Common use of Benefits, Limitations and Exclusions Clause in Contracts

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for hisƒher services or the maximum allowable amount heƒshe has agreed to accept as payment for covered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber, participant, or beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by law, and will be based on the Benefit Payment provisions set forth in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, participant, or beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed, and paid in accordance with this Plan Agreement and the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for hisƒher his/her services or the maximum allowable amount heƒshe he/she has agreed to accept as payment for covered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber, participant, or beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by law, and will be based on the Benefit Payment provisions set forth in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, participant, or beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed, and paid in accordance with this Plan Agreement and the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for hisƒher his/her services or the maximum allowable amount heƒshe he/she has agreed to accept as payment for covered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered charges, deductible and co−payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber, participant, or beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by applicable law, and will be based on the Benefit Payment provisions set forth in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, participant, or beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed, and paid in accordance with this Plan Agreement and the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.

Benefits, Limitations and Exclusions. Under the Delta Dental participating agreements with participating dentists, benefit claims are reimbursed based on the lesser of the dentist’s submitted fee for hisƒher his/her services or the maximum allowable amount heƒshe he/she has agreed to accept as payment for covered services in accordance with the Participating Dentist Agreement applicable to the plan. Participating dentists accept the maximum allowable amount as payment in full. Subscribers, participants, and beneficiaries are responsible only for any non−covered non-covered charges, deductible and co−payment co-payment amounts, and any charges over the plan maximum. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, dependent, and beneficiary, agrees to all benefit terms and conditions, limitations and exclusions, and other Plan benefit conditions as found herein and in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. The appendix(ices) defines substantially all of the benefit claims, limitations and exclusions utilized in the ordinary course of business; however, the complete benefit limitations and exclusions of this Plan may change from time to time in conjunction with new guidelines for dental care and the profession of dentistry, as approved by DDPOK’s Board of Directors to be used in processing treatment plans for predetermination of benefits and for claim adjudication payment. In order to be apprised of the current, complete benefit limitations and exclusions for this Plan, please contact Delta Dental Plan of Oklahoma, Customer Service Department, P.O. Box 54709, Oklahoma City, Oklahoma 73154. If a Subscriber, participant, or beneficiary obtains treatment from a dentist who has not signed a participating agreement with Delta Dental, any benefit payment will be paid directly to the Subscriber, or to other participant or beneficiary if required by applicable law, and will be based on the Benefit Payment provisions set forth in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. Each Subscriber, participant, or beneficiary is responsible for paying the dentist and for filing their own claims. The complete DDPOK Claim and Appeal Procedure manual shall be the governing policy of all claims and appeals, and shall be administered in accordance with the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All claims shall be evaluated, reviewed, and paid in accordance with this Plan Agreement and the appendix(ices) attached and forming a part of this Plan Agreement by reference herein. All deductibles, maximum benefit payments, and covered classes of benefit services as applicable to this Plan Agreement are defined in the appendix(ices) attached and forming a part of this Plan Agreement by reference herein.. Form No. 1000.1 Page 14 of 18 Confidential Fully-Insured Plan Agreement Revised January 2022