Benefits & Eligibility as of 
(mm/dd/yyyy) 
Use the following links to access the information you are looking for faster.
This is not a guarantee of benefits and does not cover all plan details. If there are any differences between the information stated here and the group contract, the group contract will govern. All benefits are subject to deductibles, contract maximums and eligibility on the date of service. The eligibility and benefit information is only valid for the following subscriber on the date shown above.
Eligibility and Accumulations| Subscriber Name: | HARVEY J SCHNEIDER | Group Number: | 93705-000-00000-00000 |
|---|
| Coverage Type: | Single | Group Name: | SELF INSURED |
|---|
| Electronic Claims Payer ID: | 39069 | |
|---|
|
| | Amount Used |
|---|
| Name | Date of Birth | Original Coverage Begin Date | Current Coverage End Date | | Reg Ann Deductible | Reg Ann Maximum | Orth Ann Maximum | Orth Life Maximum | Cust Ann Maximum |
|---|
| HARVEY J SCHNEIDER | 12/25/1975 | 03/01/2005 | | | $.00 | $.00 | $.00 | $.00 | $.00 |
Age Limits| Standard Coordination of Benefits |
| Child Coverage Age: | 19 | Student Coverage Age: | 23 |
| Adult Orthodontic: | No | Dependent Orthodontic Age: | 00 |
Maximums and DeductiblesProgram deductibles and maximums are calculated for a "Benefit Year" defined as: 01/01/2007 - 12/31/2007.
Subscribers are responsible for paying the following deductible amounts before Delta Dental will make payment. |
| | Delta Dental PPO | Delta Premier | Out of Network |
|---|
| Annual Maximums | $1,200.00 | $1,200.00 | $1,200.00 |
| Annual Deductibles | $25.00 | $25.00 | $25.00 |
| Lifetime Maximums | None | None | None |
| Lifetime Deductibles | None | None | None |
| Ortho Annual Maximums | None | None | None |
| Ortho Annual Deductibles | None | None | None |
| Ortho Lifetime Maximums | None | None | None |
| Ortho Lifetime Deductibles | None | None | None |
| Custom Annual Maximums | None | None | None |
| Custom Annual Deductibles | None | None | None |
| Custom Lifetime Maximums | None | None | None |
| Custom Lifetime Deductibles | None | None | None |
Benefit Levels| Services | Delta Dental PPO | Delta Premier | Out of Network |
|---|
| Benefit Level | Deductible Applies | Benefit Level | Deductible Applies | Benefit Level | Deductible Applies |
|---|
| Diagnostic | 100% | No | 100% | No | 100% | No |
| Preventive | 100% | No | 100% | No | 100% | No |
| Sealants | 100% | No | 100% | No | 100% | No |
| Basic restor | 90% | Yes | 80% | Yes | 80% | Yes |
| Major restor | 60% | Yes | 50% | Yes | 50% | Yes |
| Endodontics | 90% | Yes | 80% | Yes | 80% | Yes |
| Surg perio | 90% | Yes | 80% | Yes | 80% | Yes |
| Periodontics | 90% | Yes | 80% | Yes | 80% | Yes |
| Rmvbl prosth | 60% | Yes | 50% | Yes | 50% | Yes |
| Prosth (reb) | 60% | Yes | 50% | Yes | 50% | Yes |
| Prosth (rel) | 60% | Yes | 50% | Yes | 50% | Yes |
| Implants | None | No | None | No | None | No |
| Fixed prosth | 60% | Yes | 50% | Yes | 50% | Yes |
| Simple extract | 90% | Yes | 80% | Yes | 80% | Yes |
| Oral surgery | 90% | Yes | 80% | Yes | 80% | Yes |
| Orthodontics | None | No | None | No | None | No |
Frequency/Age Limitations| Services | Frequency Limit | Age Limitations |
|---|
| Initial/Periodic Exam | Allowed at 6 month intervals | None |
| Full Mouth or Panoramic X-rays | Allowed at 3 year intervals | None |
| Bitewing X-rays | Allowed at 6 month intervals | None |
| Child Cleaning | Allowed at 6 month intervals | 13 |
| Adult Cleaning | Allowed at 6 month intervals | 14 and Older |
| Fluoride | Allowed at 6 month intervals | 18 |
| Sealants | Generally limited to one placement per tooth on permanent unrestored 1st and 2nd molars without cavities. | 13 |
| Periodontal Maintenance | Periodontal maintenance OR regular adult prophylaxis Allowed at 6 month intervals | None |
| Periodontal Scaling | Allowed at 24 month intervals | None |
| Periodontal Surgery | Allowed at 3 year intervals | None |
| Full Mouth Debridement | Allowed at 1 per lifetime | None |
| Single Cast Restorations | Allowed at 5 year intervals | 12 and Older |
| Prosthodontics | Allowed at 5 year intervals | 16 and Older |
Waiting Periods| Services | Duration | Members Who Have Not Satisfied the Waiting Period |
|---|
| Diagnostic | None | N/A |
| Preventive | None | N/A |
| Sealants | None | N/A |
| Basic restor | None | N/A |
| Major restor | None | N/A |
| Endodontics | None | N/A |
| Surg perio | None | N/A |
| Periodontics | None | N/A |
| Rmvbl prosth | None | N/A |
| Prosth (reb) | None | N/A |
| Prosth (rel) | None | N/A |
| Fixed prosth | None | N/A |
| Simple extract | None | N/A |
| Oral surgery | None | N/A |
| Orthodontics | None | N/A |
Claims information is only included for Self-Funded groups.
Preventive History - Last Date of Service. Subject to change due to claims not yet received or processed.| HARVEY J SCHNEIDER |
| Procedure | DOS | Procedure | DOS | Procedure | DOS |
|---|
| Exam | 10/17/2006 | Fluoride | | Full Mouth or Panoramic X-rays | 08/17/2005 |
| Cleaning | 10/17/2006 | Bitewing X-rays | 10/17/2006 | | |
Claims| HARVEY J SCHNEIDER |
| Detail | From Date | To Date | Amount Charged | Delta Payment | Patient Pays | Orthodontic Schedule | Status |
|---|
| View | 12/06/2006 | 12/06/2006 | $107.00 | $68.00 | $17.00 | N | Paid |
| View | 10/17/2006 | 10/17/2006 | $145.00 | $103.20 | $25.80 | N | Paid |
| View | 04/04/2006 | 04/04/2006 | $99.00 | $67.20 | $16.80 | N | Paid |
Contact Us