A natural tooth means any tooth or part of a tooth that is organic and formed by the natural development for the body (i.e., not manufactured). Organic portions of a tooth include the crown enamel and dentin, the root cementum and dentin, and the enclosed pulp (nerve).
The Maximum Reimbursable Charge is subject to all other benefit limitations and applicable coding and payment methodologies determined by Us. Additional information about how We determine the Maximum Reimbursable Charge is available upon request.
HCDFB-DFS431
06-21
HCDFB-DFS439
06-21
Handicapping Malocclusion The term Handicapping Malocclusion means a malocclusion which severely interferes with the ability of a person to chew food, as determined by Us.
Medicaid The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.
HCDFB-DFS433
01-18
HCDFB-DFS440
01-18
Maximum Benefit Amount The term Maximum Benefit Amount means the maximum dollar amount payable under the plan for Covered Dental Services for each Covered Person in a Calendar Year. No further benefits are payable after the Maximum Benefit Amount is reached.
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.
HCDFB-DFS438
06-21
Maximum Reimbursable Charge (MRC) The Maximum Reimbursable Charge (MRC) for Covered Dental Services is determined based on the lesser of: • the provider’s normal charge for a similar service or supply; or • the Policyholder-selected percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by Us and updated annually. If sufficient data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then state, regional or national data may be used. If sufficient data is unavailable in the database, then data in the database for similar services may be used. The percentile used to determine the Maximum Reimbursable Charge is listed in The Schedule.
HCDFB-DFS441
06-21
Medicare The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
HCDFB-DFS442
01-18
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