DENTALLY NECESSARY dental services determined by a Dentist to either establish or maintain a patient's dental health based on the professional diagnostic judgment of the Dentist and the prevailing standards of care in the professional community. The determination will be made by the Dentist in accordance with guidelines established by the Plan.
DENTALLY NECESSARY. In addition to the further terms and conditions of the Agreement, including the Incorporated Documents, Participating Dentist shall furnish and will receive payment only for dental services that are Dentally Necessary. Delta Dental shall not be responsible to pay for dental services that are not Dentally Necessary. Prior to providing a Covered Enrollee with dental services that are not Dentally Necessary, a Participating Dentist shall inform the Covered Enrollee of Delta Dental’s payment policies and obtain a written acknowledgement from the Covered Enrollee that he/she has been informed that the dental services may not be paid by a third party. In the event a payment is made to Participating Dentist by Delta Dental for dental services that are later determined not to be Dentally Necessary, Delta Dental (or the applicable regulatory agency) may recoup payment pursuant to Section 9 above. A procedure, service or supply shall be considered “Dentally Necessary” if and only if Delta Dental determines that each of the following statements is true with respect to such procedure, service or supply: The diagnosis is proper; The treatment is necessary to preserve or restore the basic form and the function of the teeth and the health of the gums, bone and other tissues, which support the teeth; It is the most appropriate procedure, service or supply for the Covered Enrollee's individual circumstances; and It is consistent with and meets professionally recognized standards of dental care, and complies with criteria adopted by Delta Dental. Participating Dentist acknowledges that payments for alternate dental services in lieu of payments for services actually submitted as a claim may be made to Participating Dentist if such alternate dental services are equally effective for the treatment or maintenance of the teeth and their supporting structures. Notwithstanding the foregoing and in all events Participating Dentist shall exercise his or her independent professional judgment in providing dental services. Nothing herein shall be construed to (a) interfere with or otherwise affect the rendering of dental services by Participating Dentist in accordance with Participating Dentist’s independent professional judgment, or (b) prohibit or otherwise restrict Participating Dentist, acting within the lawful scope of his or her profession, from discussing with a Covered Enrollee the Covered Enrollee’s health status and dental care or treatment options.
