Transparency in Coverage | Subscribers

 

Transparency in Coverage

Out-of-Network Liability and Balance Billing

You can choose any dentist to provide dental services. However, the Dentist you choose will affect the total amount you pay under this policy.

Delta Dental of Virginia (DDVA) has a Maximum Plan Allowance (MPA) for benefits, which represents the highest amount DDVA will pay for dental procedures. Delta Dental PPOSM and Delta Dental Premier® dentists will not charge you more than the MPA for any covered procedure.

Delta Dental PPO and Delta Dental Premier participating dentists have agreed to accept our MPA as payment in full for your covered benefits. You are responsible for any deductible and/or coinsurance that may apply. You may visit an out-of-network dentist; however, your out-of-pocket costs will likely be higher since the dentist may balance bill you for additional charges above our MPA, in addition to your deductible and coinsurance.

Your total out-of-pocket costs for services rendered to an individual pediatric enrollee from a Delta Dental PPO or Delta Dental Premier provider will not exceed $350 per benefit accumulation period. If there are two or more pediatric enrollees receiving benefits under this policy, the out-of-pocket maximum for those Enrollees will not exceed $700 per benefit accumulation period. Only deductibles and coinsurance paid for pediatric enrollees will count toward the out-of-pocket maximum. Amounts paid for optional procedures, non-covered benefits, balance billing or any amounts paid to non-participating providers do not count toward the out-of-pocket maximum.

Enrollee Claims Submission

To file a claim with us, simply present your identification card to the receptionist at your Ddntist’s office. Claims should be filed with us within 90 days after you receive dental services or supplies. Dental procedures are considered for benefits if they are incurred during the policy term and a claim is filed within 15 months from the date of service.

Participating dentists file all claims to us directly; however, some non-participating dentists may not file a claim on your behalf. If that is the case, please mail a copy of the itemized claim form to the following address:

Delta Dental
P.O. Box 103
Stevens Point, WI 54481-0103
(Policy management and service for individual coverage is provided by Delta Dental of Wisconsin, Inc.)

Download a dental claim form.

Grace Periods and Claims Pending Policies During the Grace Period

You have a grace period of thirty (30) days past the date when your premium is due to pay your subscription charges under the policy. However, if you have received an advance payment of the premium tax credit (“APTC”) and have previously paid at least one month of subscription charges during the coverage year, you have a grace period of ninety (90) days past the date when your premium is due to pay your subscription charges under the policy. If you do not make payment when the grace period expires, Delta Dental will end your policy.

Your policy stays in force during the grace period. If you fail to pay the subscription charges during the grace period, our subsequent acceptance of a payment from you for coverage prior to the coverage expiration date shall reinstate your coverage, but such reinstatement shall not provide coverage for the period between the end of the grace period through the date we accepted your payment. Your policy ends if you have not paid the full amount of the subscription charges due by the end of the grace period.

If you receive an APTC and are subject to a ninety (90) day grace period, Delta Dental will pay claims for covered services rendered to the covered person during the first thirty (30) days of the grace period. Thereafter, Delta Dental may pend claims for covered dental services rendered to the covered person during the remaining sixty (60) days of the grace period. Claims pending is a process by which claims are held (not paid) because a premium payment has not been received.

Retroactive Denials

A retroactive denial is the reversal of a previously paid claim. Through this process the covered person then becomes responsible for payment. Claims may be denied retroactively, even after the covered person has obtained services from the provider or received payment from Delta Dental.

You can limit the possibility of retroactive claim denials by ensuring that:

  • You pay the full amount of your premium charges on time
  • Claims submitted accurately reflect the dental services provided
  • Claims submitted reflect the date the service was actually completed

Enrollee Recoupment of Overpayments

An overpayment of premium for a month will be automatically applied to the following month’s premium balance. In the event that a covered person terminates coverage, any unused premium will be automatically refunded. To contact Delta Dental regarding overpayments, covered persons may use the following address and telephone number:

Delta Dental
PO Box 103
Stevens Point, WI 54481-0103
888-899-3734

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

After an examination, a provider may recommend a treatment plan. If the services involve crowns, fixed bridgework, implants, partial or complete dentures, surgical removal of impacted third molars, or medically necessary orthodontic services, the covered person should ask the provider to send the treatment plan to Delta Dental. The available coverage will be calculated and printed on a predetermination of benefits form. Copies of the form will be sent to the covered person and the provider.

Predetermination of benefits is required for medically necessary orthodontic services or surgical removal of impacted third molars. If predetermination of benefits is not requested prior to the covered person receiving these services, the claims will be denied and the covered person will be responsible for the charges.

Predetermination of benefits is not required for other services; however, Delta Dental encourages the use of this service as a convenient way to determine what Delta Dental will pay towards the claim, as well as what the covered person will be expected to pay.

Requests for predetermination of benefits forms should be made at least four (4) days prior to the beginning of any treatment plan.

Information on Explanation of Benefits (EOBs)

An explanation of benefits (EOB) is a notice that explains the reason(s) for payment or nonpayment of a claim. Delta Dental will send an EOB within thirty (30) days of receipt of the claim unless special circumstances require more time. If a claim is denied because of incomplete information, the EOB will indicate what additional information is needed. The covered person, the person who made the claim or the provider, then has forty-five (45) days to provide Delta Dental with the information requested.

The top portion of EOB contains information such as claim number, subscriber name, subscriber ID#, patient name and date of birth, and the dentist name, along with a customer service phone number, web site address and date.

The middle portion of the EOB contains information related to a particular claim:

  • TH: The tooth or area that was treated.
  • Surf: The tooth or surface quadrant that was treated.
  • Service Date: The date the procedure was completed.
  • Proc. Code: The procedure code that identifies the treatment requested or completed.
  • Procedure Description: A description of the procedure requested or completed.
  • Submit Amt: The amount billed to Delta Dental by the provider.
  • Fee Adjust: The difference, if any, between the submitted amount and the approved amount.
  • Approved Amt: The amount the provider has agreed to accept as full payment for a service. For Delta Dental PPO and Delta Dental Premier providers, this is the lesser of the submitted amount or the applicable maximum plan allowance/negotiated amount.
  • Allowed Amt: The amount that Delta Dental uses to calculate payment responsibility under the terms of the covered person’s dental benefits.
  • Deduct Applied: The deductible amount the covered person must pay before benefits begin.
  • Coverage Percent: The portion of the allowed amount that Delta Dental will pay, up to the covered person’s plan maximum.
  • Patient Payment: The amount the covered person is responsible for paying to the provider.
  • Benefit Payment: The amount Delta Dental paid.
  • Ref. Code: Explanatory statements applicable to claims processing, benefit coverage and/or processing policy.

The portion of the EOB below this reports the amounts applied to the individual’s benefit year deductible, annual benefit year maximum and the out-of-pocket limit, and reference codes are explained. At the very bottom of the EOB, the covered person’s rights of review and appeal are explained.

Coordination of Benefits (COB)

Coordination of benefits applies when you have coverage under more than one dental policy. It determines which plan will pay benefits first. Your policy is an individual plan and does not coordinate with other policies, whether a group plan or another individual plan.