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Agmt78 California Dental Servic
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Agmt78 California Dental Servic
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Last modified
7/5/2005 2:53:23 PM
Creation date
6/10/2002 11:21:37 AM
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Template:
Agreement
Contractor Name
California Dental Service
PROJECT NAME
Dental Care Service
RMP File Number
304
Date
3/15/1978
Reso Ref
7766 8022
Amendment
Yes
Box
2450
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Applicant a~rees to bear the expenses of such payments without withholding or <br /> otherwise charging the EliElbie Employees for coverage of themselves or their <br /> dependents, <br /> <br />Paragraph q.03 is amended to readt <br /> <br /> LIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS-' The following <br /> limitations apply to Diagnostic and Preventive Benefltst <br /> <br /> a) Routine oral examinations and prophylaxis treatment shall not be provided <br /> more than twice each in any twelve mo~th period while the patient ts an <br /> Eligible Person under any CPS program. <br /> <br /> b) Unless special need is shown, full mouth x-rays are provided only alter <br /> three years have elapsed following any prior provision of full mouth x-rays <br /> under any CPS proiram. Supplementary bite-wing (individual) x-rays are <br /> provided on request by the Dentist~ but not more than once every six <br /> montfls while the patient is an Eligible Person under any CPS pro,ram. <br /> <br />Paragraph ~.0§ Is amended to readi <br /> <br /> CDS shall pay or otherwise discharge 80% of the Dentists~ Usual~ Customary and <br /> Reasonable fees or the fees actually charged~ whichever is less, for the following <br /> Crowns~ 3ackets and Gold or Cast tlestorations Benefits-. <br /> <br /> Crowns~ 3ackets and Gold or Cast Restorations for treatment of carious lesions <br /> ivislble destruction of hard tooth structure resulting from the process o! dental <br /> decay) which cannot be restored with amalgam~ synthetic porcelain or plastic <br /> restorations. <br /> <br />Paragraph ¢,08 id) is amended to reads <br /> <br /> id) CPS will Pay the applicable percentage of the Dentist's fee for a standard <br /> cast chrome or acrylic partial denture or a standard complete denture~ up <br /> to a maximum fee allowance which is at least the Prevailing Fee for a <br /> standard denture, iA "standard" complete or partial denture is defined as <br /> removable prosthetic appliance provided to replace missing natural~ <br /> permanent teeth and which is constructed usln~ accepted and conventional <br /> procedures and materials.) The maximum allowance is revised periodically <br /> as dental fees change. Any denture and/or related service for which a <br /> charge is made which exceeds this allowance is considered an optional <br /> servlce~ and the Patient is responsible for the portion of the Dentist~ fee in <br /> eXcess of the CIDS allowance. <br /> <br /> <br />
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