Certificate of Coverage Table of Contents Certificate of Coverage ................................................................................................................iii Table of Contents .........................................................................................................................iii Introduction................................................................................................................................... 1 Terms Used in This Booklet ........................................................................................................ 1 Retiree Participation..................................................................................................................... 4 Choosing a Primary Care Dentist (PCD) .................................................................................... 4 Appointments ............................................................................................................................... 5 Specialty Services ........................................................................................................................ 5 Urgent Care .................................................................................................................................. 5 Emergency Care .......................................................................................................................... 5 Benefit Period ............................................................................................................................... 5 Communication Access Assistance ............................................................................................ 6 Basic Benefits ..................................................................................................................... 15 Prosthodontic Services .............................................................................................................. 15 Implant Services......................................................................................................................... 16 Orthodontic Services.................................................................................................................. 16 Temporomandibular Joint Treatment ........................................................................................ 16 Orthognathic Surgery ................................................................................................................. 17 Dental Limitations and Exclusions ..................................................................................... 17 General Exclusions............................................................................................................. 20 Governing Administrative Policies ............................................................................................. 21 Eligibility for subscribers and dependents................................................................................. 24 Enrollment for subscribers and dependents ............................................................................. 25 Medicare eligibility and enrollment ............................................................................................ 27 When dental coverage begins ................................................................................................... 27 Making changes ......................................................................................................................... 29 When dental coverage ends ...................................................................................................... 32 General provisions for eligibility and enrollment ....................................................................... 34 When a Third Party is Responsible for Injury or Illness (Subrogation) .................................... 35 Claim Review and Appeal ...................................................................................................... 36 Confirmation of Treatment and Cost ..................................................................................... 36 Urgent Confirmation of Treatment and Cost Requests......................................................... 36 Appeals of Denied Claims ...................................................................................................... 37 How to contact us ................................................................................................................... 37 Authorized Representative..................................................................................................... 37 Informal Review ...................................................................................................................... 37 Formal Review........................................................................................................................ 37 When the Member Has Other Dental Coverage ....................................................................... 38 Subscriber Rights and Responsibilities ..................................................................................... 42 HIPAA Disclosure Policy............................................................................................................ 43 Nondiscrimination and Language Assistance Services............................................................ 44 This booklet sets forth in summary form an explanation of the coverage available under your dental plan. For customer service, call the Delta Dental of Washington DeltaCare® Client Services Team at 1-800-650-1583 2024-01-03100-BB iii DCL 20240101