HomeMy WebLinkAbout2012-038 Human Resources - Delta Dental Claims & Administrative fees~\~ t:::] i~w ~
~5 ~1! t ~y
~ ~~~~o ~
,~E~~~
DELTA DENTAL SERVICE CONTRACT
for
ORANGE COUNTY
THIS DELTA DENTAL SERVICE CONTRACT (this "Contract") is effective the lst day of January, 2012, by
and among Orange County, hereinafter referred to as Contractor and Delta Dental of North Carolina, a nonprofit
corporation incorporated under the laws of the State of North Carolina, hereinafter referred to as Delta Dental.
WHEREAS, the Contractor wishes to provide self-funded dental benefits plans for its employees; and
WHEREAS, Delta Dental is in the business of underwriting, administering, and/or marketing dental plans as a
member of the Delta Dental Plans Association ("DDPA"), and wishes to facilitate the Contractor's choice of a
Delta Dental Plan for its employees; and
VVHEREAS, the Contractor wishes to adopt a Delta Dental PPO and/or Delta Dental Premier dental benefit plan
as its self-funded dental benefits plans (collectively, the "Contractor's Dental Plan"); and
WHEREAS, the Contractor wishes Delta Dental to provide all of the administrative services for the Contractor
related to the Conlractor's Dental Plan, and Delta Dental wishes to perform such administrative services.
NOW THEREFORE, in consideration of the mutual representations, warranties and covenants and subject to the
conditions contained herein, the parties hereto agree as follows:
Section I. Declarations
Attached hereto as Exhibit A are the terms, conditions, plan designs, and rates of Contractor's Dental Plan.
Attached hereto as Exhibit B are the terms and conditions contained in the Summary of Dental Plan Benefits and
Certificate or the Contractor's Summary Plan Description approved by Delta Dental.
Section II. De~nitions
A. Benefit Year
means the calendar year, unless the Contractor elects a different period to serve as the Benefit Year.
B. Benefits
means payment for Covered Services that have been selected under the Contract.
C. Contract
means this document, including, if applicable, any appendices, additional Declarations (successor
agreements or renewals, or renewal letters now or hereafter issued or executed.
Revised 09/2011
D. Copayment
means the percentage of the charge, if any, that the Eligible Person must pay for Covered Services.
E. Covered Services
means the unique dental services selected for coverage as described in Exhibit A and subject to the terms
and conditions of this Contract.
F. Deductible
means the amount a person and/or a family must pay toward Covered Services before Delta Dental begins
paying for services under this Contract. If the Contractor has selected a Deductible, it will be indicated in
Exhibit A.
G. Delta Dental
means Delta Dental of North Carolina, a non-profit health service plan corporation. Delta Dental is not a
commercial insurance company.
H. Delta Dental Plan
means an individual dental benefit plan that is a member of the Delta Dental Plans Association, the
nation's lazgest, most experienced system of dental health plans.
I. Delta Dental PPO plus Premier
means Delta Dental's national preferred provider organization that can reduce out-of-pocket expenses for
Eligible Persons if they receive care from one of Delta Dental's PPO Dentists. This program has back-up
coverage through the Delta Dental Premier network when treatment is received from a Non-PPO Dentist.
J. Delta Dental PPO (Standard)
means Delta Dental's national preferred provider organization that can reduce out-of-pocket expenses for
Eligible Persons if they receive care from one of Delta Dental's PPO Dentists.
K. Delta Dental Premier
means Delta Dental's national fee-for-service dental benefits program.
L. Dentist
means a person licensed to practice dentistry in the state or country in which dental services are rendered.
1. Delta Dental PPO Dentist (PPO Dentist) means a Dentist who has signed an agreement with the
Delta Dental Plan in his or her state to participate in Delta Dental PPO. PPO Dentists agree to accept
Delta Dental's payment and the Eligible Person's Copayment, if any, as payment in full for Covered
Services.
2. Delta Dental Premier Dentist (Premier Dentist) means a Dentist who has signed an agreement
with the Delta Dental Plan in his or her state to participate in Delta Dental Premier. Premier Dentists
agree to accept Delta Dental's payment and the Eligible Person's Copayment, if any, as payment in
full for Covered Services.
3. Nonparticipating Dentist means a Dentist who has not signed an agreement with any Delta Dental
Plan to participate in Delta Dental PPO or Delta Dental Premier.
4. Out-of-Country Dentist means a Dentist whose office is located outside of the United States and its
territories. Out-of-Country Dentists are not eligible to sign participating agreements with Delta Dental,
but may participate in the Passport Dental program.
Revised 09/2011 2
PPO Dentists and Premier Dentists are sometimes collectively referred to herein as "Participating
Dentists". Wherever a definition or provision of this Contract differs from another state's Delta Dental
Plan and its agreement with a Participating Dentist, the agreement in that state with that Dentist shall be
controlling.
Premier Dentists, Nonparticipating Dentists, and Out-of-Country Dentists are sometimes collectively
referred to herein as"Non-PPO Dentists".
M. Eligible Dependent
means (a) the Subscriber's legal spouse and (b) any other dependents who meet the criteria for eligibility
set forth in E~chibits A and/or B. If dependent coverage has been selected, it will be indicated in Exhibit A.
N. Eligible Person
means any Subscriber or Eligible Dependent under this Contract.
O. Maximum Approved Fee
means a system used by Delta Dental to detemrine the approved fee for a given procedure for a given
Participating Dentist. A fee meets Maximum Approved Fee requirements if it is the lowest o£
1. The Submitted Amount.
2. The lowest fee regularly charged, offered, or received by an individual Dentist for a dental service
or supply, irrespective of the Dentist's contractual agreement with another dental benefits
organization.
3. The xnaximum fee that the local Delta Dental Plan approves for a given procedure in a given
region and/or specialty, under normal circumstances, based upon applicable Delta Dental PPO or
Delta Dental Premier Participating Dentist schedules and intemal procedures.
Delta Dental may also approve a fee under unusual circumstances.
Participating Dentists are not allowed to charge Delta Dental patients more than the Maximum
Approved Fee for a Covered Service. In all cases, Delta Dental will make the final determination
regarding the Ma~cimum Approved Fee for a Covered Service.
P. Maximum Payment
means the maximum dollaz amount Delta Dental will pay in any Benefit Year or lifetime for Covered
Services. The Maximum Payment is specified in Exhibit A and Exhibit B.
Q. Nonparticipating Dentist Fee
means the ma~cimum fee that Delta Dental will pay per procedure for services rendered by a
Nonparticipating Dentist.
R. Out-of-Country Dentist Fee
means the maximum fee that Delta Dental will pay per procedure for services rendered by an Out-of-
Country Dentist.
S. Plan
means the dental coverage established for Eligible Persons pursuant to this Contract.
T. Post Service Claims
means claims for benefits that are not conditioned on the Eligible Person seeking advance approval,
certification, or authorization to receive the full amount of any covered benefit. In other words, Post
Service Claims arise when the Eligible Person receives the dental service or treatment before the claim
is filed for the benefit payment.
Revised 09/2011
U. PPO Dentist Schedule
means the ma~cimum amount allowed per procedure for services rendered by a PPO Dentist as
deternuned by that Dentist's local Delta Dental Plan.
V. Premier Dentist Schedule
means the maximum fee allowed per procedure for services rendered by a Premier Dentist as deternuned
by that Dentist's local Delta Dental Plan.
W. Predetermination
means a voluntary and optiona.l process where, at the request of a Subscriber, Eligible Dependent or
Dentist, Delta Dental issues a written estimate of dental benefits which may be available for a proposed
dental service under the terrns of the Subscriber's coverage.
Predeternunation is provided for informational purposes only and is not required in advance of obtaining
dental care or as a prerequisite or condition for approval of fuhue dental benefits payment. The benefits
estimate provided on a Predetermination notice is determined based on the benefits available for the
Subscriber or Eligible Dependent on the date the notice is issued, and is not a guarantee of future dental
benefits payment.
Availability of dental benefits at the time a dental service is completed depends on factors such as, but not
limited to, eligibility for benefits, annual or lifetime Maximum Payrnents, coordination of benefits,
Contract and Dentist status, Contract limitations and other provisions. A request for a Predeternunation is
not a claim for benefits or a preauthorization, precertification or other reservation of future benefits..
X. Processing Policies
means Delta Dental's policies and guidelines used for Predeternunation and payment of claims. The
Processing Policies may be amended from time to time.
Y. Rate
means the amount, per Subscriber and Subscriber classification, the Contractor agrees to pay Delta Dental each
month. This amount, or the information necessary to compute it, is specified in Exhibit A.
Z. Submitted Amount
means the amount a Dentist bills to Delta. Dental for a specific treatment. A Participating Dentist cannot charge
the Eligible Person for the difference between this amount and the amount Delta Dental approves for the
h-eatment.
AA. Subscriber
means all people who are a members of the group specified in Exhibit A and aze certified as being eligible
by the Contractor and are enrolled to receive Benefits under this Contract.
Section III. Agreements
A. Delta Dental agrees:
1. To provide all claims processing, service, and administration for a group. Delta Dental shall provide
all administrative services related to the Plan, including, but not limited to (a) adjudication,
processing, and payment of claims; (b) providing the Plan with access to the Delta Dental National
Provider network, network development, contracting and ongoing relations with dentists with respect
to the Dental Plan, and interfacing with other Delta Dental Plans for network access and
development activities in other states as required by the Plan; (c) assisting the Plan with establishing
underwriting standazds, if any, for the Dental Plan; (d) providing all customer service functions for
the Plan and the Plan Subscribers; and (e) maintaining adequate books and records of all transactions
related to the services to be provided hereunder by Delta Dental.
Revised 09/2011 4
2. To make no payments from the money received from the Contractor for any services rendered to a
person who is not eligible for dental benefits as defined in this Plan; provided, however, that Delta
Dental receives timely information from the Contractor regazding the eligibility of each Subscriber
and Eligible Dependent, as set forth in Section III.B.2. No retroactive eligibility updates, including
additions and ternunations, will be accepted for an effective date more than 90 days prior to the date
of receipt of the update by Delta DentaL
3. To endeavor to enlist Dentists to become Participating Dentists in sufficient number to ensure an
adequate choice of Dentists, and to make periodic checks regarding the adequacy of care provided by
Dentists to people covered by this Plan. Delta Dental is not required to schedule a dental
appointment for an Eligible Person.
4. To contractually require each Participating Dentist to schedule and render all dental treatment
provided under this Plan according to the standards of the dental profession in the community in
which the dental procedures are rendered.
5. To make payments in the following manner for dental services provided to Eligible Persons. The
program that is chosen by the Contractor (or its affiliates) will determine how payment is made:
a. Delta Dental Premier
If the Dentist is a Participating Dentist, Delta Dental will base payment on the Maximum
Approved Fee. Delta Dental will send payment directly to Participating Dentists and the Eligible
Person will be responsible for any applicable Copayments or Deductibles. Unless prohibited by
state law, the Eligible Person will be responsible for the Maximum Approved Fee for most
commonly-performed non-covered services. For other non-covered services, the Eligible Person
will be responsible for the Dentist's Submitted Amount.
ff the Dentist is a Nonparticipating Dentist, Delta Dental will base payment on the lesser of the
Submitted Amount or the Nonparticipating Dentist Fee. Delta Dental will usually send payment
to the Subscriber, who is responsible for making full payment to the Nonparticipating Dentist.
The Eligible Person will be responsible for any difference between Delta Dental's payment and
the Dentist's Submitted Amount.
If the Dentist is an Out-of-Country Dentist, Delta Dental will base payxnent on the lesser of the
Submitted Amount or the Out-of-Country Dentist Fee. Delta Dental will send payment to the
Subscriber, who is responsible for making full payment to the Dentist. The Eligible Person will
be responsible for any difference between Delta Dental's payment and the Dentist's Submitted
Amount.
b. Delta Dental PPO (Standard)
To make payments for Covered Services provided to Eligible Persons based on the lesser of the
Submitted Amount or the PPO Dentist Schedule.
Delta Dental will send payment directly to Participating Dentists and the Eligible Person will be
responsible for any applicable Copayments or Deductibles. If the Dentist is not a PPO Dentist,
but is a Premier Dentist, the Eligible Person will also be responsible for any difference between
the PPO Dentist Schedule and the Premier Dentist Schedule for Covered Services, in addition to
Copayments or Deductibles. Unless prohibited by state law, the Eligible Person will be
responsible for the Malcimum Approved Fee for most commonly-performed non-covered
services. For other non-covered services, the Eligible Person will be responsible for the Dentist's
Submitted Amount.
For Covered Services rendered by a Nonparticipating Dentist or Out-of-Country Dentist, Delta
Dental will usually send payment to the Subscriber, who is responsible for inaking full payment
to the Denrist. The Eligible Person will be responsible for any difference between Delta Dental's
payment and the DentisYs Submitted Amount.
c. Delta Dental PPO plus Premier
Revised 09/2011
To make payments for Covered Services provided to Eligible Persons based on the lesser of the
Submitted Amount or the PPO Dentist Schedule.
Delta Dental will send payment directly to Participating Dentists and the Eligible Person will be
responsible for any applicable Copayments or Deductibles. If the Dentist is not a PPO Dentist,
but is a Premier Dentist, the Eligible Person wi11 also be responsible for any difference between
the PPO Dentist Schedule and the Premier Dentist Schedule for Covered Services, in addition to
Copayments or Deductibles. Unless prohibited by state law, the Eligible Person will be
responsible for the Maximum Approved Fee for most commonly-performed non-covered
services. For other non-covered services, the Eligible Person will be responsible for the Dentist's
Submitted Amount.
For Covered Services rendered by a Nonparticipating Dentist or Out-of-Country Dentist, Delta
Dental will usually send payxnent to the Subscriber, who is responsible for making full payment
to the Dentist. The Eligible Person will be responsible for any difference between Delta Dental's
payment and the Dentist's Submitted Amount.
6. Consistent with any applicable law protecting the confidentiality of a patient's health records, data,
or information, to make standard reports available to Contractor at no additional charge and to
provide non-standard reports for an additional charge based on the time and materials necessary to
create the reports.
7. To allow the Contractor the right to audit its files, books, and records (both paper and electronic)
pertaining to services provided. The Contractor will beaz the entire cost of any such audits. The
Contractor may assign this right to audit to an agent, provided the agent is a licensed firm and the audit
is led by an individual who holds a nationally recognized audit accreditation. Delta Dental will allow
the Contractor or the Contractor's agent to audit the work areas at which services under this Contract
aze performed, within 14 business days of receipt of a fully-signed Authorization, Hold Hannless and
Indemnification Agreement consistent with the limitations imposed by applicable law. Where
applicable, Delta Dental agrees to segregate the Contractor's records from third-party records in order
to allow accurate assessment of Contractor-specific processes. Such audits will take place no more than
once in a 12-month period, unless both the Contractor and Delta Dental mutually agree that there is
reasonable cause to conduct an audit more frequently, in which case the Contractor will give 14
business days' written notice before such audit. During the audit, if claims samples are selected using a
financially stratified methodology, the results will be extrapolated to the entire population of claixns
during the audit period using a weighted average method for each category.
B. Contractor Agrees:
1. To pay Delta Dental the Administrative Services Fees and Claims Payment Reimbursement
amounts specified in Exhibit A as billed by Delta Dental, with no payment adjustments for updates
not yet reflected on the current invoice. If payment is not received by the due date, Delta Dental
shall, notify Contractor and shall have the right to suspend claims processing if payment is not
received within two (2) business days from notification, have the right to suspend claims
processing.
Delta Dental may, at its sole option, send notification to the Contractor of an adjustment in Rates,
Benefits, or Copayments to correct potential adverse group experience resulting from the
following:
a. Information provided upon enrollment proves to be in error; or
b. Terms and provisions of the Plan are violated; or
c. Invoices are not paid as billed.
Delta Dental will provide the Contractor written notice 60 days prior to implementing any
adjustment. If the Contractor refuses to accept this adjustment, Delta Dental may, in its sole
discretion, implement the adjustment, implement an alternative adjustment acceptable to both
parties, or cancel this Plan.
Revised 09/201 I 6
2. To enroll as Subscribers all eligible employees or members of the Contractor or entities affiliated
with it and to list, if covered, all Eligible Dependents of those employees or members to the extent
required under the Plan. The Contractor will provide Delta Dental with eligibility updates to
Subscribers and, if applicable, all Eligible Dependents as necessary, but no less than monthly. No
retroactive eligibility updates will be accepted for an effective date more than 90 days from the
date on which Delta Dental receives notification of the update. If the Contractor requests that a
Subscriber's eligibility be terminated retroactively and a claim was incurred for that Subscriber or
any Eligible Dependent of the Subscriber after the requested ternunation date, the Subscriber's
eligibility will continue until the end of the month in which the claim was incurred.
3. To pernut Delta Dental, by its auditors or other authorized representatives, on reasonable advance
written notice, to inspect the Contractor's records to verify the accuracy of Subscribers and
Eligible Dependents submitted to Delta Dental. Clerical errors or delays in keeping or relaying
data will not invalidate eligibility that would otherwise be validly in force or continue eligibility
that would otherwise be validly ternunated, if, after discovery of the errors or delays, an equitable
adjustment of the Contractor's payment can be made in a reasonable period of time not to exceed
90 days.
4. To provide each Subscriber with all required privacy notices at such intervals as are required by law,
as well as a certificate or summary of benefits provided under this Plan as shown in Exhibit B.
Customized benefit literature can be provided by Delta Dental to Contractor for an additional cost.
5. To collect and remit, or to cause to have collected and remitted, to Delta Dental any amounts that
the Contractor's employees (or members) are required to pay to Delta Dental under this Plan or
any written employment contracts, including amounts for COBRA continuation coverage. Any
amounts not collected will be the responsibility of the Contractor.
Should the Contractor collect any amounts paid by employees and not remit them to Delta Dental in
a tunely fashion, with the result that an Eligible Person's coverage is lost, the Contractor, not Delta
Dental, will be liable for any benefits to which the Eligible Person may have been entitled but for the
Contractor's tardy remittance or failure to remit, unless after discovery of the errors or delays, an
equitable adjustment of the Contractor's payment can be made in a reasonable period of time not to
exceed 90 days.
6. To pay for any agreed upon non-standard reports based on the time and materials needed to create
the reports.
Section IV. General Provisions
A. Independent Contractors. Dentists providing services are independent conixactors, and neither the
Contractor nor Delta Dental will be liable for any act or omission of any Dentist, his or her employees or
agents, or any person providing dental or other professional services under this Plan.
B. Binding Effect. All Dentists and Eligible Persons, by perfornvng or receiving services under this Plan, are
bound by all its terms.
C. Payment Limitations. Delta Dental will make no payment for dental services if a claim for those services
has not been received by Delta Dental within one year after the dental services were furnished.
D. Marketin~ Materials. No materials bearing the Delta Dentallogo or other protected Delta Dental
trademark, copyright, or other intellectual property will be published or distributed by the Contractor
conceming this Plan unless Delta Dental approves the materials in advance. This provision shall not be
construed to prohibit Contractor from publishing or distributing informal communications concerning this
Plan that merely reference the involvement of Delta Dental in the administration of the Plan.
E. Le~a1 Action. No action on a legal claim arising out of or related to this Plan that is not a claim for dental
benefits by a Subscriber or an Eligible Dependent may be brought unti130 days after notice of the legal
claim has been given to Delta Dental. In addition, no action, including a claim for dental benefits by a
Subscriber or Eligible Dependent, may be brought more than three years after the claim first arose. Any
Revised 09/2011
person or entity seeking to bring suit more than three years after the legal claim first arose will be deemed
to have waived their right to bring suit on such legal claim.
F. Indemnification. Delta Dental and Contractor to the extent pernutted by law, agree to defend, indemnify,
and hold harmless the other and its directors, officers, and employees (who are acting in the course of their
employment, but not as claimants) from any loss, cost, or expense (including reasonable attorney fees and
court costs) resulting from or arising out of or in connection with its breach of this Plan, or any negligent act
or omission of any of its directors, officers, or employees, unless liability for such act or omission is
expressly assigned elsewhere in this Plan. No section of this agreement is intended to create a waiver of the
Contractor's rights and privileges as a sovereign entity.
G. Re~uired Information. While an Eligible Person is covered by Delta Dental, that person agrees to provide
Delta Dental with any information it needs to process the claims and administer the Benefits. This includes
allowing Delta Dental to have access to his or her dental records, subject, in all events, to all provisions of
applicable law.
H. Dispute Resolution. Delta Dental, or its delegee, will establish procedures for resolving all questions
raised by a Dentist, Contractor, or an Eligible Person in regard to claims for Benefits allowed or rejected
under the terms of the Plan. These procedures will be used both for the initial determination of those
questions and for the resolution of disputes made on the basis of those initial deternunations. The
procedures established for deternuning the entitlement and amount of Benefits to which an Eligible Person
is entitled under any benefit plan sponsored by the Plan or that is regulated under the Employee
Retirement Income Security Act of 1974 ("ERISA"), as amended, will comply with ERISA Section 503,
and the regulations thereunder, for providing a"full and fair review" of all benefit claims. The ERISA-
required claixns procedures will be set forth in detail in the Certificate that is to be distributed to Eligible
Persons and that describes the Benefits under this Plan. All deternunations made according to this
procedure will be final and binding on the Dentist, the Contractor, and the Eligible Person; provided,
however, that the Eligible Person may exercise his or her legal rights after this deternunation as described
in the Disputed Claixns Procedure.
I. Notices. Any notice required or pernutted to be given by Delta Dental will be considered given if in
writing and personally delivered, or if in writing and deposited in the United States mail with postage
prepaid, addressed to the Conixactor, a Dentist, or a Subscriber at the last address of record. T'his notice
will be considered given when personally delivered or mailed.
J. Amendment and Assienment. No agent has authority to change any part of this Contract. No changes to
this Contract will be valid unless Delta Dental approves them in writing. Delta Dental sha11 have the
discretion to assign its rights and responsibilities under this Contract to an affiliated entiry. If Delta Dental
chooses to assign its rights and responsibilities, it sha11 assign them to an appropriately licensed entity
capable of performing similar functions at similar levels as Delta Dental. Delta Dental shall serve written
notice of the assignment to Contractor and said notice shall provide the name and address of the assignee.
Neither this Contract nor any part of it shall be assigned by Contractor without the prior written consent of
Delta Dental, and any attempt at assignment by Contractor without such consent by Delta Dental shall be
null and void. Subject to the foregoing limitation, this Contract shall be binding upon the parties and their
respective successors and assigns.
K. Third-Party Ri ts. This Contract is entered into by and between the parties hereto solely for their benefit.
Except as specifically provided herein to the contrary, the parties have not created or established any third-
party beneficiary status or rights in any person or entity not a party hereto including, but not limited to, any
covered person, provider, subcontractor, or other third-party, and no such third-party will have any right to
enforce any right or enjoy any benefit created or established under this Contract.
L. Subro~ation and Right of Reimbursement. To the extent that the Plan provides or pays benefits for
Covered Services, Delta Dental is subrogated to any right the Eligible Person may have to recover from
another, his or her insurer, or under his or her "Medical Payments" coverage ar any "Uninsured Motorist,"
"Underinsured Motorist," or other similar coverage provisions. The Eligible Person or his or her legal
representative must do whatever is necessary to enable Delta Dental to exercise its rights and do nothing to
prejudice them. If the Eligible Person recovers damages from any party or through any coverage named
Revised 09/2011
above, the Eligible Person must reimburse Delta Dental from that recovery to the extent of payments made
under the Plan.
M. AssiQaunent of Benefits. Benefits to Eligible Persons are for the personal benefit of those people and
cannot be transferred or assigned; provided, however, that Delta Dental may pay Participating Dentists
directly on behalf of Eligible Persons. Benefits paid to Participating Dentists sha11 discharge the
obligation of Delta Dental with respect to the amount of Benefits paid.
N. Limitation of Services. Contractor aclmowledges and agrees that: (1) Delta Dental does not provide, direct,
or control the provision of dental services to covered people (as such terms are defined by the Dental Plan);
(2) the provision of contract provider infomiation in any medium by Delta Dental is not the provision of
dental diagnostic or treatment services, dental advice, or health advice; (3) all decisions regarding dental
services are made solely by the covered person and the practitioner rendering dental services to a covered
person and the results thereof are solely within the control of the provider of such dental services providing
the services and the covered person(s); and (4) Delta Dental's execution of this contract and the perfom~ance
of its obligations hereunder do not constitute an undertaking by Delta Dental to render any dental services, or
to assume or guarantee the results thereof to covered persons, or to guarantee that dental services will be
rendered in accordance with generally accepted standards or procedures.
O. Plan Fiduciary Status; Discretion. The Contractor, or a person designated by the Contractor (other than
Delta Dental), shall be the "Named Fiduciary" (as defined in ERISA Section §402[a][2]) of Contractor's
Dental Plan for which Delta. Dental shall provide administrative services hereunder. However, Delta
Dental shall maintain authority to adjudicate claims and review all denied claims for benefits under the
Dental Plan, including, but not limited to, the deternunation of covered services, interpretation of the terrns
of the Dental Plan and any rules, practices, and procedures established for adjudication of claims of the
Dental Plan. However, Delta Dental sha11 not have discretionary authority or control conceming the
determination of eligibility for and entitlement to any benefits in accordance with the terms of the Dental
Plan. Delta Dental shall not have any discretionary authority or discretionary control respecting the
management of the Dental Plan itself or its assets, if any, and the Contractor retains a11 responsibility and
authority, including all other fiduciary responsibility as defined in ERISA for the operation of the Dental
Plan, with the exception of claims adjudication by Delta Dental as described herein. Delta Dental shall
indemnify and hold harmless, the County from any and all damages, including reasonable attorney's fees,
arising from or related to the negligent or improper adjudication of claims by Delta Dental.
P. F~. Contractor agrees that the Contractor shall be solely responsible for funding the payment of
benefits and expenses under the Contractor's Dental Plan.
Q. Adjustment Procedures for Under~ayment and Overpayment of Claims. If it is determined that more or less
than the correct amount has been paid under the Plan by Delta Dental, Delta Dental shall attempt, on behalf
of the Contractor and the Plan, to make such adjushnents as may be necessary to have the Dental Plan pay
only the amounts that are properly payable under its terms.
If Delta Dental deternunes that it has, for any reason, paid a Dentist more for dental services than is provided
for under the Dental Plan (the "Overpayment Amount"), Delta Dental has the right to recover the
Overpayment Amount from the Dentist to which the Overpayment Amount was paid. Delta Dental will
provide the Dentist with notice of the Overpayment Amount, and the basis on which Delta Dental believes
that the payment made was in excess of the amount properly due under the Dental Plan, and will request that
the Overpayment Amount be returned. Should the Dentist fail to return the requested Overpayment Amount,
Delta Dental reserves the right to offset the Overpayment Amount from any future payments due that Dentist
for dental services provided to Subscribers and/or beneficiaries under the Dental Plan, or other self-funded
dental plans of sponsoring employers administered by Delta Dental; provided, however, that the amounts
properly payable under any of the affected Dental Plan(s) shall be neither diminished nor enhanced by this
recovery procedure. Where Overpayment Amounts are recovered by means of an offset, the Overpayment
and Offset Amounts will be properly credited to, or debited from, the affected Dental Plan(s)_so that all
involved Dental Plans will have been administered according to their terms and will have paid only the
amount that is properly payable for the dental services provided.
Revised 09/2011 9
In no event, however, will Delta Dental be required to initiate court proceedings to recover an Overpayment
Amount or attempt to recover the amount of overpayment from the Contractor or any Eligible Person.
Should it be determined that less than the correct amount has been paid under the Dental Plan by Delta
Dental, then Delta Dental may ask the Contractor for additional funding to make up for the shortfall, and
ensure that the Benefits under the Dental Plan are properly paid according to the ternLS of the Contractor's
Dental Plan.
In all cases, any methods utilized by Delta Dental to correct any benefit payment that has been deternuned to
be more or less than the correct amount, shall only be performed when appropriate and permitted under the
Plan documents or this Contract.
R Rig,ht of Recoverv Due to Fraud. If Delta Dental pays for dental services that were sought or reeeived
under fraudulent, false, or misleading pretenses or circumstances, pays a claim that contains false or
misrepresented information, or pays a claim that is deternuned to be fraudulent due to the acts of the
Contractor, Subscriber, and/or Eligible Dependent, it ma.y recover that payment from the Contractor,
Subscriber, and/or Eligible Dependent. Contractor, Subscriber, and/or Eligible Dependent authorizes Delta
Dental to recover any payment deternuned to be based on false, fraudulent, misleading, or misrepresented
information by deducting that amount from any payments properly due to the Contractor, Subscriber,
and/or Eligible Dependent. Delta Dental will provide an explanation of the payxnent being recovered at
the time the deduction is made.
S. Force Majeure. Neither Delta Dental (including its agents, directors, officers, and employees) nor the Plan
shall be liable for delays in performance due to circumstances beyond their reasonable control. Each party
shall be excused from performance under this Contract and shall have no liability to the other party for any
period that it is prevented from perfornung any of its obligations (other than payment obligations), in
whole or in part, as a result of delays caused by the other party or by an act of God, war, terrorism, civil
unrest, civil disturbance, court order, labor dispute, or other cause beyond its reasonable control, including
failures or fluctuations in electrical power, heat, light, or telecommunications, and such nonperformance
shall not be a default under, or grounds for ternunation of, this Contract.
T. Governin~. This Contract is governed by and interpreted under the laws of the State of North
Carolina unless preempted by federal law. The parties further agree that jurisdiction and venue for any
matter arising out of or pertaining to this Agreement shall be proper only in the state and federal courts
located in Orange County, North Cazolina and Middle Dishict of the State of North Cazolina, and the
parties hereby consent to such jurisdiction and venue.
U. Compliance with Applicable Laws. The invalidity or unenforceability of any provision of this Contract
shall not affect the validity or enforceability of any other provision of this Contract; each such other
provision shall remain in full force and effect.
V. This Contract may be executed in counterparts, each of which shall be deemed an original but all of which
together shall constitute one and the same Contract.
W. Le ag_lly Mandated Benefits. If any applicable law requires bmader coverage or more favorable treatment for
the Subscriber or an Eligible Dependent than is provided by this Contract, that law shall control over the
language of this Contract.
X. A person whose eligibility is ternunated may not continue group coverage under this Contract, except as
required by the continuation coverage provisions of the Consolidated Budget Reconciliation Act of 1985
(COBRA) or comparable, non-preempted state law. An affiliate of Delta Dental also may offer coverage
under an individual direct payment policy to a person whose eligibility is ternunated.
Y. With notice to the Contractor, Delta Dental shall have the right, in its sole discretion, to make and
implement global, universal business changes that may revise provisions of this Contract without seeking
or obtaining written approval from Contractor.
Revised 09/2011 1 ~
Section Y. Satisfaction o HIPAA Requirements
The parties have agreed and entered into a Business Associate Addendum to this Contract concerning the
confidentiality of protected health information of Subscribers and Eligible Dependents as attached and
incorporated by reference herein as Exhibit C. .
Section Vl. Ternz and Termination
This Contract will remain in full force and effect for the initial term and any renewal terms of this Contract as
specified in Fxhibit A of this Contract or in a renewal letter. Delta Dental shall have the option of terminating
this Contract if
A. The Contractor fails to xnake a required payment by the due date; or
B. Delta Dental elects to cancel pursuant to Section III (B) (1) of this Contract; or
C. The Contractor fails to fiunish Delta Dental with accurate enrollment data pursuant to Section III (B) (2); or
D. The Contractor permits voluntary enrollment of employees or members and their eligible dependents,
unless otherwise specified in Exhibit A; or
E. The Contractor refuses to allow Delta. Dental(by its auditors or other authorized representatives) to inspect
the Contractor's records to verify the accuracy of the Eligible Persons.
The parties shall have the option of terminating this Contract if either party breaches any material provision of
this Contract or if the terminating pariy provides the other with 30 days written notice of its intent to cancel.
At the expiration of the initial Contract term or any renewal term and/or in the event this Coniract is terminated
for any of the precedi.ng reasons, there will be a six-month run-out period following the ternrination date. During
this period, the Conlractor shall reimburse Delta Dental for all claims incurred before the terxnination date but
not billed to Delta Dental until after the termination date. If applicable and specified in Exhibit A, the Contractor
shall also pay Delta Dental adxnnusirative costs. Payments to Delta Dental will be made from the account
established for the payment of claims pursuant to this Contract. Should these funds be insufficient, the
Contractor shall make up the deficiency. ~
During the.run-out period, funds for paying claims will be transferred to Delta Dental by the Contractor in the
same maruier and in accord with the same formula as had been provided prior to ternunation. At the conclusion
of the six-month run-out period, all unencumbered funds remaining in the account established for payment will
be returned to the Contractor without any claim thereon by Delta Dental. Delta Dental shall ha.ve no further
obligation to pay claims that were submitted following the termination date for services performed prior to the
ternunation date. The obligation to pay those claims shall be the obligation of the Contractor.
Entire Agreement: This Contract with the attached EJChibits and Business Associate Addendum represents the
entire and integrated agreement between the County and the Contractor and supersedes a11 prior negotiarions,
representations or agreements, either written oral. This Agreement may be amended only by written instrument
signed by both parties. Modifications may be evidenced by facsimile signatures.
Revised 09/2011 11
ACCEPTED:
DELTA DENTAL OF NORTH CAROLINA
By:
Date: Februarv 9, 2012
ORANGE COiINTY
By: E 1~, ~~ ,t--~Y' ~~~
Date: ~"J " ~ 2' ~' I ~-/~
This ' strument s been approved as to technical content.
Katherine Cathey, Department Direct
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act.
~~~w ~ ~
Office of the Finance Director
This instru ent ha en ap roved as to form and legal sufficiency.
Office of.y n ey
%
Revised 09/201 I I Z
Exhibit A
Delta Dental PPO plus Premier
This Contract is effective the lst day of January, 2012 A.D., by and between Orange County, hereinafter referred to
as the Contractor and Delta Dental Plan of North Carolina, Inc., a North Carolina non-profit corporation, hereinafter
refened to as Delta Dental.
Section I. Declarations
The benefits afforded are only with respect to such benefits as are indicated in this Contract. Delta Dental's liability
is limited to the benefits stated herein; subject to all the terms of this Contract having reference thereto. This
Declarations Section supersedes any contrary provision of the subsequent sections of this Contract.
A. Effective Date of Contract Year: 12:01 A.M. Standard Time, January 1, 2012 A.D.
B. First Renewal Date: January 1, 2014
C. Group Number: 8702-0001, 0999
D. Eligibility (Subscribers and dependents):
All eligible employees who have met the eligibility requirements as established by the Contractor.
Dependents and domesric partners of above mentioned Subscribers are also eligible. Children under age 19
are eligible for benefits regardless of student status and/or disability. Eligibility is extended to age 26 only
for children who are full time students. Subscribers and eligible dependents must enroll for a minimum of
12 months. If coverage is terminated after 12 months, they may not re-enroll prior to the open enrollment
that occurs at least 12 months from the date of termination. Dependents may only enroll if the Subscriber
is enrolled (except under COBRA) and must be enrolled in the same plan as the Subscriber. Plan changes
are only allowed during open enrollment periods, except that an election may be revoked or changed at any
time if the change is the result of a qualifying event as defined under Intemal Revenue Code Section 125.
A domestic partner is defined as follows:
Domestic Partner - A person of the same or opposite gender, not related by blood to the employee, who is
not legally married to the employee or anyone else, and who shares the following with the employee:
i) an exclusive, committed relationship as provided in the Declaration of Domestic Partnership statement,
2) a residence, and
3) responsibility for each otherT"'s common welfare and financial obligations.
Note: To qualify for pomestic Partner coverage, the employee and his or her pomestic Partner must meet
all of the following criteria and must sign the North Carolina Association of County CommissionersT"' Risk
Management Poo1T"'s Declaration of Domestic Partner status attesting that they are:
a. At least 18 years old and mentally competent to consent to a civil contract,
b. Not acting under force or duress,
c. Not legally married to any other person and not engaged in another domestic partner relationship,
d. Not related by blood,
e. Engaged in an exclusive, committed relationship that has existed for at least 12 consecutive months,
f. Currently reside together and intend to do so permanently,
g. Responsible for each otherT"'s common welfare and either:
- Are jointly responsible for their assets and debts as provided by applicable law, or
- Have executed a written agreement or civil contract which defines their domestic partner
relationship and their liabilities with respect to their assets and debts.
- Not Medicare eligible.
E.
F.
G.
Where two legally married Subscribers are both eligible for coverage under this Contract, they may be
enrolled together on one application card or separately on individual application cards, but not both.
Dependent children may only be enrolled on one application card. Delta Dental will not coordinate benefits
for married Subscribers who are both eligible under this Contract.
Waiting Period:
All new Subscribers (and their dependents, if covered above), defined as eligible Subscribers added to the
covered group who are hired after the effective starting date of the Contract will be eligible for enrollment
on the first day of the month following date of hire.
Deductible: $50 deductible per person total per calendar year limited to a maximum deductible of $150 per
family per calendar year. The deductible does not apply to diagnostic and preventive services, emergency
palliative treatment, x-rays, sealants, brush biop"sy, periodontal maintenance, and orthodontic services.
Covered Services:
Premier Non-
Dentist Participating
Dentist
Plan Pavs Plan Pavs
Diagnostic and Preventive Services - includes
exams, cleanin s, fluoride, and s ace maintainers 100% .
;, .~ ,;. ~ 100%
~ 100%
Emergency Palliative Treatment - to temporarily
relieve ain 1D0°~o
~ ; ~ =
:_....: ~ < ~...:9 ..~ 100% l OQ%
Sealants - to revent deca of permanent teeth -, ' 10U°la ;~ ~ ' 100%0 100%
Brush Biopsy - to detect oral cancer ~ LOQ"/o ;: ~ ~~s~ 100% 100%
Radio ra hs - X-rays ~_:100°~0 ~';, .. ~: ~~~ ~~ ~~~~ 100% ~ 100%
Periodontal Maintenance - cleanings by a
s ecialist ~ QO°la
~ ~ ~°, 100%0 100%
Minor Restorative Services - fillings and crown
g~o~«
?
~ 85% 85%
re air „
~ ~
Endodontic Services - root canals $5% '; 85%~ ~~~~ gs~/a
Periodontic Services - to treat gum disease `` 85% ~.~:' : ~~ 85%0 ' ~~ 85%
Oral Surgery Services - extractions and dental
;: g$o~o 85% 85%
sur ery
Other Basic Services - misc. services 85% .:: , 85%0 85%
Ma'or Restorative Services - crowns '~~ : 50~~ ,i ~ 50% `~~ 50°/a
Relines and Re airs - to bridges and dentures ; 50% 50% 50%
Prosthodontic Services - includes brid es, LL
implants, and dentures g ~~ 50°~ 50% 50% ~
~ Orthodontic Services - includes braces ~ ;: 50°l0 ,:: = ~~ ~ 50% 50%
~ Orthodontic Age Limit - No Aqe Lirriit ,- No A¢e Limit No Aee Limit
- Oral exams (including evaluations by a specialist) are payable twice per calendar year.
- Prophylaxes (cleanings) are payable twice per calendar year.
- Fluoride treatments are payable twice per calendar year for people up to age 19.
- Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent
molars up to age 16. The surface must be free from decay and restorations. ,
- Reline and rebase of dentures are payable once in any two-year period.
- Implants and implant related services are payable once per tooth in any five-year period.
- Vestibuloplasty is a Covered Service.
- Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X-
rays) are payable once in any three-year period.
- Porcelain and resin facings on crowns and onlays are Covered Services on posterior teeth.
- Porcelain and resin facings on bridges are Covered Services on posterior teeth.
- Composite resin (white) restorations are optional treatment on posterior teeth.
- People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings)
or fluoride treatment. The patient should talk with his or her dentist about treatment.
Enrollees can receive expert dental care when they are outside of the United States through our Passport
Dental program. Passport Dental gives our enrollees access to a worldwide network of dentists and dental
clinics. English-speaking operators are available around the clock to answer questions and help them
schedule care. Delta Dental coverage outside of the United States is the same as Delta Dental coverage
within the United States. Access to the Passport Dental program is offered through an agreement with a
third party vendor, and it may not be available if that agreement terminates.
H. Maximum Payment: $1,200 per person total per calendar year on all services except orthodontics. $2,000
per person total per lifetime on orthodontic services.
Rate(s):
Administrative Services fee:
Composite -$2.80 per month per Subscriber
This rate is contingent upon the enrollment of a minimum of 75 percent of the eligible members of the
defined group and their eligible dependents with 50 percent of the cost paid by the Contractor.
In addition to the Administrative Service Fee, the Contractor agrees to transfer to Delta Dental by
electronic funds transfer (EFT) the amount of claims paid during the previous week. Invoices will be
submitted to the Contractor on Monday of each week for the amount of claims paid during the previous
week. The Contractor will transfer this amount to Delta Dental by the end of the following working day.
October 25, 2011
Exhibit B
Delta Dental PPO plus Premier
Summary of Dental Plan Benefits
For Group# 8702-0001, 0999
Orange County
This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental
Care Certificate will provide you with additional information about your Delta Dental plan, including information
about plan exclusions and limitations. The percentages below will be applied to the lesser of the dentist's submitted
fee and Delta Dental's allowance for each service. Delta Dental's allowance may vary by the dentist's network
participation. PLEASE NOTE - If you choose a Nonparticipating Dentist, you will be responsible for any difference
between the amount Delta Dental allows and the amount the Nonparticipating Dentist charges, in addition to any
Copayment or Deductible.
Control Plan -De lta Dental of North Carolina
Benefit Year - January 1 through December 31
Covered Services -
Non-
Premier Dentist participating
Dentist
Plan Pays Plan Pays*
Diagnostic and Preventive Services - includes exams, ,~UO°1a 100%0 100%
cleanin s, fluoride, and s ace maintainers
Emergency Palliative Treatment - to temporarily ~~jpo~ 100%
relieve ain a 100%
Sealants - to revent decay of ermanent teeth 1QQ fo ' 100% 100%
Brush Bio sy - to detect oral cancer '.1b0% 100% 100%
Radio ra hs - X-ra s =:10~°~0 , ~ ~~ 100% ~ 100%
Periodontal Maintenance - cleanin s b a specialist ;.~ , ~ i~D°~o ~~~ 100% ~~~ ~~~ 100%
e
Minor Restorative Services - fillin s and crown re air " $5°l 85%' ' 85%
Endodontic Services - root canals $5% 85% 85%
Periodontic Services - to treat um disease 8S°/u ' 85% 85%
Oral Sur e Services - extractions and dental sur er 85°10 . 85% ' 85%
Other Basic Services - misc. services 85% . 85% 85°/a
Ma'or Restorative Services - crowns " SU°/a 50%' ` 50%
Relines and Re airs - to brid es and dentures 50°~'0 ; 50% 50%
Prosthodontic Services - includes bridges, implants S~dJa 50% 50%
and dentures
~ Orthodontic Services - includes braces 50°/a ; 50% 50%
~ Orthodontic Age Limit - ~'No A~e:Lirtiit ~-_ ~ No Aee Limit No Aee Limit
* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of
Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee
may be less than what your dentist charges, which means that you will be responsible for the difference.
- Oral exams (including evaluations by a specialist) are payable twice per calendar year.
- Prophylaxes (cleanings) are payable twice per calendar year.
Customer Service Toll-Free Number: 800-524-0149
www. DeltaDentalNC. com
October 25, 2011
- Fluoride treatments are payable twice per calendar year for people up to age 19.
- Sealants are payable once per tooth per lifetime for the occiusal surface of first and second permanent molars up
to age 16. The surface must be free from decay and restorations.
- Reline and rebase of dentures are payable once in any two-year period.
- Implants and implant related services are payable once per tooth in any ftve-year period.
- Vestibuloplasty is a Covered Service.
- Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X-rays) are
payable once in any three-year period.
- Porcelain and resin facings on crowns and onlays are Covered Services on posterior teeth.
- Porcelain and resin facings on bridges are Covered Services on posterior teeth.
- Composite resin (white) restorations are optional treatment on posterior teeth.
- People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings) or
fluoride treatment. The patient should talk with his or her dentist about treatment.
Having Delta Dental coverage makes it easy for our enrollees to get dental care almost everywhere in the world!
You can now receive expert dental care when you are outside of the United States through our Passport Dental
program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking
operators are available around the clock to answer questions and help you schedule care. For more information,
check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet.
Maximum Payment -$1,200 per person total per benefit year on all services except orthodontics. $2,000 per
person total per lifetime on orthodontic services.
Deductible -$50 deductible per person total per benefit year limited to a ma~cimum deductible of $150 per family
per benefit year. The deductible does not apply to diagnostic and preventive services, emergency palliative
treahnent, x-rays, sealants, brush biopsy, periodontal maintenance, and orthodontic services.
Waiting Period - Employees who are eligible for dental benefits are covered on the first day of the month
following date of hire.
Eligible People -All eligible employees who have met the eligibility requirements as established by the Contractor.
The Contractor and Subscriber share the cost of this plan. Benefits will cease on the last day of the month in which
the employee is terminated.
Dependents and domestic partners of above mentioned Subscribers are also eligible. Children under age 19 are
eligible for benefits regardless of student status and/or disability. Eligibility is extended to age 26 only for children
who are full time students. Subscribers and eligible dependents must enroll for a minimum of 12 months. If
coverage is terminated after 12 months, they may not re-enroll prior to the open enrollment that occurs at least 12
months from the date of termination. Dependents may only enroll if the Subscriber is enrolled (except under
COBRA) and must be enrolled in the same plan as the Subscriber. Plan changes are only allowed during open
enrollment periods, except that an election may be revoked or changed at any time if the change is the result of a
qualifying event as defined under Internal Revenue Code Section 125.
A domestic partner is defined as foilows:
Domestic Partner - A person of the same or opposite gender, not related by blood to the employee, who is not legally
married to the employee or anyone else, and who shares the following with the employee:
1) an exclusive, committed relationship as provided in the Declaration of Domestic Partnership statement,
2) a residence, and
3) responsibility for each otherT"'s common welfare and financial obligations.
Customer Service Toll-Free Number: 800-524-0149
www. DeltaDentalNC. co m
October 25, 2011
Note: To qualify for pomestic Partner coverage, the employee and his or her pomestic Partner must meet all of the
following criteria and must sign the North Carolina Association of County CommissionersT"' Risk Management
Poo1T"'s Declaration of Domestic Partner status attesting that they are:
a. At least 18 years old and mentally competent to consent to a civil contract,
b. Not acting under force or duress,
c. Not legally married to any other person and not engaged in another domestic partner relationship,
d. Not related by blood,
e. Engaged in an exclusive, committed relationship that has existed for at least 12 consecutive months,
f. Currently reside together and intend to do so permanently,
g. Responsible for each otherT"ss common welfare and either:
- Are jointly responsible for their assets and debts as provided by applicable law, or
- I-Iave executed a written agreement or civil contract which defines their domestic partner
relationship and their liabilities with respect to their assets and debts.
- Not Medicare eligible.
Customer Service Toll-Free Number: 800-524-0149
www. DeltaDentalNC.com
October 25, 2011
Exhibit B
SM
e a en a
Our national
PPO plus Premier
program
Welcome!
Your dental program is administered by Delta Dental of North Carolina, a North Carolina nonprofit health service
plan corporation. Delta Dental of North Carolina is the state's dental benefits specialist. Good oral health is a vital
part of good general health, and your Delta Dental program is designed to promote regular dental visits. We encourage
you to take advantage of this program by calling your Dentist today for an appointment.
This Certificate, along with your Summary of Dental Plan Benefits, describes the specific benefits of your Delta
Dental program and how to use them. If you have any questions about this program, please call our Customer Service
department at (800) 662-8856 or access our website at www.deltadentalnc.com.
You can easily verify your own benefit, claims and eligibility information online 24 hours a day, seven days a week by
visiting www.deltadentalnc.com and selecting the link for our Consumer Toolkit. The Consumer Toolkit will also
allow you to print claim forms and ID cards, select paperless explanation of benefits (EOBs), search our dentist
directories, and read oral health tips.
We look forward to serving you!
~ ~
,~
TABLE OF CONTENTS
I. Certificate ..................................................................................................................................... 2
II. Definitions ...................................................................................................................................... ..2
III. Selecting a Dentist ......................................................................................................................... ..5
N. Accessing Your Benefits ................................................................................................................ ..5
V. How Payment is Made ................................................................................................................... ..7
VI. Benefit Categories .......................................................................................................................... ..7
VII. Exclusions and Limitations ............................................................................................................ ..8
VIII. Coordination of Benefits ................................................................................................................ 12
IX. Disputed Claims Procedure ............................................................................................................ 14
X. Termination of Coverage ............................................................................................................... 15
XI. Continuation of Coverage .............................................................................................................. 16
XII. General Conditions ........................................................................................................................ 16
Note: This Certificate should be read in conjunction with the Summary of Dental Plan Benefits that is provided with the
Certificate. The Swiunary of Dental Plan Benefits lists the specific provisions of your group dental Plan and supersedes any
contrary provision of this Certificate.
1
Form No. 1752-NC
NCPPOpIus-A
0]/2012
I. Delta Dental PPO
Certificate
Delta Dental of North Carolina., referred to herein as
Delta Dental, issues this Certificate to you, the
Subscriber. The Certificate is an easy-to-read summary
of your dental benefits Plan. It reflects and is subject to
the agreement between Delta Dental and your
employer or organization.
The benefits provided under the Plan may change if
any state or federal laws change.
Delta Dental agrees to provide dental benefits as
described in this Certificate.
All the provisions in the following pages form a part
of this document as fully as if they were stated over
the signature below.
IN WITNESS WHEREOF, this Certificate is executed
at Delta Dental's home office by an authorized o~cer.
~ •
Curtis R. Ladig, CPA
President and CEO
Delta Dental of North Carolina
II. Definitions
Benefit Year
Normally, the calendar year, unless your employer or
organization elects a different period to serve as the
Benefit Year. (See the Summary of Dental Plan
Benefits for your Benefit Yeaz.)
Certificate
This document. Delta Dental will provide dental
benefits as described in this Certificate. Any changes
in this Certificate will be based on changes to the Plan.
Children or Child
Your natural children, stepchildren, foster children,
adopted children, children by virtue of legal
guardianship, or children who are residing with you
during the waiting period for adoption or legal
guardianship.
Completion Dates
Some procedures may require more than one
appointment before they can be completed. Treatment
is complete:
• For dentures and partial dentures, on the
delivery dates;
• For crowns and bridgework, on the cementation
dates;
• For root canals and periodontal treatment, on the
date of the final procedure that completes treatment.
Concurrent Care Claims .
Claims for benefits where an ongoing course of
treatment has been agreed to by Delta Dental and/or
the administrator of your Plan and the coverage for
that treatment is reduced or ternunated before the
treatment has been completed. A Concurrent Caze
Claim may also arise if you ask the Plan to extend
coverage beyond the time period or number of
treatments previously agreed to.
Control Plan (Delta Dental
Delta Dental acts as the Control Plan for your contract.
The Control Plan will provide all claims processing,
service, and administration for your group. The
Control Plan will be referred to as Delta Dental in this
document.
Copayment
As provided by your Plan, the percentage of the charge,
if any, that you will have to pay for Covered Services.
Covered Services
The unique benefits selected in your Plan. The Sux~unary
of Dental Plan Benefits provided with this Certificate
lists the Covered Services provided by your Plan.
Deductible
'The amount.a person and/or a family must pay toward
Covered Services before Delta Dental begins paying
for services. The Summary of Dental Plan Benefits
lists the Deductible that applies to you, if any.
Form No. 1752-NC 2
NCPPOpIus-A
01l2012
Delta Dental
Means Delta Dental of North Carolina, a North
Cazolina nonprofit health service plan corporation
providing dental benefits. Delta Dental is not a
commercial insurance company.
Delta Dental Plan
An individual dental benefit plan that is a member of
the Delta Dental Plans Association, the nation's largest,
most experienced system of dental health plans.
Delta Dental PPO qlus Premier
Delta Dental's national preferred provider organization
program that can reduce your out-of-pocket expenses
if you receive care from one of Delta Dental's PPO
Dentists. This program has back-up coverage through
the Delta Dental Premier network when treatment is
received from a Non-PPO Dentist.
Delta Dental Premier
Dentist
A person licensed to practice dentistry in the state or
jurisdiction in which dental services are rendered.
• Delta Dental PPO Dentist (PPO Dentist) - a
Dentist who has signed an agreement with the
Delta Dental Plan in his or her state to participate
in Delta Dental PPO. PPO Dentists agree to
accept Delta Dental's payment and the Eligible
Person's Copayment, if any, as payment in full for
Covered Services.
• Delta Dental Premier Dentist (Premier Dentist)
- a Dentist who has signed an agreement with the
Delta Dental Plan in his or her state to participate
in Delta Dental Premier. Premier Dentists agree to
accept the Maximum Approved Fee as payxnent in
full for Covered Services.
• Nonparticipating Dentist - a Dentist who has not
signed an agreement with any Delta Dental Plan to
participate in Delta Dental PPO or Delta Dental
Premier.
• Out-of-Country Dentist - a Dentist whose off'ice
is located outside of the United States and its
territories. Out-of-Country Dentists are not eligible
to sign participating agreements with Delta Dental,
but may participate in the Passport Dental
program.
PPO Denrists and Premier Dentists are sometimes
collectively referred to herein as "Participating
Dentists". Wherever a definition or provision of this
Contract differs from another state's Delta Dental Plan
and its agreement with a Participating Dentist, the
agreement in that state with that Dentist shall be
controlling.
Premier Dentists, Nonparticipating Dentists, and Out-
of-Country Dentists are sometimes collectively
referred to herein as "Non-PPO Dentists".
EliQible De~endent
The Surrunary of Dental Plan Benefits will have
specific information about your Plan's rules for
dependent eligibility but, generally, your Eligible
Dependents are:
• Your legal spouse;
• Your unmarried Children who have not yet reached
the end of the calendar year of their 19th birthday;
• Your unmarried Children who have reached the
end of the calendar year of their 19th birthday and
who are chiefly dependent on you for support and
maintenance;
• Any unxnarried Children for whom you or your
legal spouse are financially responsible for
medical, health, or dental care under the terms of
a court decree or who have been named as
alternate recipients under a qualified medical
child support order; and
• Your Children who have reached the end of the
calendar year of their 19th birthday, but who were
Form No. 1752-NC 3
NCPPOpIus-A
01/2012
Delta Dental's national fee-for-service dental
benefits program that covers you when you go to a
Non-PPO Dentist.
at that time (and continue to be), totally and
permanently disabled by a physical or mental
condition and who are chiefly dependent upon
you for support and maintenance. If Delta Dental
asks you to do so, you must submit medical
reports conf"urning your Child's initial disability
within 31 days of the end of the calendar year of
that Child's 19~ birthday. Thereafter, Delta
Dental may request proof of your Child's
continuing disability, but no more frequently than
annually.
Eliqible Person
Any Subscriber or Eligible Dependent with coverage
under the Plan.
Maximum Approved Fee
A system used by Delta Dental to determine the
approved fee for a given procedure for a given
Participating Dentist. A fee meets Maximum
Approved Fee requirements if it is the lowest o£
• The Submitted Amount.
• The lowest fee regularly charged, offered, or
received by an individual Dentist for a dental service
or supply, irrespective of the Dentist's contractual
agreement with another dental benefits organization:
• The maximum fee that the local Delta Dental Plan
approves for a given procedure in a given region
and/or specialty, under noxmal circumstances
based upon applicable Participating Dentist
schedules and intemal procedures.
Delta Dental may also approve a fee under unusual
circumstances.
Participating Dentists are not allowed to charge Delta
Dental patients more than the Maximum Approved
Fee for a Covered Service. In a11 cases, Delta Dental
will ma.ke the final detemunation regarding the
Maximum Approved Fee for a Covered Service.
Maximum Pavment
The maximum dollaz amount Delta Dental will pay in
any benefit year or lifetime for covered dental
services. (See the Summary of Dental Plan Benefits.)
Nonparticipating Dentist Fee
The maximum fee that Delta Dental will pay per
procedure for services rendered by a Nonparticipating
Dentist.
Out-of-Countrv Dentist Fee
The maximum fee that Delta Dental will pay per
procedure for services rendered by an Out-of-Country
Dentist.
Plan
The azrangement for the provision of dental benefits to
Eligible Persons established by the contract between
Delta Dental and your employer or organization.
Post-Service Claims
Claims for benefits that are not conditioned on your
seeking advance approval, certification, or authorization
to receive the full amount of any covered benefit. In
other words, Post-Service Claims arise when you
receive the dental service or treatment before you file a
claim for the benefit payment.
PPO Dentist Schedule
The maximum fee allowed per procedure for services
rendered by a PPO Dentist as deternuned by that
Dentist's local Delta Dental Plan.
Premier Dentist Schedule
The maximum fee allowed per procedure for services
rendered by a Premier Dentist as deternuned by that
Dentist's local Delta Dental Plan.
Predetermination
Predetermination is a voluntary, optional procedure
where Delta Dental issues a written estimate of
Benefits which may be available under your Plan for
your proposed dental treatment. Your Dentist submits
the proposed dental treatment to Delta Dental in
advance of providing the treatment.
Predetermination is provided for informational
purposes only and is not required before you receive
any dental care. It is not a prerequisite or condition for
approval of future dental benefits payment. You will
receive the same Benefits under your Plan whether or
not a Predeterminafion is requested. The Benefits
estimate provided on a Predeternunation notice is
based on Benefits available on the date the notice is
issued. It is not a guarantee of future Benefits or
payment.
Availability of Benefits at the time your treatment is
completed depends on several factors such as, but not
limited to, your continued eligibility for Benefits, your
Form No. 1752-NC 4,
NCPPOpIus-A
01 /2012
available annual or lifetime Maximum Payments, any
coordination of benefits, the status of your Plan and
your Dentist, your Plan's limitations and any other
Plan provisions. A request for a Predeternunation is
not a claim for Benefits or a preauthorization,
precertification or other reservation of future Benefits.
Processinq Policies
Delta Dental's policies and guidelines used for
Predetermination and payment of claims. The
Processing Policies may be amended from time to time.
Submitted Amount
The amount a Dentist bills to Delta Dental for a
specific treatrnent or service.
Subscriber
You, when your employer or organization notifies
Delta Dental that you aze eligible to receive dental
benefits under your employer's or organization's Plan.
Summarv of Dental Plan Benefits
A description of the specific provisions of your
group dental Plan. The Summary of Dental Plan
Benefits is, and should be read as, a part of this
Certificate, and supersedes any contrary provision
of this Certificate.
III. Selecting a Dentist
You may choose any Dentist. Your out-of-pocket costs
are likely to be less if you go to a Delta Dental PPO
Dentist. PPO Dentists agree to accept payment
according to the PPO Denrist Schedule, and, in most
cases, this results in a reduction of their fees. Delta
Dental may also pay a higher percentage for Covered
Services if you go to a PPO Dentist. If the Dentist you
select is not a PPO Dentist, you will still be covered.
Your coverage levels may be slightly lower, but you
can still save money. In this case, there aze two options:
• If you go to a Non-PPO Dentist who participates
in Delta Dental Premier, the fee reduction is not
the same as with the PPO Dentists. However,
Premier Dentists agree to accept Delta Dental's
Maximum Approved Fee as payment in full for
Covered Services.
• If you choose a Dentist who does not participate
in either program, you will be responsible for any
difference between Delta Dental's allowed fee
and the Dentist's Submitted Amount, in addition
to any Copayments and/or Deductibles.
IV. Accessing Your
Benefits
To use your Plan, follow these steps:
1. Please read this Certificate and the Summary of
Dental Plan Benefits carefully so you are familiar
with the benefits, payment mechanisms, and
provisions of your Plan.
2. Make an appointment with your Dentist and tell
him or her that you have dental benefits coverage
with Delta Dental. If your Dentist is not familiar
with your Plan or has questions about the Plan,
have him or her contact Delta Dental by (a) writing
Delta Dental, Attention: Customer Service, P.O.
Box 9089, Farnrington Hills, Michigan, 48333-
9089, or (b) calling the toll-free number, (800)
662-8856.
3. After you receive your dental treahnent, you or
the dental office staff will file a claim form,
completing the information portion with:
a. The Subscriber's full name and address;
b. The Subscriber's Member ID number;
c. The name and date of birth of the person
receiving dental care;
d. The group's name and number.
Form No. 1752-NC 5
NCPPOpIus-A
Ot/2012
To verify that a Dentist is a Participating Dentist, you
can use Delta Dental's online Dentist Directory at
www.deltadentalnc.com or ca11(800) 662-8856.
Notice of Claim Forms
Delta Dental does not require special claixn forms.
However, most dental offices have claim forms
available. Participating Dentists will fill out and
submit your claims paperwork for you.
Claims and completed information requests should be
mailed to:
Delta Dental
P.O. Box 9085
Farmington Hills, Michigan 48333-9085
Written Notice of Claim/Time of
Pavment
Because the amount of your benefits is not conditioned
on a Predeternunation decision by Delta Dental, a11
claixns under this Plan are Post-Service Claims. Once
a claim is filed, Delta Dental will decide it within 30
days of receiving the proof of loss. If there is not
enough information to decide your claim, Delta Dental
will notify you or your Dentist within 30 days. The
norice will (a) describe the inforxnation needed, (b)
explain why it is needed, (c) request an extension of
time in which to decide the claim, and (d) inform you
or your Dentist that the information must be received
within 90 days or your claim will be denied. You will
receive a copy of any notice that is sent to your
Dentist. Once Delta Dental receives the requested
information, it will have 30 days to decide your claim.
If you or your Dentist fails to supply the requested
information, Delta Dental will have no choice but to
deny your claim. Once Delta Dental decides your
claim, it wili notify you within five days.
Proof of Loss
Written proof of loss must be given within one year
after such loss. If it is not reasonably possible to give
written proof in the time required, the claim will not be
reduced or denied solely for this reason, provided
proof is filed as soon as reasonably possible. In any
event, proof of loss must be given no later than one
year from such time unless the claimant was legally
incapacitated.
Concurrent Care Claims
If you have been approved for a course of treatment
and that course of treatment is reduced or ternunated
before it has been completed, or if you wish to extend
the course of treatment beyond what was agreed upon,
Form No. 1752-NC 6
NCPPOpIus-A
Ot/2o12
you may file a Concurrent Care Claim seeking to
restore the remainder of the treatment regimen or
extend the course of treatment. All Concurrent Care
Claims will be decided in sufficient time so that, if
your claim is denied (in whole or in part), you can
seek a review of that decision before the course of
treatment is scheduled to terminate.
Authorized Representative
You may also appoint an authorized representative to
deal with the Plan on your behalf with respect to any
benefit claim you file or any review of a denied claim
you wish to pursue (see the Disputed Claims
Procedure section). You should contact your Human
Resources department, ca11 Delta Dental's Customer
Service departrnent, toll-free, at (800) 662-8856, or
write them at P.O. Box 9089, Farmington Hills,
Michigan, 48333-9089, to request a form to fill out
designating the person you wish to appoint as your
representative. While in some circuxnstances your
Dentist may be treated as your authorized
representative, generally only the person you have
authorized on the last dated form filed with Delta
Dental will be recognized. Once you have appointed
an authorized representative, Delta Dental will
communicate directly with your representative and
will not inform you of the status of your claim You
will have to get that information from your
representative. If you have not designated a
representative, Delta Dental will communicate with
you directly.
Predetermination Estimate
Delta Dental recommends Predetermination before
your Dentist provides any services where the total
charges will exceed $200. Predeternunation is not a
prerequisite to payment, but it allows claims to be
processed more efficiently and allows you to know
what services may be covered before your Dentist
provides them. You and your Dentist should review
your Predeternunation Notice before treatment. Once
treatment is complete, the dental office will enter the
dates of service on the Predetermination Notice and
submit it to Delta Dental for payment.
Questions?
Questions regarding your Plan or coverage should be
directed to your Human Resources deparhnent or ca11
Delta Dental's Customer Service department, toll-free,
at (800) 662-8856. You may also write to Delta
Dental's Customer Service department, P.O. Box
9089, Farcnington Hills, Michigan, 48333-9089. When
writing to Delta Dental, please include your name, the
group's name and number, the Subscriber's Member
ID number, and your daytime telephone number.
V. How Payment is
Made
If your Dentist is a Participating Dentist, Delta Dental
will base payment on the Maximum Approved Fee for
Covered Services.
Delta Dental will send payment directly to
Participating Dentists and you will be responsible for
any applicable Copayments or Deductibles. Unless
otherwise prohibited by state law, you will be
responsible for the Maximum Approved Fee for most
commonly-performed non-covered services. For other
non-covered services, you will be responsible for the
Dentist's Submitted Amount.
If your Dentist is a Nonparticipating Dentist, Delta
Dental will base payment on the Nonparticipating
Dentist Fee for Covered Services.
If your Dentist is an Out-of-Country Dentist, Delta
Dental will base payment on the Out-of-Country
Dentist Fee for Covered Services.
For Covered Services rendered by a Nonparticipating
Dentist or Out-of-Country Dentist, Delta Dental will
usually send payxnent to the Subscriber, and you will
be responsible for making full payment to the Dentist.
You will be responsible for any difference between
Delta Dental's payment and the Dentist's Submitted
Amount.
VI. Benefit Categories
Important
Eligible people are entitled to ONLY those benefits
listed in the Summary of Dental Plan Benefits. The
following is a description of various dental benefits
that can be selected for a dental program. Please be
certain to review the Exclusions and Limitations
section regarding the benefit information listed below.
Diagnostic and Preventive
Services
DiaQnostic and Preventive Services
Services and procedures to evaluate existing conditions
and/or to prevent dental abnormalities or disease. These
services include examinations/evaluations, prophylaxes
(cleanings), space maint~iiners, and fluoride treatments.
Brush Biopsy
Oral brush biopsy procedure and laboratory analysis to
detect oral cancer. Using this diagnostic procedure,
dentists can identify and treat abnoxrnal cells that
could become cancerous, or they can detect the disease
in its earliest and most treatable stage. The test is
quick, accurate, and involves little or no patient
discomfort.
Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain,
Sealants
A resinous material applied to the occlusal surface of
posterior teeth to prevent decay.
Radiographs
Form No. 1752-NC 7
NCPPOpIus-A
01/2012
X-rays as required for routine care or as necessary for
the diagnosis of a specific condition.
Basic Services
Oral Surgery Services
Extractions and dental surgery, including pre-operative
and post-operative care.
Endodontic Services
The treahnent of teeth with diseased or damaged
nerves (for example, root canals).
Periodontic Services
The treatment of diseases of the gums and
supporting structures of the teeth. This includes
periodontal maintenance following active therapy
(teeth cleaning by a specialist).
Restorative Services
Services to rebuild and repair natural tooth structure
damaged by disease or injury. Restorative services
include:
• Minor restorative services, such as amalgam
(silver) fillings and composite resin (white)
fillings.
• Major restorative services, such as crowns, used
when teeth cannot be restored with another
filling material.
Major Services
Relines and Repairs
Relines and repairs to partial and complete dentures,
and repairs to bridges.
Prosthodontic Services
Services and appliances that replace missing natural
teeth (such as bridges, endosteal implants, partial
dentures, and complete dentures).
Orthodontic Services
Services, treatment, and procedures to correct
malposed teeth (such as braces).
Other Benefits
The Summary of Dental Plan Benefits lists any other
benefits that may have been selected.
VII. Exclusions and
Limitations
Exclusions
Delta Dental will make no payment for the following
services or supplies, unless otherwise specified in the
Summary of Dental Plan Benefits. All charges for
the following services or supplies will be the
responsibility of the Eligible Person (though the
Eligible Person's payment obligation may be
satisfied by insurance or some other arrangement
for which he or she is eligible):
1. Services or supplies for the treatment of an
occupational injury or sickness which are paid
under the North Carolina Worker's Compensation
Act only to the extent such services or supplies are
the liability of the employee, employer or workers'
compensation insurance carrier according to a
final adjudication under the North Carolina
Workers' Compensation Act or an order of the
North Carolina Industrial Coxnmission approving a
settlement agreement under the North Carolina
Workers' Compensation Act.
2. Benefits or services received from any government
agency, political subdivision, community agency,
foundation, or similar entity.
NOTE: This provision does not apply to any
programs provided under Title XIX Social
Security Act; that is, Medicaid.
3. Services or supplies, as detertnined by Delta
Dental, for correction of congenital or
developmental malformations, except that when a
child covered from the moment of birth or
placement in the adoptive home requires dental
care associated with congenital defects and
anomalies, congenital defects will be covered to
the same extent an otherwise Covered Service is
provided by the Plan.
4. Cosmetic surgery or dentistry for aesthetic
reasons, as detennined by Delta Dental, except
that when a Child covered from the moment of
birth or placement in the adoptive home requires
dental care associated with congenital defects and
anomalies, congenital defects will be covered to
the same extent an otherwise Covered Service is
provided by the Plan
5. Services or appliances started before a person
became eligible under this Plan. This exclusion
Form No. 1752-NC $
NCPPOpIus-A
01/2012
does not apply to orthodontic treatment in progress
(if a Covered Service).
6. Prescription drugs (except intramuscular injectable
antibiotics), premedicarions, medicaments/
solutions, and relative analgesia.
7. General anesthesia and/or intravenous sedation for
surgical procedures, unless medically necessary,
or for restorative dentistry.
8. Chazges for hospitalization, laboratory tests, and
histopathological examinations.
9. Charges for failure to keep a scheduled visit with
the Dentist.
10. Services or supplies, as detemvned by Delta
Dental, for which no valid dental need can be
demonstrated.
11. Services or supplies, as determined by Delta
Dental, that are investigational in nature, including
services or supplies required to treat complications
from investigational procedures.
12. Specialized techniques, as deternuned by Delta
Dental.
13. Services or supplies, as deternuned by Delta
Dental, which are not rendered in accordance with
generally accepted standards of dental practice.
14. Treatment by other than a Dentist, except for
services performed by a licensed dental hygienist
or other dental professional as detemuned by
Delta Dental under the scope of his or her license
as pernutted by applicable state law.
15. Services or supplies excluded by the policies and
procedures of Delta Dental, including the
Processing Policies.
16. Services or supplies for which no charge is made,
for which the patient is not legally obligated to
pay, or for which no charge would be made in the
absence of Delta Dental coverage.
17. Services or supplies received as a result of dental
disease, defect, or injury due to an act of war,
declared or undeclared.
18. Services or supplies that are covered under a
hospital, surgicaUmedical, or prescription drug
prograin.
19. Services or supplies that aze not within the
categories of benefits that have been selected and
that are not covered in the Plan.
20. Fluoride rinses, self-applied fluorides, or
desensitizing medicaments.
21. Preventive control programs (including oral
hygiene instruction, caries susceptibility tests,
dietary control, tobacco counseling, home care
medicaxnents, etc.).
22. Space maintainers for maintaining space due to
premature loss of anterior primary teeth.
23. Lost, missing, or stolen appliances of any type and
replacement or repair of orthodontic appliances or
space maintainers.
24. Cosmetic dentistry, as determined by Delta Dental,
except that when a Child covered from the moment
of birth or placement in the adoptive home requires
dental care associated with congenital defects and
anomalies, congenital defects will be covered to the
same extent an otherwise Covered Service is
provided by the Plan.
25. Veneers.
26. Prefabricated crowns used as final restorations on
permanent teeth.
27. Appliances, surgical procedures, and restorations
for increasing vertical dimension; for altering,
restoring, or maintaining occlusion; for replacing
tooth structure loss resulting from attrition,
abrasion, abfraction, or erosion; or for periodontal
splinting. If orthodontic services are Covered
Services, this exclusion will not apply to
orthodontic services as limited by the terms and
conditions of the Plan.
28. Paste-type root canal fillings on permanent teeth.
29. Replacement, repair, relines, or adjustments of
occlusal guards.
30. Chemical curettage.
31. Services associated with overdentures.
32. Metal bases on removable prostheses.
33. The replacement of teeth beyond the normal
complement of teeth.
34. Personalization/characteriza.tion of any service or
appliance.
35. Temporary crowns used for temporization during
crown or bridge fabrication.
36. Posterior bridges in conjunction with partial
dentures in the same arch.
Form No. 1752-NC 9
NCPPOpIus-A
01 /2012
37. Precision attachments and stress breakers.
38. Specialized implant surgical techniques, including
a radiographic/surgical implant index.
39. Appliances, restorations, or services for the
diagnosis or treatment of disturbances of the
temporomandibular joint (TMJ).
40. Diagnostic photographs, diagnostic casts (study
models), and cephalometric films, unless done for
orthodontics.
41. Myofunctional therapy.
42. Mounted case analyses.
Delta Dental will make no payment for the following
services or supplies. Participating Dentists may not
charge Eligible Persons for these services or
supplies. All charges from Nonparticipating
Dentists for the foilowing services or supplies will be
the responsibility of the Eligible Person:
1. The completion of forms or submission of claims.
2. Consultations, when performed in conjunction with
examixiations/evaluations.
3. Local anesthesia.
4. Acid etching, cement bases, cavity liners, and
bases or temporary fillings.
5. Infection control.
6. Temporary crowns.
7. Gingivectomy as an aid to the placement of a
restoration.
8. The correction of occlusion, when performed with
prosthetics and restorations involving occlusal
surfaces.
9. Diagnostic casts, when performed in conjunction
with restorative or prosthodontic procedures.
10. Palliative treatment, when any other service is
provided on the same date except X-rays and tests
necessary to diagnose the emergency condition.
11. Post-operative X-rays, when done following any
completed service or procedure.
12. Periodontal charting.
13. Pins and/or preformed posts, when done with core
buildups for crowns, onlays, or inlays.
14. A pulp cap, when done with a sedative filling or
any other restoration. A sedative or temporary
filling, when done with pulpal debridement for the
relief of acute pain before conventional root canal
therapy or another endodontic procedure. The
opening and draina.ge of a tooth or palliative
treatment, when done by the same Dentist or
dental office on the same day as completed root
canal treatrnent.
15. A pulpotomy on a permanent tooth, except on a
tooth with an open apex.
16. A therapeutic apical closure on a permanent tooth,
except on a tooth where the root is not fully formed.
17. Retreatment of a root canal by the same Dentist or
dental office within two years of the original root
canal treatment.
18. A prophylaxis or full mouth debridement, when
done on the same day as periodontal maintenance
or scaling and root planing.
19. An occlusal adjustment, when performed on the
same day as the delivery of an occlusal guard.
20. Reline, rebase, or any adjustment or repair within
six months of the delivery of a partial denture.
21. Tissue conditioning, when performed on the same
day as the delivery of a denture or the reline or
rebase of a denture.
Limitations
The Benefits for the following services or supplies
are limited as follows, unless otherwise specified in
the Summary of Dental Plan Benefits. All charges
for services or supplies that exceed these limitations
will be the responsibility of the Eligible Person. All
time limitations are measured from the last date of
service in any Delta Dental Plan record or, at the
request of your group, any dental plan record:
1. Bitewing X-rays are payable once per calendar
year. Full mouth X-rays (which include bitewing X-
rays) aze payable once in any five-year period. A
panographic X-ray (including bitewings) is
considered a full mouth X-ray.
2. Any combination of prophyla~ces (teeth cleanings)
and periodontal maintenance procedures are
payable twice per calendar year.
3. Oral exaininations/evaluations are only payable
twice per calendar year, regardless of the Dentist's
specialty.
4. Preventive fluoride treatments are payable twice
per calendar year for people under age 19.
Form No. 1752-NC 1 Q
NCPPOpIus-A
01/2012
5. Space maintainers are payable for people under
age 14.
6. Sealants are payable once per tooth per lifetime for
the occlusal surface of first and second permanent
molazs for people under age 16. The surface must
be free from decay and restorations.
7. Cast restorations (including j ackets, crowns, and
onlays) and associated procedures (such as core
buildups and post substructures) are payable once
in any five-year period per tooth.
8. Crowns or onlays are payable only for extensive
loss of tooth structure due to caries (decay) and/or
fracture.
9. Individual crowns over implants are payable at the
prosthodontic benefit level.
10. Substructures, porcelain, porcelain substrate, and
cast restorations are not payable for people under
age 12.
11. An occlusal guard is payable once in a lifetime.
12. An interim partial denture is payable only for the
replacement of permanent anterior teeth for people
under age 17 or during the healing period for
people age 17 and over.
13. Prosthodontic Services limitations:
a. One complete upper and one complete lower
denture are payable once in any five-year
period.
b. A removable partial denture, implant, or fixed
bridge is payable once in any five-yeaz period
unless the loss of additional teeth requires the
construction of a new appliance.
c. Fuced bridges and removable cast partial
dentures are not payable for people under
age 16.
d. A reline or the complete replacement of
denture base material is payable once in any
two-year period per appliance.
e. Implant removal is payable once per lifetime
per tooth or area.
f. Implant maintenance is payable once per
calendar yeaz.
14. Orthodontic Services limitations:
a. Orthodontic benefits are payable for people
under age 19.
b. If the treatment plan is ternunated before
completion of the case for any reason, Delta
Dental's obligation for payxnent of benefits
ends on the last day of the month in which the
patient was last treated.
c. The Dentist may ternunate treatment, with
written notification to Delta Dental and to the
patient, for lack of patient interest and
cooperation. In those cases, Delta Dental's
obligation for payment of benefits ends on the
last day of the month in which the patient was
last treated.
d. An observation and adjustment is a benefit
twice in a 12-month period.
15. Delta Dental's obligation for payment of benefits
ends on the last day of coverage. However, Delta
Dental will make payment for Covered Services
provided on or before the last day of coverage, as
long as it receives a claim for those services within
one year of the date of service. Failure to submit a
claim within the time required does not invalida.te
or reduce any claim however, if it was not
reasonably possible for the claimant to file the
claim within that time, provided that the claim is
submitted as soon as possible and in no event,
except in the absence of legal capacity of the
claimant, later than one year from the time
submittal of the claim is otherwise required.
16. When services in pmgress aze interrupted and
completed later by another Dentist, Delta Dental
will review the claim to determine the amount of
payment, if any, to each Dentist.
17. Care ternunated due to the death of an Eligible
Person will be paid to the limit of Delta Dental's
liability for the services completed or in progress.
18. Optional treatment: If you select a more expensive
service than is customarily provided, Delta Dental
will make an allowance based on the fee for the
customarily provided service. You are responsible
for the difference in cost.
Listed below are some examples of optional
services. Remember, you are responsible for the
difference in cost for any optional treatment.
a. Overdentures - the Plan will pay only the
applicable amount that it would pay for a
conventional denture.
b. Inlays, regardless of the material used - the
Plan will pay only the applicable amount that
Form No. 1752-NC 11
NCPPOpIus-A
01 /2012
it would pay for an amalgam or composite
resin restoration.
c. All-porcelain/ceramic bridges - the Plan will
pay only the applicable amount that it would
pay for a conventional fixed bridge.
d. Implanbabutment supported complete or
partial dentures - the Plan will pay only the
applicable amount that it would pay for a
conventional denture.
19. Maximuxn Payment:
a. The maximum benefit payable in any one
benefit year will be limited to the Maximum
Payment specified in the Sumrnary of Dental
Plan Benefits.
b: Delta Dental's payment for Orthodontic
Services will be limited to the annual or
lifetime Maximum Payment specified in the
Summary of Dental Plan Benefits.
20. If a Plan Deductible amount is specified in the
Surnmary of Dental Plan Benefits, Delta Dental
will not be obligated to pay for any services or
supplies, in whole or in part, to which the
Deductible applies until the Plan Deductible
amount is met.
21. Processing Policies may limit Delta Dental's
payment for dental services or supplies.
Delta Dental will make no payment for services or
supplies that exceed the following limitations.
Participating Dentists may not charge Eligible
Persons for these services or supplies. All charges
from Nonparticipating Dentists that exceed these
limitations wffl be the responsibility of the Eligible
Person:
1. Amalgam and composite resin restorations by the
same Dentist or dental office are payable once in
any two-year period, regardless of the number or
combination of restorations placed on a surface.
2. Core buildups and other substructures are payable
only when needed to retain a crown on a tooth with
excessive breakdown due to caries (decay) and/or
fractures.
3. Recementation of a crown, onlay, inlay, space
maintainer, or bridge by the same Denrist or dental
office within six months of the seating date.
4. Retention pins are payable once in any two-year
period. Only one substructure per tooth is a Covered
Service.
5. Root planing by the same Dentist or dental office
is payable once in any two-year period.
6. Periodontal surgery by the same Dentist or dental
office is payable once in any three-year period.
7. A complete occlusal adjustment is payable once in
any five-year period. The fee for a complete occlusal
adjustment includes a11 adjustments that are
necessary for a five-year period. A limited occlusal
adjustment is not payable more than three times in
any five-year period. The fee for a lunited occlusal
adjustment includes a11 adjustments that are
necessary for a six-month period
8. Tissue conditioning is not payable more than twice
per arch in any three-year period.
9. The allowance for a denture repair (including
reline or rebase) will not exceed half the fee for a
new denture.
10. Services or supplies, as determined by Deita
Dental, which are not rendered in accordance with
generally accepted standards of dental practice.
11. Processing Policies may limit Delta Dental's
payment for dental services or supplies.
VIII. Coordination of
Benefits
Coordination of Benefits (COB) applies to this Plan
when you or your Eligible Dependents are covered
under more than one Plan.
In that case, North Carolina COB rules deternune
whether this Plan's benefits are determined before or
after another plan's benefits. When this Plan is a
Primary Plan, its benefits are deternuned before the
other plan's benefits and without considering those
benefits. When this Plan is a Secondary Plan, its
benefits are deternuned after those of the other plan
and may be reiiuced because of those benefits.
When you are covered by more than two plans, this Plan
may be a Primaiy Plan as to one or more of "those plans
and may be a Secondary Plan as to the other plans.
Which Plan is Primary?
In general, this Plan is a Secondary Plan. Its benefits
are deternuned after the other plan's benefits, unless:
1. The other plan has rules coordinating its benefits
with this Plan's benefits; and
Form No. t752-NC 1 2
NCPPOpIus-A
01 /2012
2. Those rules and this Plan's rules require that this
Plan's benefits be deternuned first.
Delta Dental deternunes which plan is the Primary Plan
by using the first of the following rules that applies:
The benefits of the plan that covers you as an
employee or a Subscriber (that is, as other than a
dependent) are determined before those of the
plan that covers you as a dependent. This rule
does not apply if you are also a Medicare
beneficiary and, as a result of the rule established
by Title XVIII of the Social Security Act and
implementing regulations, Medicare is:
a. Secondary to the plan covering you as a
dependent; and
b. Primary to the plan covering you as other than a
dependent (for example, as a retired employee).
2. Delta Dental uses the birthday rule when more
than one plan covers a dependent child of parents
who aze not divorced or separated. Under this rule:
a. The benefits of the plan of the parent whose
birthday falls eazlier in the year are
deternuned before the benefits of the plan of
the parent whose birthday falls later in that
year, but
b. If both parents have the same birthday, the
benefits of the plan that covered the parents
longer are deternuned before the benefits of
the plan that covered them for a shorter
period of time.
If the other plan does not use the birthday rule,
but instead uses a rule based upon the gender of
the parent, and if, as a result, the plans do not
agree on the order of benefits, the other plan's
rule deternunes the order of benefits.
3. When more than one plan covers a dependent
child of divorced or separated parents, the child's
benefits are detennined in this order:
a. First, the plan of the parent with custody of
the Child;
b. Then, the plan of the spouse of the parent
with custody of the Child;
c. Then, the plan of the parent without custody
of the Child; and
d. Then, the plan of the spouse of the parent
without custody of the Child.
If the other plan does not have this rule, and if, as
a result, the plans do not agree on the order of
benefits, this rule is ignored.
However, if tYie specific terms of a court decree
state that one of the parents is responsible for the
child's health care expenses, and the entity
obligated to pay or provide the benefits of that
parent's plan has actual knowledge of those
terms, that plan's benefits aze deternuned first.
The other parent's plan is the Secondary Plan.
This paragraph does not apply with respect to any
benefit year during which any benefits are
actually paid or provided before the entity has
that actual knowledge. If the specific terms of the
court decree state that the parents will share
custody without stating that one of the parents is
responsible for the child's health care expenses,
the plans covering the Child are subject to the
birthday rule.
4. The benefits of a plan that covers you as an
employee who is neither laid off nor retired (or as
your dependent) are deternuned before those of a
plan that covers you as a laid-off or retired
employee (or as your dependent). ff the other
plan does not have this rule, and if, as a result, the
plans do not agree on the order of benefits, this
rule is ignored.
5. . If your coverage is provided under a right of
continuation pursuant to federal law (COBR.A) or
state law and you are also covered under another
plan, the benefits of the plan covering you as an
employee or a Subscriber (or as your dependent)
will be deternuned before the benefits under the
continuation coverage. ff the other plan does not
have this rule, and if, as a result, the plans do not
agree on the order of benefits, this rule is ignored.
6. If none of the above rules deternunes the order of
benefits, the benefits of the plan that covered you
longer are detemuned before those of the Plan
that covered you for the shorter term.
How Delta Dental Pays as Primary
Plan
When Delta Dental is the Primary Plan, it will pay for
Covered Services as if you had no other coverage.
Form No. 1752-NC ,~ 3
NCPPOpIus-A
Ot/2012
made" includes providing benefits in the form of
services, in which case "payment made" means
reasonable cash value of the benefits provided in the
forxn of services.
Right of Recovery
If Delta Dental pays more than it should have paid
under this COB provision, it may recover the excess
from the people it has paid or for whom it has paid.
Payrnent includes the reasonable cash value of any
benefits provided in the forxn of services. This right of
recovery is limited to two years after the date of the
original claim payment, unless Delta Dental has
reasonable belief that fraud or intentional misconduct
occurred.
IX. Disputed Claims
Procedure
When Delta Dental is the Secondary Plan, it will pay
for Covered Services based on the amount left after the
Primary Plan has paid. It will not pay more than that
amount, and it will not pay more than it would have
paid as the Primary Plan. Delta Dental may, however,
pay less than it would have paid as the Primary Plan.
When Delta Dental's payments are reduced as
described above, each payxnent is reduced in
proportion. The payments are then charged against any
applicable benefit limit.
Right to Receive and Release
Needed Information
Delta Dental needs certain facts to apply these COB
rules, and it has the right to decide which facts it
needs. It may get needed facts from, or give them to,
any other organization or person. Delta Dental need
not tell, or get the consent of, any person to do this.
Each person claiming benefits under this Plan must
give Delta Dental any facts it needs to pay the claim.
Facility of Payment
A payment made under another plan may include an
amount that should have been paid under this Plan. If
it does, Delta Dental may pay that amount to the
organization that made the payment.
That amount will then be treated as though it were a
benefit paid under this Plan, and Delta Dental will not
have to pay that amount again. The term "payment
Delta Dental will notify you or your authorized
representative if you receive an adverse benefit
determination after your claim is filed. An adverse
benefit determination is any denial, reduction, or
termination of the benefit for which you filed a claim,
or a failure to provide or to make payxnent (in whole or
in part) of the benefit you sought. This includes any
such determination based on eligibility, application of
any utilization review criteria, or a determination that
the item or service for which benefits are otherwise
provided was experimental or investigational or was
not medically necessary or appropriate. If Delta
Dental informs you that the Plan will pay the benefit
you sought but will not pay the total amount of
medical expenses incurred, and you must make a
Copayment to satisfy the balance, you may also treat
that as an adverse benefit deternunation.
ff you receive notice of an adverse benefit
deternunation, and if you think that Delta Dental
incorrectly denied a11 or part of your claim, you can
take the following steps:
First, you or your Dentist should contact Delta
Dental's Customer Service department at their toll-free
number, (800) 662-8856, and ask them to check the
claim to make sure it was processed correctly. You
may also mail your inquiry to the Customer Service
department at P.O. Box 9089, Farmington Hills,
Michigan, 48333-9089. When writing, please enclose
a copy of your Explanation of Benefits and describe
the problem. Be sure to include your name, your
telephone number, the date, and any information you
Form No. 1752-NC 14
NCPPOpIus-A
01 /2012
How Delta Dental Pays as
Secondary Plan
would like considered about your claim. This inquiry
is not required, and it should not be considered a
formal request for review of a denied claim. Delta
Dental provides this opportunity for you to describe
problems and submit information that might indicate
that your claim was improperly denied and allow Delta
Dental to correct this error quickly.
Formal Disputed Claims Procedure
Whether or not you have asked Delta Dental
informally, as described above, to recheck its initial
determination, you can submit your claim to a formal
review through the Disputed Clanns Procedure
described here. To request a fornial dispute of your
claim, you must send your request in writing to:
Dental Director
Delta Dental
P.O. Boz 30416
Lansing, Michigan 48909-7916
You must include your name and address, the
Subscriber's Member ID number, the reason you
believe your claim was wrongly denied, and any other
inforniation you believe supports your claim, and
indicate in your letter that you are requesting a formal
dispute of your claim. You also have the right to
review the Plan and any documents related to it. If
you would like a record of your request and proof that
it was received by Delta Dental, you should mail it
certified mail, return receipt requested.
You or your authorized representative should seek a
review as soon as possible, but you must file your
dispute within 180 days of the date on which you
receive your notice of the adverse benefit
determination. If you are disputing an adverse
deternunation of a Concurrent Care Claim, you will
have to do so as soon as possible so that you may
receive a decision on review before the course of
treatment you are seeking to extend ternunates.
The Dental Director or any other person(s) reviewing
your claim will not be the same as, nor will they be
subordinate to, the person(s) who initially decided
your claim. The Dental Director will grant no
deference to the prior decision about your claim.
Instead, he will assess the information, including any
additiona.l information that you have provided, as if he
were deciding the claim for the first time.
The Dental Director will make his decision within 30
days of receiving your request for the review of Pre-
Service Claims and within 60 days for Post-Service
Claims. If your claim is denied on review (in whole or
in part), you will be notified in writing. The notice of
any adverse determination by the Dental Director will
(a) inform you of the specific reason(s) for the denial,
(b) list the pertinent Plan provision(s) on which the
denial is based, (c) contain a description of any
additional infoimation or material that is needed to
decide the claim and an explanation of why such
information is needed, (d) reference any internal rule,
guideline, or protocol that was relied on in making the
decision on review and inform you that a copy can be
obtained upon request at no charge, (e) contain a
statement that you are entitled to receive, upon request
and at no cost, reasonable access to and copies of the
documents, records, and other information relevant to
the Dental Director's decision to deny your claim (in
whole or in part), and ( fl contain a statement that you
may seek to have your claim paid by bringing a civil
action in court if it is denied again on dispute.
If the Dental Director's adverse determination is based
on an assessment of inedical or dental judgment or
necessity, the notice of his adverse deternunation will
e~lain the scientific or clinical judgment on which the
determination was based or include a statement that a
copy of the basis for that judgment can be obtained upon
request at no charge. If the Dental Director consulted
medical or dental experts in the appropriate specialty, the
notice will contain the name(s) of those expert(s).
If your claim is denied in whole or in part a.fter you
have completed this required Disputed Claixns
Procedure, or if Delta Dental fails to comply with any
of the deadlines contained therein, you have the right
to seek to have your claim paid by filing a civil action
in court. However, you will not be able to do so unless
you have completed the review described above. If
you wish to file your claim in court, you must do so
within one year of the date on which you receive
notice of the fmal denial of your claim.
X. Termination of
Coverage
Delta Dental must give your employer or
organization at least 45 days advance notice of
cancellation, expiration, non-renewal, or a change in
rates. In the event Delta Dental chooses to terminate
the Plan due to nonpayment of premium, Delta
Dental will give your employer or organization notice
of the termination within 45 days after the premium
due date. The effective date of such ternunation shall
be the first day of the period for which the prexnium
is due and not paid.
Form No. 1752-NC 15
NCPPOpIus-A
01 /2012
Your Delta Dental coverage may automatically
terminate:
• When your employer or organization advises Delta
Dental to terminate your coverage.
• On the first day of the month for which your
employer or organization has failed to pay Delta
Dental.
Delta Dental will not continue eligibility for any person
covered under this program beyond the eligibility
ternunation date requested by your employer or
organization. A person whose eligibility is terminated
may not continue group coverage under this Contract,
except as required by the continuation coverage
provisions of the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) or comparable,
non-preempted state law.
XI. Continuation of
Coveraqe
If your employer or organization is required to comply
with provisions under COBRA and the Health
Insurance Portability and Accountability Act of 1996
(HIPAA) and your coverage would otherwise end, you
and/or your covered Eligible Dependents have the
right under certain circumstances to continue coverage
in the medical and dental plans sponsored by your
employer or organization, at your expense, beyond the
time coverage would normally end.
When is Plan Continuation
Coverage Available?
Continuation coverage is available if your coverage or
a covered Eligible Dependent's coverage would
otherwise end because:
l. Your employment ends for any reason other than
your gross misconduct;
2. Your hours of work are reduced so that you are
no longer a full-time employee;
3. You are divorced or legally separated;
4. You die;
5. Your Child is no longer eligible to be a covered
Eligible Dependent (for example, because he or
she turns 19);
6. You become enrolled in Medicare (if applicable); or
7. You are called to active duty in the anned forces
of the United States.
If you believe you are entitled to continuation
coverage, you should contact your employer or
organization to receive the appropriate docuxnentation
required under the Employee Retirement Income
Security Act of 1974 (ERISA).
XII. General Conditions
Chanae of Status
You must notify Delta Dental, through your employer
or organization, of any event that changes the status of
an Eligible Dependent. Events that can affect the status
of an Eligible Dependent include, but are not lixnited
to, marriage, birth, death, divorce, and entrance into
military service.
In no event will retroactive updates to eligibility be
accepted for an effective date more tha.n 90 days prior
to receipt of the update by Delta Dental.
Notwithstanding the foregoing, when no additional
premium is required, a newborn child will be covered
from the moment of birth, and a foster child or adopted
child will be covered from the date of placement in the
home, without regard to the timeliness of the update to
eligibility.
AssiQnment
Services and/or benefit payments to Eligible Persons
are for the personal benefit of those people and cannot
be transferred or assigned, other than to the extent
necessary to allow direct payments to Participating
Dentists. .
Obtaining and Releasing
Information
While you are covered by Delta Dental, you agree to
provide Delta Dental with any information it needs to
process your claims and administer your benefits. This
includes allowing Delta Dental to have access to your
dental records.
Late Claims Submission
Delta Dental will make no payment for services if a
claim for those services has not been received by Delta
Dental within one year following the date the services
were completed. Failure to submit a claim within the
time required does not invalidate or reduce any claim
however, if it was not reasonably possible for the.
Form No. 1752-NC 16
NCPPOpIus-A
01 /2012
claimant to file the claim within that time, provided
that the claim is submitted as soon as possible and in
no event, except in the absence of legal capacity of the
claimant, later than one year from the time submittal
of the claim is otherwise required.
Dentist-
Patient
Relationship
Eligible Persons are
free to choose any
Dentist. Each Dentist
maintains the dentist-
patient relationship
with the patient and is
solely responsible to
the patient for dental
advice and treatment
and any resulting
liability.
Loss of Eligibility During Treatment
If an Eligible Person loses eligibility while receiving
dental treatrnent, only Covered Services received while
that person was covered under the Plan will be payable.
Certain services begun before the loss of eligibility
may be covered if they are completed within a 60-day
period measured from the date of termination. In those
cases, Delta Dental evaluates those services in
progress to determine what portion may be paid by
Delta Dental.
Entire Contract/Chan4es
This Certificate, along with your Summary of Dental
Plan Benefits, constitutes the entire contract of your
Delta Dental program. No agent has the authority to
change any provisions in this Certificate or the
provisions of the contract on which it is based. No
changes to this Certificate or the underlying contract
are valid unless Delta Dental approves them in writing.
Note: This Certificate and your Plan are subject to
change if, in the future, federal or state laws or
regulations require Delta Dental or your employer or
organization to comply with such laws or regulations.
Leaal Actions
No action on a legal claim arising out of or related to
this Certificate will be brought unti160 days after the
time written proof of loss is required to be given. In
addition, no action can be brought more than three
years after the legal claim first arose. Any person
seeking to do so will be deemed to have waived his or
her right to bring suit on such legal claim.
Governinq Law
The group contract and/or Certificate will be governed
by and interpreted under the laws of the state of North
Carolina.
Ri4ht of Recoverv Due to Fraud
If Delta Dental pays for dental services that were sought
or received under fraudulent, false, or misleading
pretenses or circumstances, pays a claim that contains
false or misrepresented inforn~ation, or pays a claim that
is determined to be fraudulent due to the acts of the
Eligible Person, it may recover that payment from the
Eligible Person. The Eligible Person authorizes Delta
Dental to recover any payxnent deternuned to be based
on false, fraudulent, misleading, or misrepresented
information by deducting that amount from any
payments properly due to the Eligible Person. Delta
Dental will provide an explanation of the payment
being recovered at the time the deduction is made.
Leaallv Mandated Benefits
If any applicable law requires broader coverage or more
favorable treatment for the Subscriber or an Eligible
Dependent than is provided by this Certificate, that law
shall control over the language of this Certificate.
Any person who, with intent fo defraud or
knowing that he or she is facilitating a fraud
against an insurer, submits an application or files
a claim confaining a fa/se or deceptive statement
is guilty of insurance fraud.
lnsurance fraud signi~cantly increases the cosf of
healfh care. If you are aware of any false
informafion submitted to Delta Dental, please call
our toll-free hotline. Only anti-fraud ca/!s can be
accepted on this line.
ANTI-FRAUD TOLL-FREE HOTLINE:
(800) 524-0147
Form No. 1752-NC 17
NCPPOpIus-A
Ot/2012
Claims, Predeterminations
P.O. Box 9085
Farmington Hills, MI 48333-9085
Inquiries, Review
P.O. Box 9089
Farmington Hills, MI 48333-9089
An Equal Oppoitunity Employer
Fortn No. 1752-NC
NCPPOpIus-A
Ot/2012
EXHIBIT C
BUSINESS ASSOCIATE ADDENDUM
THIS BUSINESS ASSOCIATE ADDENDUM ("the ADDENDUM") is an addendum to the most recently executed
Agreement between Delta Dental of North Carolina ("Business Associate") and Contractor ("Plan Sponsor"). This
Addendum is also entered into by and between Business Associate, the Plan Sponsor, and the Contractor's Benefit Plan as
named in the Contractor's ERISA Plan documents (the "Plan"). Business Associate, the Plan Sponsor, and the Plan are
sometimes coliecrively referred to herein as the "Parties." This Addendum is effective on the same date as the Contract
attached hereto.
I. INTRODUCTION
A. WHEREAS, pursuant to the terms and conditions set forth in the Agreement, Business Associate performs, for
or on behalf of the Plan, certain services described in the Agreement (the "Services'~; and
B. WHEREAS, in performing the Services, Business Associate will receive, create, or access certain Protected
Health Information of Participants or Beneficiaries covered under the Plan, and, accordingly, is a"Business
Associate" as defined in the Privacy Rule; and
C. WHEREAS, the Plan is a"Covered Entity" within the meaning of the Privacy Rule; and
D. WHEREAS, the Parties desire to enter into this Addendum to comply with the provisions in the Privacy Rule
requiring a Business Associate to provide adequate assurances to a Covered Entity with respect to the
confidenriality of PHI.
E. NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which are hereby
aclmowledged, the Parties hereby agree as follows:
II. DEFINITIONS
A. "Beneficiary" means any Individual entitled to benefits under the Plan by virtue of being a covered dependent of
a Participant.
B. "Business Associate" shall have the same meaning as the term "business associate" in 45 CFR 160.103. Delta
Dental is a Business Associate of the Plan.
C. "Covered Enrity" shall have the same meaning as the term "covered entit}~' in 45 CFR 160.103. The Plan is a
Covered Enrity.
D. "Designated Record SeY' shall have the same meaning as the term "designated record set" in 45 CFR 164.501
limited to a group of records maintained by or for the Plan that includes (a) enrollment, payment, and claims
adjudication record of an Individual maintained by or for the Plan, (b) other Protected Health Informarion used,
in whole or in part, by or for the Plan to make coverage decisions about an Individual.
E. "Electronic Protected Health Information" or "EPHI" shall have the same meaning as the term "electronic
protected health information," at 45 CFR 160.103, limited to the electronic protected health information that is
created, received, maintained, or ttansmitted to or on behalf of the Plan.
F. "ERISA" means the Employee Retirement Income Security Act of 1974, as amended.
G. "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as amended.
H. "HITECH Act " means the Health Information Technology for Economic and Clinical Health Act, found in
the American Recovery and Reinvestment Act of 2009 at Division A, title XIII and Division B, Title IV.
I. "Individual" shall have the same meaning as the term "individual" in 45 CFR 160.103, and shall include a
person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).
Page 1 of 8
Exhibii C- Nonh Carolina - BA Addendum 92011
J. "Minimum Necessary" shall have the meaning set forth in the Health Information Technology for Economic and
Clinical Health Act, § 13405(b)
K. "ParticipanY' means any Individual who is an employee of the Plan Sponsor and is entitled to benefits under the
Plan.
L. "Plan" means the Contractor's Benefit Plan as named in the Contractor's ERISA Plan documents. Whenever
reference is made in this Addendum to actions or undertakings of the Plan, to reports or information provided by
the Business Associate to the Plan or to instructions to the Business Associate from the Plan, the reference to the
Plan shall be to the person or entity designated in the Plan documents as having responsibility for Plan
administration, or, if no designation is made therein, the Plan Sponsor. In short, the reference is to a person or
enrity with authority to act or speak on behalf of the Plan.
M. "Plan Sponsor" means the Contractor. The Plan Sponsor is neither a Covered Entity nor a Business Associate.
N. "Privacy Rule" means the "Standards for Privacy of Individually Identi~able Health Information," at 45 CFR
parts 160 and 164, subparts A and E, as promulgated pursuant to HIPAA.
O. "Protected Health Information" or "PHI" shall have the same meaning as the term "protected health
information" in 45 CFR 160.103, limited to the information created, received, or accessed by Business Associate
from or on behalf of the Plan.
P. "Required By Law" shall have the same meaning as the term "required by law" in 45 CFR 164.103.
Q. "Secretar~' shall mean the Secretary of the Department of Health and Human Services, or his designee.
R. "Security Rule" means the "Standards for the Security of Electronic Protected Health Information," at 45 CFR
parts 160, 162 and 164, as promulgated pursuant to HII'AA.
III. AGREEMENTS
A. Oblieations of Business Associate.
1. Application of Security Rule and Privacy Rule to Business Associate. The administrative, physical and
technical safeguards set forth in the HIPAA Security Rule at 45 CFR 164.308, 164.310, 164312, and
164.316, shall apply to Business Associate in the same manner that such sections apply to a covered entity.
The additional requirements of Subtitle D of the HITECH Act (Sections 13400 through 13411) that relate to
privacy or security and that are made applicable with respect to covered entities shall also be applicable to
Business Associate and are hereby incorporated into this Agreement.
2. Uses and Disclosures. Business Associate shall not use or further disclose PHI other than (a) as permitted
or required by this Agreement and Addendum, (b) as permitted or required by the Plan documents, (c) as
permitted or required by the Pri~+acy Rule, (d) as Required by Law, (e) in a manner that would be
pernussible if used or disclosed by the Plan, or (fl in a manner that would not violate the Privacy Rule or
other applicable federal or state law or regulation. Business Associate may use and disclose PHI that
Business Associate obtains or creates only if such use or disclosure, respecrively, is in compliance with each
applicable requirement of 45 CFR 164.504(e).
3. Minimum Necessary Staadard. Business Associate shall use and disclose PHI in a manner minimally
necessary to accomplish the intended purpose of the use or disclosure. Business Associate shall be
responsible for making minimum necessary determinations.
4. Security. Business Associate agrees to (a) implement safeguards in accordance with the Security Rule that
reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic
Protected Health Information that it creates, receives, maintains, or transmits on behalf of the Plan, (b)
ensure that any agent, including subcontractor, to whom Business Associate provides PHI agrees to
implement reasonable and appropriate safeguards in accordance with the Security Rule to protect the PHI,
and (c) report to the Plan any violation of the Security Rule of which it becomes aware.
Page 2 of 8
Exhibi~ C- North Carolina - BA Adderdum 9/201 I
NotiTication of Unauthorized Access, Use or Disclosure of Unsecured PHI. Business Associate shall
notify Covered Entity in writing of any unauthorized access, use or disclosure of unsecured PHI as soon as
reasonably possible but no later than five (5) days following the date of discovery. Such notice shall include:
(a) a brief description of what happened, including the date of the breach and the date of the
discovery,
(b) the name(s) of the individual(s) whose PHI was used or disclosed,
(c) the identity(ies) of the entity(ies)/person(s) to whom the use or disclosure was made,
(d) description of the types of unsecured PHI that were disclosed,
(e) the steps taken by Business Associate to discontinue and minimize the impact of any inappropriate
use or disclosure.
6. Reporting. Business Associate shall report to the Plan any use or disclosure of PHI not provided for under
Section III.A.2 of this Addendum of which Business Associate becomes aware. Additionally, Business
Associate agrees that, to the extent practicable, it shall mitigate any harmful effect of a use or disclosure of
PHI of which it becomes aware that is in violation of the requirements of Section III.A.2 of this Addendum.
7. Mitigation of Uaauthorized Access, Use or Disclosure of Unsecured PHI. Business Associate agrees
that, to the extent pracricable, it shall mitigate any harmful effect resulting from any unauthorized
acquisirion, use or disclosure of unsecured PHI caused by Business Associate's violation of the requirements
of this Agreement or its failure to properly secure PHI in accordance with the April 17, 2009 guidelines
published by the Depariment of Health and Human Services.
8. Agents and Subcontractors. Business Associate shall ensure that any subcontractors or agents to whom it
provides PHI that has been created or received by Business Associate from or on behalf of the Plan agrees to
the same restrictions and condirions with respect to such PHI as are applicable to Business Associate as set
forth herein. Should Business Associate, at its sole discretion, enter into a written contract with such
subcontractors or agents to assure that such subcontractors or agents abide by the same restrictions and
conditions that apply to Business Associate with regard to PHI, Business Associate shall, upon request,
provide a copy of such contract(s) to the Plan.
9. Requests for Information or Access. Business Associate shall process any requests it receives from
individuals seeking access to or copies of PHI maintained by Business Associate for or on behalf of the
Plan. T'he Plan hereby expressly delegates its authority regarding requests for access to Business Associate
and agrees to abide by Business Associate's determinations to grant or deny access in accordance with the
Privacy Rule.
10. Requests to Amend. Business Associate shall make any amendment(s) to PHI in a Designated Record Set
that the Plan directs or agrees to pursuant to 45 CFR 164.526 at the request of the Plan or an Individual. The
Business Associate shall make amendments as soon as administratively feasible.
11. Business Associate agrees to document disclosures of Protected Health Information, and information related
to such disclosures, as would be required for Health Plan Sponsor to respond to a request by an Individual
for an accounting of disclosures of Protected Health Information in accordance with 45 CFR § 164.528 and
any additional regulations promulgated by the Secretary pursuant to HITECH Act § 13405(c). Business
Associate agrees to implement an appropriate record keeping process that will track, at a minimum, the
following information: (i) the date of the disclosure; (ii) the name of the entity or person who received the
Protected Health Information, and if lrnown, the address of such entity or person; (iii) a brief description of
the Protected Health Information disclosed; and (iv) a brief statement of the purpose of such disclosure
which includes an explanation of the basis for such disclosure.
12. Requests for Accountings. With respect to requests for an accounting, Business Associate shall notify the
Plan in writing within twenty (20) business days of any requests received by Business Associate from
individuals seeking an accounting of disclosures of PHI and respond to such requests only when and as
directed by the Plan. Additionally, when and as directed by the Plan, Business Associate shall provide for
an accounting to the Plan or the requesting individual (as directed) of any and all disclosures of PHI made
Page 3 of 8
Exhibit C- Nonh Camlina - BA Addcndum 9201 I
by Business Associate on behalf of the Plan during the six years prior to the date of the request. Business
Associate shall maintain and make available to the Plan, upon request, a record of all disclosures of PHI
made by Business Associate, inciuding, at a minimum, the date of the disclosure, the name and address of
the recipient of the PHI, a descriprion of the PHI disclosed, and the purpose of and basis for the disclosure.
The accounting obligations of Business Associate hereunder shall not apply to (a) disclosures made for
purposes of treahnent, payment, or health care operations (as defined in the Privacy Rule), (b) disclosures
made to the individual who is requesring the accounting, (c) disclosures made prior to April 14, 2003, (d)
disclosures made to law enforcement officers, conectional institutions, or for national security purposes, (e)
disclosures incidental to a use or disclosure otherwise permitted or required as provided in 45 CFR 164.502,
(~ pursuant to an authorization as provided in 45 CFR 164.508, (g) as part of a limited data set in
accordance with 45 CFR 164.514(e).
13. Books and Records. Business Associate shall make its internal practices, books, and records relating to the
use and disclosure of PHI received from the Plan, or created or received by Business Associate on behalf of
the Plan, available to the Secretary and to the Plan for purposes of determining the Plan's compliance with
HIPAA, the Privacy Rule, and other applicable federal and/or state law. Business Associate shall notify the
Plan immediately of any such requests and shail pravide the Plan with a copy of the request and any
documents or information provided in response to such requests.
14. Termination. Upon learning of any pattern of improper uses or disclosures by Business Associate that the
Plan determines amounts to a material breach of Business Associate's obligations under this Addendum, the
Plan shall promptly notify Business Associate in writing as to the nature and extent of such breach, and shall
provide Business Associate a reasonable amount of time to cure such breach. A reasonable amount of time
shall depend on the nature and extent of the breach, shall be clearly stated in the notice, but in no case shall
the period for cure be less than 30 days: Notwithstanding the foregoing, should the Plan determine that the
breach is incurable, or that Business Associate has repeatedly engaged in such impermissible uses or
disclosures despite prior norice, the Plan may have the Plan Sponsor immediately terminate the Agreement
to which this Addendum applies, upon written notice to Business Associate, without damages or liability to
the Plan Sponsor or the Plan.
15. Return of PHI Upon Termination. At temunation of the Agreement, Business Associate shall retum or
destroy all PHI received from the Plan, or created by Business Associate on behalf of the Plan, that Business
Associate maintains in any form. Business Associate shall retain no copies of such PHI. Upon request of
the Plan, Business Associate shall provide a written certification of the return and/or destruction of the PHI.
ff the parties agree that the return or destruction of such PHI by Business Associate is not feasible, then
Business Associate shall continue to extend the protections required hereunder to the PHI for as long as it
maintains the PHI. Further, Business Associate shall limit any further use or disclosure of the PHI to those
purposes that make its return or destruction infeasible. This provision shall survive the termination of this
Agreement.
16. Prohibition against Sale or Marketing of PHI. Except as otherwise provided in Section 13405 of the
HITECH Act, Business Associate shall not (a) directly or indirectly receive remuneration in
exchange for any PHI of an individual; or (b) use or disclose PHI for any purpose related directly or
indirectly to any marketing or marketing communication.
B. Additional Permissible Uses and Disclosures of PHI bv Business Associate. Subject to the foregoing
provisions, and in addition to the use and disclosure by Business Associate of PHI authorized elsewhere in this
Addendum, Business Associate may use and disclose PHI for the following additional purposes:
1. As necessary for data aggregation purposes relating to the health care operations of the Plan, but only as
separately authorized by the Plan in writing,
2. As necessary for data aggregation purposes of Business Associate, but only if the PHI is de-identified
pursuant to 45 CFR 164.514,
3. For the proper internal management and administration of Business Associate,
4. To carry out the legal responsibilities of Business Associate, and
Page 4 of 8
Fachibit C~- North Carolina - BA Addendum 9/201 I
5. To provide summary health information (as defined in 45 CFR 164.504) to the Plan Sponsor for the
purposes of obtaining premium bids for other health insurance coverage or, if needed, to amend or terminate
the Plan.
For purposes (3) and (4) above, Business Associate may use or disclose PHI to third parties only if the
disclosure is Required by Law, Business Associate obtains reasonable assurances from the person to whom
the PHI is disclosed that it will be held confidentially and used or further disclosed only as Required by Law
or for the purposes for which it was disclosed to the person, and the person to whom the disclosure is made
is obligated to notify Business Associate of any instances of which that person is or becomes aware in which
the confidenriality of the information has been breached.
C. Oblieations of the Plan.
1. Comply With the Privacy Rule. The Plan shall comply with all the obligations imposed on Covered
Entiries under the Privacy Rule with respect to the pemritted and required uses and disclosures of PHI.
2. Notice of Privacy Practices. The Plan shall provide Business Associate with a copy of its Notice of
Privacy Practices, as well as any changes made to such Notice from time to time.
3. Communicate Changes in Permitted Uses and Disclosures. T'he Plan shall provide Business Associate
with any changes in, or revocarion of, permission by Participants or Beneficiaries to use or disclose PHI, if
such changes affect Business Associate's pernutted or required uses and disclosures of PHI.
4. Communication of Restrictions on Uses and Disclosures. The Plan shall notify Business Associate of
any restriction to the use or disclosure of PHI that the Plan has agreed to.
5. Prohibirion of Employment-Related Disclosures. The Plan shall not use or disclose the PHI of any
Participant or Beneficiary to the Plan Sponsor for any employment-related purposes, or in connection with
any other benefit plan of the Plan Sponsor, nor shall it direct Business Associate to do so.
6. Guarantee of Individual Rights. The Plan shall ensure that Participants and Beneficiaries have the rights
of access, amendment, and accounting with respect to their own PHI as set forth under the Privacy Rule.
7. Limitation on Access for Administrative Purposes. The Plan shall ensure that access to the PHI of
Participants and Beneficiaries will be limited to those employees or agents of the Plan Sponsor designated in
the Plan documents as being entitled to receive and use PHI in connecrion with the administrarion of the
Plan, and will notify Business Associate in a timely fashion of the identity of such persons, any changes in
the persons so designated, and a means for Business Associate to verify that it is in fact communicating with
such persons.
8. Safeguards. The Plan shall establish or cause to be established adequate administrative, physical, and
technical safeguards for protecting PHI and will provide Business Associate with sufficient information
about such safeguards as wili allow Business Associate to provide the Services while respecting and
maintaining the safeguards.
9. Sponsor Certification. The Plan will require that the Plan Sponsor certify that it has agreed to the
obligations set forth in Section III.D below and that the Plan documents have been amended to incorporate
the condirions to which the Plan Sponsor has agreed.
10. Limitation on Plan Requests of Business Associate. Except to the extent pemutted under Section III.B
above, the Plan shall not ask Business Associate to use or disclose PHI in a manner that would not otherwise
be permitted under the Privacy Rule if done by the Plan.
D. ObliPations of the Plan Soonsor.
1. Prohibition on Employment-Related Uses and Disclosures. The Plan Sponsor shall not use or disclose
the PHI of any Participant or Beneficiary for employment-related purposes or in connection with any other
benefit plan of the Plan Sponsor.
Page 5 of 8
Exhibil C- North Carolina - BA Adde~um 9/201 I
2. Permitted Uses and Disclosures. The Plan Sponsor shall only use or disclose the PHI of any Participant or
Beneficiary as permitted or required by the Plan documents, the Privacy Rule, this Addendum, or as
Required by Law.
3. Obligation to Report. The Plan Sponsor shall report to the Plan and Business Associate any use or
disclosure of PHI of which it becomes aware that is inconsistent with the uses and disclosures permitted
under Section III.D.2 above.
4. Cooperation for Plan Compliance. T'he Plan Sponsor shall make its internal practices, books, and records
relating to the use and disclosure of PHI received from Business Associate or the Plan available to the
Secretary for determining the Plan's compliance with the Privacy Rule.
5. Return of Pffi. The Plan Sponsor shall return, if feasible, all PHI received from the Plan or Business
Associate when the PHI is no longer needed for the purpose(s) for which it was disclosed.
6. Amend Plan Documents. The Plan Sponsor shall amend or cause to be amended the Plan documents to (a)
identify the pernutted and required uses and disclosures of PHI by the Plan Sponsor, (b) identify those of its
employees or classes of employees to whom PHI may be disclosed for purposes of payment and health care
operations in the normal course of Plan operarions, (c) restrict the Plan administrative functions performed
by the Plan Sponsor to those employees and classes of employees identified in the Plan documents, and (d)
establish an effective mechanism for resolving any instances of non-compliance with the permitted uses and
disclosures by those employees and classes of employees identified in the Plan documents as being allowed
to access PHI.
7. Individual Rights. The Plan Sponsor shall ensure all Participants and Beneficiaries the right to access,
request amendments, and receive accounrings of disclosure of their own PHI maintained by the Plan.
8. Certification. The Plan Sponsor will certify to the Plan and Business Associate that it has fulfilled all of the
obligarions set forth in Sections III.D.1-7 above.
E. Security. The Parties shall work together in good faith to cooperate with each other's current and future security
policies and procedures to ensure the integrity, confidentiality, and availability of PHI in a manner that complies
with HIPAA and the Security Rule, as amended from time to time.
F. Record Keeping. Business Associate agrees to implement an appropriate record keeping process to enable it to
comply with the HIPAA requirements applicable to it under this Addendum and the Privacy Rule.
G. Confidential and Proprietary Information. Business Associate may receive, create, or have access to
confidenrial and/or proprietary information of the Plan Sponsor conceming its business affairs, property,
products, operations, computer systems, and strategies. Business Associate agrees to hold such confidential
and/or proprietary information in strict confidence, to maintain and safeguard the confidentiality of such
informarion, and to use such information solely to perform the Services as required by this Agreement.
Likewise, the Plan Sponsor or the Plan may receive, create, or have access to confidential and/or proprietary
information of Business Associate conceming its business affairs, property, operations, computer systems,
dentists, providers, and strategies. The Plan Sponsor and the Plan agree to hold such confidential and/or
proprietary information in strict confidence, to maintain and safeguard the confidentiality of such information,
and to use such information solely to perform their obligations as required by this Agreement.
H. Amendment. Upon enactment of any law or regulation affecting the use or disclosure of PHI, or the publication
of any decision of a court of the State or the United States relaring to any such law, or the publication of any
interpretative policy or opinion of any government agency charged with the enforcement of any such law or
regulation, Business Associate, by written notice to the Plan and the Plan Sponsor, may amend the Agreement
and/or this Addendum in such manner as Business Associate detemvnes necessary to comply with such law or
regulation, and the Plan and the Plan Sponsor agree to be bound by such amendment, unless within thirty (30)
days of the Plan's and the Plan Sponsor's receipt of notice of such amendment the Plan and the Plan Sponsor
notify Business Associate that they reject such amendment. Upon receipt of such notice of rejection, Business
Associate may terminate the Agreement immediately upon written notice to the Plan and the Plan Sponsor.
Page 6 of 8
Bxhibi~ C- North Carolina - BA Adde~dum 9/201 I
I. Binding Effect. Except as otherwise provided herein, the terms and conditions of the Agreement shall remain in
full force and effect. Additionally, the terms and conditions of this Addendum shall remain in full force and
effect following ternunation of the Agreement.
Indemnification by Plan or Plan Sponsor. To the extent permitted by law, the Plan and Plan Sponsor hereby
agree to indemnify, defend, and hold hannless the Business Associate, its board of directors, officers, members,
agents, employees, subcontractors, and personnel (the "Indemnities") from and against any and all claims,
demands, suits, acrions, losses, expenses, costs (including reasonable attomey fees), obligations, damages,
deficiencies, causes of action, and liabilities (collectively, "Claims") incurred by the Indemnities as a result of, or
that are proatimately caused by, the negligence, intentional misconduct, willful malfeasance, fraud, or
misrepresentation of Plan or Plan Sponsor, its employees, officers, subcontractors, and agents. The Plan or Plan
Sponsor does not waive its sovereign immunity by entering into this contract and fully retains all immunities and
defenses provided by law with respect to any action based on this contract.
Business Associate shall provide prompt written notice of relevant information conceming the Claims to the Plan
and Plan Sponsor. The Plan and Plan Sponsor shall provide such reasonable assistance (at Plan Sponsor's
expense) as may reasonably be requested by Business Associate in connection with the defense of any Claim.
Notwithstanding the foregoing: (1) Business Associate shall not settle any such Claim without the consent of the
Plan Sponsor or the Plan, which consent shall not be unreasonably withheld, and (2) the indemnification
obligations of Plan Sponsor and the Plan hereunder shall not extend to Claims ariributable solely to the gross
negligence, intentional misconduct, or willful malfeasance of Business Associate.
K. IndemniTication by Business Associate. Business Associate hereby agrees to indemnify, defend, and hold
harmless the Plan Sponsor or the Plan, their board of directors, officers, members, agents, employees,
subcontractors, and personnel (the "Indemnities") from and against any and all claims, demands, suits, actions,
losses, expenses, costs (including reasonable attomey fees), obligations, damages, deficiencies, causes of action,
and liabilities (collectively, "Claims") incurred by the Indemnities as a result of, or that are proximately caused
by, the negligence, intentionai misconduct, willful malfeasance, fraud, or misrepresentation of Business
Associate, its employees, officers, subcontractors, and agents; nothing in this secrion shall purport to indemnify
or hold harmless a Plan fiduciary for any breach of his or her fiduciary duries under ERISA except where the
Plan and/or the Plan Sponsor has delegated some or all of its responsibilities as to the Business Associate
pursuant to the Contract..
The Plan Sponsor or the Plan shall provide prompt written notice of relevant information conceming the Claims
to Business Associate. Business Associate shall provide such reasonable assistance (at Business Associate's
expense), as may reasonably be requested by the Plan and Plan Sponsor, in connection with the defense of any
Claim. Notwithstanding the foregoing: (1) neither the Plan nor the Plan Sponsor shall settle any such Claim
without the consent of Business Associate, which consent shall not be unreasonably withheld, and (2) the
indemnification obligations of Business Associate hereunder shall not extend to Claims amibutable solely to the
negligence, gross negligence, intentional misconduct, or willful malfeasance of the Plan or the Plan Sponsor.
L. Injunction. The Parties acknowledge and agree that in the event of a breach or threatened breach by Business
Associate, the Plan Sponsor, or the Plan of their duries and obligations hereunder, each of the affected Parties
shall be irreparably and substantially harmed, and that remedies at law will not be an adequate remedy for such
breach. Accordingiy, in such event, Business Associate, the Plan Sponsor, and the Plan shall be entitled to
immediate injunctive relief against such breach or threatened breach. Such rights to injunctive relief shall be in
addition to, and not in limitation of, any other legal and equitable relief available to Business Associate, the Plan
Sponsor, or the Plan under applicable law.
M. Counterparts. This Agreement may be executed in the original or by facsimile or other electronic means
in any number of counterparts, each of which shall be deemed an original, and all of which together shall
constitute one and the same instrument.
N. Disputes, Venue. The parties further agree that jurisdiction and venue for any matter arising out of or
pertaining to this Addendum shall be proper only in the state and dederal courts located in Orange County,
NHorth Carolina and the Middle District of the State of North Carolina, and the parties hereby consent to
such jurisdiction and venue.
O. Waiver. The failure of the Plan Sponsor to require compliance by the Business Associate with any
provisions fo this agreement or the waiver by the Plan Sponsor of any breach of this agreement shall not
Page 7 of 8
Ezhibi~ C- North Carolina - BA Adde~um 9/2011
constitute a waiver of any claim for damages by the Plan Sponsor for any breach of this agreement or a
waiver of any other required compliance.
This agreement represents the entire and integrated agreement between the parties and supersedes all prior
negotiations, representations or agreements, either written or oral. This Agreement may be amended only
by written instrument signed by the parties.
Page 8 of 8
Erhibit C- North Carolina - BA Addendum 9/201 I