistant, and the Law 13 Standard of Care 13 Dental Records 14 Ethics 14
Cigna Dental Care DMO Patient Charge Schedules 887394 09/15 CDT 2016 Covered under Procedure Code1 Dental Description and Nomenclature Cigna Dental 01 and 02 PCS Cigna Dental 03 PCS Cigna Dental 04 PCS Cigna Dental 05 PCS Cigna Dental 06 PCS Cigna Dental 07 PCS Cigna Dental 08 PCS Chair Time Per Y/N Minutes Code # (if different) Y/N Code # (if .
is a detailed list of dental services provided by a dental office and given to Delta Dental for payment. Delta Dental means Delta Dental Plan of Michigan, Inc., a service provider for dental benefits under the Michigan Dental Program. Delta Dental ID Card is a permanent (not monthly) card. We send
The Dentists Insurance Company, an insurance company domiciled in the State of California ("TDIC"), TDIC Insurance Solutions, a California corporation ("TDIC IS" and together with TDIC, each a "Purchaser" and together the "Purchasers"), and Moda, Inc., an Oregon corporation ("Moda"), and Moda .
Delta Dental of Oregon at no charge to the patient. 2. Accept Delta Dental of Oregon benefit payments for services provided. 3. Submit a list of fees to be filed with Delta Dental of Oregon for payment of dental services provided to covered patients. a. Any change in fee schedules is limited to once every six months. b.
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