Dental Plan definitions
A person licensed to practice dentistry in the state or country in which the dental services are provided.
Diagnostic and preventive services
Services and procedures used to evaluate existing conditions and/or to prevent the occurrence of dental abnormalities or disease. Such services include examinations, prophylaxis (cleaning) and topical application of fluoride solution.
Maximum Approved Fee
A system used by Delta Dental to determine the approved fee for a given procedure for a given Delta Dental participating dentist. A fee meets Maximum Approved Fee requirements if it is the lowest of:
- The submitted amount
- The lowest fee regularly charged, offered, or received by an individual dentist for a dental service, irrespective of the dentist's contractual agreement with another dental benefits organization
- The maximum fee that Delta Dental approves for a given procedure in a given region and/or specialty, under normal circumstances
Delta Dental may also approve a fee under unusual circumstances. Participating dentists are not allowed to charge Delta Dental patients more than the Maximum Approved Fee for the covered service. In all cases, Delta Dental will make the final determination about what is the Maximum Approved Fee for the covered service.
A licensed dentist who has not signed an agreement with Delta Dental. Delta Dental's payment is sent to the employee, who is responsible for making full payment to the non-participating dentist.
Services and treatment required for the correction of malpositioned teeth.
A licensed dentist who has signed an agreement to participate in Delta Dental Premier or Delta Dental PPO. A participating dentist agrees to accept Delta Dental's payment and the patient's payment, if any, as payment in full. Delta Dental's payment is sent directly to the participating dentist.
A procedure in which the dentist submits a treatment plan and expected charges to Delta Dental before rendering services. Delta Dental reviews the treatment plan and notifies the patient and dentist of its determination regarding covered services and the amount of benefits payable. Payment for predetermined services is contingent on continued eligibility of the patient. Generally, a pre-treatment estimate is recommended for procedures that are expected to cost $200 or more, but Delta Dental will predetermine benefits for less expensive procedures.
Services to rebuild and repair natural tooth structure damaged by disease or injury. Minor restorative services include amalgam and resin fillings. Major restorative services include crowns, jackets and gold-related services when the teeth cannot be restored with another filling material.