Appeal — An appeal is a written or oral request from an enrollee or, if authorized by the enrollee, the enrollee's representative to change a previous decision made by DDWA concerning: a) access to dental care benefits, including an adverse determination made pursuant to utilization review; b) claims handling, payment, or reimbursement for dental care and services; c) matters pertaining to the contractual relationship between an enrollee and DDWA or d) other matters as specifically required by state law or regulation. For an appeal related to PEBB eligibility or enrollment, see “Appeal Rights” in the “Eligibility and Enrollment” section for more information. Caries — Decay. A disease process initiated by bacterially produced acids on the tooth surface. Coinsurance — DDWA will pay a predetermined percentage of the cost of your treatment (see Reimbursement Levels for Allowable Benefits under the Benefit Levels for Uniform Dental Plan) and you are responsible for paying the balance. What you pay is called the coinsurance. It is paid even after a deductible is reached. Continuation coverage: The temporary continuation of PEBB benefits available to enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), the Uniformed Services Employment and Reemployment Rights Act (USERRA), or PEBB policies. DDWA — Delta Dental of Washington, a not-for-profit dental service corporation. Dental Emergency — The emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a dental condition exists that requires immediate dental attention, if failure to provide dental attention would result in serious impairment to oral functions or serious dysfunction of the mouth or teeth, or would place the person's oral health in serious jeopardy. Dental Necessity — A service is “dentally necessary” if it is recommended by your treating provider and if all of the following conditions are met. Dentist — A licensed dentist legally authorized to practice dentistry at the time, and in the place, services are performed. This Plan provides for covered services only if those services are performed by or under direction of a licensed dentist or other DDWA-approved licensed professional. A “licensed dentist” does not mean a dental mechanic or any other type of dental technician. Dependent — Eligible dependent as described in the dependent eligibility section of this certificate who is covered under the subscriber. Eligible Dependent — Any dependent of an Eligible Subscriber who meets the conditions of eligibility established by Group as described in the eligibility section of this certificate. Employing agency — A division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by HCA statute. Endodontics — The diagnosis and treatment of dental diseases, including root canal treatment, affecting dental nerves and blood vessels. Enrollee — The subscriber or dependent enrolled in this plan. Experimental or Investigative — A service or supply that is determined by the Uniform Dental Plan to meet any one of the following criteria. If any of these situations are met, the service or supply is considered experimental and/or investigative, and benefits will not be provided. 1. It cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration (FDA), and such approval has not been granted on the date it is furnished. 2. The provider has not demonstrated proficiency in the service, based on knowledge, training, experience, and treatment outcomes. 3. Reliable evidence shows the service is the subject of ongoing clinical trials to determine its safety or effectiveness. 2024-01-03000-BB 2 LG PPOL 20240101