Common use of Dental Services Clause in Contracts

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which the Member turns nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which the Member turns nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or orthodontic care. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Us. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation • Radiographs (x-rays)

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which when the Member member turns nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which when the Member member turns nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodonticperiodontics, prosthetic, or orthodontic careorthodonticcare. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Us. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months months. o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation evaluation. • Radiographs (x-rays)

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which when the Member member turns nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which when the Member member turns nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodonticperiodontics, prosthetic, or orthodontic care. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Us. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • ● Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months months. o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation • evaluation. ● Radiographs (x-rays)

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which when the Member member turns nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which when the Member member turns nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodonticperiodontics, prosthetic, or orthodontic care. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Us. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months months. o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation evaluation. • Radiographs (x-rays)

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which the Member turns under nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which the Member turns under nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or orthodontic care. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Usus. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation • Radiographs (x-rays)

Dental Services. Child For Members under nineteen (19) years of age The dental benefits described in this section only apply to Members until the end of the month in which the Member turns nineteen (19) years of age. See “Dental – Child Dental Services” in the SUMMARY OF BENEFITS for additional information. This Agreement covers the dental services below for Members until the end of the month in which the Member turns nineteen (19) years of age when they are performed by a licensed dentist and when they are necessary and customary, as determined by the standards of generally accepted dental practice. If there is more than one professionally acceptable treatment for Your dental condition, the Plan will cover the least expensive treatment. Benefits for pediatric oral care are covered under the dental benefit received by children under the Medi-Cal program as of 2014, pursuant to the Medi-Cal Dental Program Provider Handbook in effect during the first quarter of 2014, including coverage pursuant to the Early Periodic Screening. Your Dental Benefits Oscar does not determine whether the dental services (except orthodontic services) listed in the following sections are Medically Necessary to treat Your specific condition or restore Your dentition. When orthodontic care is covered by this Agreement, claims will be reviewed to determine if it was Medically Necessary orthodontic care. See the section “Orthodontic Care” below for more information. Your dentist may recommend or prescribe dental care services that are not covered by this Agreement, including those that are cosmetic in nature. We will cover pediatric dental benefits when medically necessary. Additional requests, beyond the stated frequency limitations shall be considered when documented dental necessity is justified due to a physical limitation and/or an oral condition that prevents daily hygiene. The decision as to what dental care treatment is best for You is solely between You and Your dentist. Pretreatment Estimate A pretreatment estimate is a valuable tool for You and Your dentist. It gives You and the dentist an idea of what Your out of pocket costs will be. This allows You and Your dentist to make any necessary financial arrangements before treatment begins. It is a good idea to get a pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or orthodontic careorthodonticcare. The pretreatment estimate is recommended, but not required for You to get benefits for Covered Services. A pretreatment estimate does not authorize treatment or determine its Medical Necessity (except for orthodontics), and does not guarantee benefits. The estimate will be based on Your current eligibility and the Agreement benefits in effect at the time the estimate is sent to Us. This is an estimate only. Our final payment will be based on the claim that is sent to Us at the time of the completed dental care service(s). Sending in other claims or changes to Your eligibility or to the Agreement may affect Our final payment. You can ask Your dentist to send pretreatment estimate for You, or You can send it to Us Yourself. Please include the procedure codes for the services to be performed (Your dentist can give these to You). Pretreatment estimate requests can be sent to Oscar. If You have questions on where to send the estimate, call Us at the number on the back of Your ID card. Diagnostic and Preventive Services • Oral evaluations – Periodic Oral Evaluation is covered up to one (1) time per six (6) months, per provider. Comprehensive Oral Evaluation is limited to one (1) per patient for initial evaluation. o Limited and problem focused oral evaluations are covered up to one per patient per provider. o Limited problem-focused oral re-evaluations are is covered up to six (6) in a three (3) month period, no more than twelve (12) in twelve (12) months o Comprehensive periodontal evaluation covered as a comprehensive oral evaluation • Radiographs (x-rays)