• 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. 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.
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-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
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”).
HCDFB-DFS439
06-21
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-DFS445
06-21
HCDFB-DFS440
01-18
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.
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.
HCDFB-DFS446
06-21
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.
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