2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 100
Dentist means an individual who is duly licensed to practice dentistry or to perform oral Surgery in the state where
the service is performed and is operating within the scope of such license. A Physician will be considered a Dentist
when performing any covered dental services allowed within such license.
Dependent is a Covered Person, other than the Employee, who is covered by the Dental/Vision Plan pursuant to
the terms and conditions set forth in the "Eligibility and Enrollment" section of the Group Health Care Plan.
Employee is defined in the “Eligibility for Participation” section of the Group Health Care Plan.
Employer means RCAA Administrative Services, Inc., or any successor thereto, and its participating Affiliated
Companies.
Endodontic Treatment means procedures for the prevention and treatment of diseases of the dental pulp, pulp
chamber, root canal and surrounding periapical structures.
HIPAA means the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as may be amended from
time to time.
Hour(s) of Service mean each hour for which an Employee is paid, or entitled to payment, for the performance of
duties for the Employer (or a related Employer) and each hour for which an Employee is paid, or entitled to payment
by the Employer (or a related Employer) for a period of time during which no duties are performed due to vacation,
holiday, Illness, incapacity (including disability), layoff, jury duty, military duty, or leave of absence, but excluding
Hours of Service to the extent that the compensation for those services constitutes income from sources outside
the United States or performed as (1) a bona fide volunteer (as defined in Treas. Reg. Section 54.4980H-1(a)(7))
or (2) part of a Federal or State work study program. For purposes of this definition, a related Employer is any entity
that must be treated as part of the same “applicable large employer” as the Employer for purposes of Code Section
4980H, as determined at the time that the applicable Hour of Service is performed or credited.
Incurred means the date the service is rendered or the supply is obtained. With respect to a course of treatment or
procedure which includes several steps or phases of treatment, expenses are Incurred for the various steps or
phases as the services related to each step are rendered and not when services relating to the initial step or phase
are rendered. More specifically, Covered Expenses for the entire procedure or course of treatment are not Incurred
upon commencement of the first stage of the procedure or course of treatment.
Late Enrollee is an eligible Employee or eligible Dependent that does not elect coverage under this Dental/Vision
Plan during their original 31-day eligibility period. A Special Enrollee is not considered a Late Enrollee.
Legal Guardian is defined in the "Eligibility for Participation" section of the Dental/Vision Plan.
Medically Necessary/Medical Necessity means treatment is generally accepted by Physicians or Dentists in the
United States as proven, effective and appropriate for the condition based on recognized standards of the health
care specialty involved.
(1)
"Proven" means the care is not considered Experimental and/or Investigational, meets a particular standard
of care accepted by the medical community and is approved by the Food and Drug Administration (FDA) for
general use.
(2)
“Effective" means the treatments beneficial effects can be expected to outweigh any harmful effects. Effective
care is treatment proven to have a positive effect on your health, while addressing particular problems caused
by disease, Injury, Illness or a clinical condition.
(3)
"Appropriate" means the treatment's timing and setting are proper and cost effective.
Medical treatments which are not proven, effective and appropriate are not covered by the Dental/Vision Plan.
All criteria must be satisfied. When a Physician or Dentist recommends or approves certain care it does not mean
that care is Medically Necessary.
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