8. Services for accidental injury to natural teeth when evaluation of treatment and development of a written plan is performed more than 30 days from the date of injury. Treatment must be completed within the time frame established in the treatment plan unless delay is medically indicated and the written treatment plan is modified. 9. Expenses incurred after termination of coverage, except expenses for: a. Prosthetic devices that are fitted and ordered prior to termination and delivered within 30 days after termination. b. Crowns, if the tooth is prepared prior to termination and the crown is seated on the tooth within 30 days after termination. c. Root canal treatment, if the tooth canal is opened prior to termination and treatment is completed within 30 days after termination. 10. Missed appointments. 11. Completing insurance forms or reports, or for providing records. 12. Habit-breaking appliances which are, fixed or removable device(s) fabricated to help prevent potentially harmful oral health habits (e.g., chronic thumb sucking appliance, tongue thrusting appliance etc.), except as specified under the orthodontia benefit. 13. Full-mouth restoration or replacement of sound fillings. (Replacement of sound fillings will not be covered unless at the recommendation of a licensed dentist, and a Confirmation of Treatment and Cost is required.) 14. Charges for dental services performed by anyone who is not a licensed dentist, registered dental hygienist, denturist or physician, as specified. 15. Services or supplies that are not listed as covered. 16. Treatment of congenital deformity or malformations. 17. Replacement of lost or broken dentures or other appliances. 18. Services for which an enrollee has contractual right to recover cost, whether a claim is asserted or not, under automobile, medical, personal injury protection, homeowners or other no-fault insurance. 19. In the event an Eligible Person fails to obtain a required examination from a DDWA-appointed consultant dentist for certain treatments, no benefits shall be provided for such treatment. Delta Dental of Washington shall determine whether services are covered dental benefits in accordance with standard dental practice and the general limitations and exclusions shown in the Contract. Should there be a disagreement regarding the interpretation of such benefits; the subscriber shall have the right to appeal the determination in accordance with the non-binding appeals process in this contract and may seek judicial review of any denial of coverage of benefits. Dental Plan Eligibility and Enrollment In these sections, the term “retiree” or “retiring employee” includes an elected or full-time appointed official of the legislative and executive branch of state government eligible to continue enrollment in Public Employees Benefits Board (PEBB) retiree insurance coverage. The term “retiree” or “retiring school employee” includes a retiring non- represented employee of an educational service district (ESD) or retiring school employee from a School Employees Benefits Board (SEBB) organization. Additionally, “health plan” is used to refer to a plan offering medical or dental, or both, developed by PEBB and provided by a contracted vendor or self-insured plans administered by the Health Care Authority (HCA). Eligibility for subscribers and dependents Employee eligibility The employee’s state agency will inform the employee in writing whether or not they are eligible for PEBB benefits upon employment and whenever their eligibility status changes. The written notice will include information about the employee’s right to appeal eligibility and enrollment decisions. 2024-01-03000-BB 18 LG PPOL 20240101