Reso 2001-399 - Laserfiche WebLink

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(22) itemized or separated charges for dental services, supplies or materials when those services, supplies and materials may be combined into a single, more comprehensive procedure payable under this Policy. This also includes itemized charges which are routinely included in the Dentist's charge for the primary service, such as: (a) sterilization or asepsis charges; (b) a charge for local anesthesia; (c) charges for pre- and post-operative care; (d) temporary dental services (for example, a temporary crown), which are considered to be part of the permanent service. If the temporary service is billed separately, benefIts for the temporary service will be deducted from the amount payable for the permanent service. (23) duplication of services. (24) charges for which the Covered Person is not liable, or which would not have been made had no coverage been in force. (25) a Covered Person's dental injury or condition: (a) for which he or she is paid under Workers' Compensation or any similar law; or (b) sustained while performing military service, (26) services received for dental conditions caused directly or indirectly by: (a) war or an act of war; (b) intentionally self-inflicted injury; (c) engaging in an illegal occupation; (d) commission or attempt to commit a felony; or (e) a Covered Person's active participation in a riot. (27) treatment rendered by a Dentist or dental hygienist: (a) who ordinarily resides in the Covered Person's household; or (b) who is related to the Covered Employee or Dependent by blood, marriage or legal adoption, "Related" persons include the Employee's or Dependent's spouse, siblings, parents, children and grandparents. (28) root planing; unless the presence of periodontal disease (bone and attachment loss of 4mm or more) is confmned by x-rays and pocket depth charting of each tooth involved. 22 Has lMJ, (I-Ill) 09/01/01 GLll-16B-EX FL