Hansel

DDPIN Eligibility and Benefits are based on information available on 06/11/2025 . This is an overview of benefits that should be reviewed in its entirety, and not a guarantee of payment. Refer to the patient's summary plan description (SPD) for detailed benefits, limitations, and exclusions. Estimated patient out of pocket expenses can be determined by the submission of a pre-treatment estimate. Eligibility Member Name: Patient Name: Relationship: Client Name: Client Number: Product: Currently Eligible: CHRISTOPHER COLWELL CHRISTOPHER COLWELL Subscriber Aisin Chemical, LLC- Delta Dental PPO (Point-of-Service) Yes as of 04/01/2023 Claims Mailing Address Client Information: The Employer has selected the following benefit plan. Eligibility is not a guarantee of coverage as actual benefit payments are determined only when a claim is processed. Delta Dental P.O. Box 9085 Farmington Hills, MI- Payer ID DDPMI, DDPIN, DDPOH Contact your clearing house if you have any issues with these payer IDs Coordination of Benefits Internal: No External: Yes Be sure to visit us at www.deltadentalin.com to submit claims and review benefits. Coordination of benefits information is based on the information submitted on the claim. Maximum and Deductibles PPO Dentist Premier Dentist Nonparticipating Dentist Maximum Individual (used/max) $ 0.00 / $ 1500.00 $ 0.00 / $ 1500.00 Orthodontic General PPO Dentist Premier Dentist Nonparticipating Dentist Orthodontic General Family (used/max) applies to on orthodontic services. The maximum does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants and orthodontic services. Benefit Periods Lifetime 01/01/2025 to 12/31/2025 PPO Dentist Premier Dentist Nonparticipating Dentist Deductible Individual (met/ded) $ 0.00 / $ 50.00 General PPO Dentist Premier Dentist Nonparticipating Dentist Office Visit Exam Cleaning Perio Maintenance Cleaning Bitewings General Family (met/ded) $ 0.00 / $ 150.00 applies to The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants, and orthodontic services. Benefit Periods 01/01/2025 to 12/31/2025 Based on contract limitations for the services listed below, the patient is currently eligible for those services where 'Yes' is displayed provided maximum is available and waiting periods have been met. 'No' indicates the patient has met the time limitations for the procedure, or the procedure is otherwise not covered, and if the service was performed today, no payment will be made by Delta Dental Yes Yes Yes Yes Full Mouth X-rays No Fluoride No Perio Risk Test No Occlusal Guard Yes Payment was issued on service date of 05/03/2024 Not covered due to the patient's age Service is not a covered benefit for this patient Benefit Breakdown This page provides the levels of coverage and frequencies based on this client's contract with Delta Dental. This listing covers the most commonly requested procedure codes, but it is not all-inclusive listing of possible covered procedures. If you need information about a code not listed below, you may inquire on it using our automated system under the Benefits section. Benefit levels and payments are based on the client's contract and Delta Dental's processing policies. Please note, this information is not a guarantee of coverage or payment. Benefits and payments are determined only when a claim is received and processed by Delta Dental. In the event that treatment is rendered from a dentist that does not participate in any of Delta Dental's programs, the patient may be responsible for more than the percentage indicated below. Diagnostic D0120 D0140 D0150 D9110 mbb_-_-_DOT % 100% 100% 100% 100% Oral Exam Oral Exam Oral Exam Emergency Page 1 PPO Dentist Premier Dentist Nonparticipating Dentist Waiting Period Met Date N/A N/A N/A N/A Patient Name: CHRISTOPHER COLWELL Client/Sub-Client #:- Relationship: SUBSCRIBER • Oral examinations (including examinations by a specialist) are payable twice per calendar year. Preventive D1110 D1120 D1206 D1208 D1510 Cleaning Cleaning Fluoride Fluoride Space main 100% 100% 100% 100% 100% N/A N/A N/A N/A N/A 100% 100% N/A N/A 100% 100% 100% 100% N/A N/A N/A N/A 100% Not Covered N/A N/A • Prophylaxes (cleanings) are payable twice per calendar year. • Space maintainers are payable once per area in a lifetime for age 13 and under. • Fluoride treatments are payable twice per calendar year for age 15 and under. Bitewing Radiographs D0272 D0274 Xrays Xrays • Bitewing x-rays are payable once per calendar year. All Other Radiographs D0210 D0330 D0220 D0240 Xrays Xrays Xrays Xrays • Full mouth x-rays (which include bitewing x-rays) or a panorex are payable once in any three year period. Sealants D1351 D1352 Sealant Restore • Sealants are payable for first and second permanent molars and bicuspids for age 13 and under; once per tooth per lifetime. Minor Restorative D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2920 D2980 Amalgam Amalgam Amalgam Amalgam Resin Resin Resin Resin Resin Resin Resin Resin Resin Recement Restore 80% 80% 80% 80% 80% 80% 80% 80% 80% Optional Optional Optional Optional 80% 80% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A • Composite resin (white) restorations on a posterior tooth is not covered and the Plan will pay only the applicable amount that it would have paid for an amalgam restoration. Major Restorative D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2790 D2950 D2954 ResinCrown Crown Crown Crown Crown Crown Crown Crown Crown Crown Restore Restore 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A • Metallic inlays are covered benefits. • Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any seven-year period. mbb_-_-_DOT Page 2 Patient Name: CHRISTOPHER COLWELL Client/Sub-Client #:- Relationship: SUBSCRIBER Endodontics D3220 D3310 D3320 D3330 Pulpotomy Root Canal Root Canal Root canal 80% 80% 80% 80% N/A N/A N/A N/A Periodontics D4910 Perio Maint 80% N/A D4260 D4341 D4342 D4355 D4381 D9944 Perio surg Perio Perio Cleaning Perio Occl Guard 80% 80% 80% 80% Not Covered 80% N/A N/A N/A N/A N/A N/A • Occlusal guards are payable once in any 60 month period. • Root planing and scaling is payable once per quadrant in 24 consecutive months. Simple Extractions D7140 Extraction 80% N/A Other Oral Surgery D7210 D7220 D7230 D7240 Extraction Extraction Extraction Extraction 80% 80% 80% 80% N/A N/A N/A N/A Other Basic Services D0350 D0431 D0470 D9223 D9230 D9243 Xrays Tests Tests Anesthesia Nitrous Anesthesia 80% Not Covered 80% 80% Not Covered 80% N/A N/A N/A N/A N/A N/A • Procedure code D9997 (Dental Case Management - patient with special health care needs) is subject to client contract and the services it is performed in conjunction with. Prosthodontics D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D6240 D6750 Denture Denture Denture Denture Partial den Partial den Partial den Partial den Pontic Crown 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 50% N/A 50% 50% 50% N/A N/A N/A • Payment will be made to replace a tooth that has been missing prior to the effective date of coverage. • Full and partial dentures are limited to once in a seven year period. • Bridgework is limited to once in a five year period. Implants D6010 Implant • Implants and/or the restorations are payable once per tooth per five-year period. Orthodontic Services D8020 D8080 D8670 Ortho Ortho Ortho Orthodontic age limit for this patient is covered for age 18 and under for the following networks: PPO Dentist, Premier Dentist, Nonparticipating Dentist The patient's client provides coverage for Enhanced Preventive Benefits. Therefore high-risk medical patient may be eligible for additional cleanings. Delta Dental pays for crowns, bridges, full and partial dentures based on the seat/delivery date of the permanent appliance. X-rays are required when submitting claims for fixed bridges or when three or more anterior single crowns are performed in the same arch. X-rays will only be returned if sent with a self-addressed stamped envelope. General anesthesia and IV sedation may not be covered in conjunction with all services and are subject to review. mbb_-_-_DOT Page 3 Patient Name: CHRISTOPHER COLWELL Client/Sub-Client #:- Relationship: SUBSCRIBER People with special health care needs may be eligible for additional services including exams, hygiene visits, dental case management, and silver diamine fluoride treatment. mbb_-_-_DOT Page 4