Medically Necessary and/or Dentally Necessary Services provided by a Dentist or physician as determined by Us are Medically Necessary and/or Dentally Necessary if they are: • required for the diagnosis and/or treatment of the particular dental condition or disease; and • consistent with the symptom or diagnosis and treatment of the dental condition or disease; and • commonly and usually noted throughout the medical/dental field as proper to treat the diagnosed dental condition or disease; and • the most fitting level or service which can safely be given to You or Your Dependent. A diagnosis, treatment and service with respect to a dental condition or disease, is not Medically Necessary and/or Dentally Necessary if made, prescribed or delivered solely for convenience of the patient or provider.
Orthodontic Treatment The term Orthodontic Treatment means the corrective movement of the teeth through the alveolar bone by means of an active appliance to correct a Handicapping Malocclusion of the mouth.
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Participating Provider The term Participating Provider means: a Dentist, or a professional corporation, professional association, partnership, or other entity which is entered into a Contract with Us to provide dental services at predetermined fees. The providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers will be provided by Your Employer. Services received from Participating Providers are considered in- network (“In-Network”).
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Medicare The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
Policy The term Policy means a written agreement between the Policyholder and Us outlining the terms and conditions under which We agree to insure certain Employees and pay benefits.
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Non-Participating Provider The term Non-Participating Provider means a Dentist, or a professional corporation, professional association, partnership, or other entity that has not entered into a Contract with Us to provide dental services. Services received from Non- Participating Providers are considered out-of-network (“Out- of-Network”).
Policyholder The term Policyholder means the owner of the group Policy as identified on the certification page.
HCDFB-DFS455
06-21
Qualified Medical Child Support Order A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) or administrative notice, which is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child
HCDFB-DFS445
06-21
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