View definitions of commonly used benefits terms.
As part of the Affordable Care Act (ACA), Delta Dental has outlined the following transparency in coverage information for members enrolled in dental plans purchased through healthcare.gov.
Balance billing occurs when a dentist bills a member for charges—other than copayments, coinsurance or any amounts that may remain on a deductible—following Delta Dental's payment on a claim. Our network dentists agree to accept Delta Dental’s contracted fees as full payment and not to bill the member above that amount. Balance billing is not allowed within the Delta Dental network.
If the submitted amount for an out-of-network dentist is more than the allowed amount, the member is responsible for paying the dentist that percentage listed in the policy, as well as the difference between the submitted amount and the allowed amount. Nonparticipating dentists are under no obligation to limit the amount of their fees and the member will be responsible for paying the amount that is charged.
If an in-network dentist is not readily available within a reasonable period of time or driving distance, it may be possible for a member to receive covered services from an out-of-network dentist and be reimbursed at the same benefit level as if the covered services were provided by an in-network dentist. If this situation occurs, the member should call customer service to discuss options prior to visiting the out-of-network dentist.
If a member requires emergency treatment and receives covered services from an out-of-network dentist, covered services for the emergency care rendered during the course of the emergency will be treated as if they had been provided by an in-network dentist.
One benefit of staying in the Delta Dental network is that our participating dentists will submit claims on your behalf. If you choose to visit a nonparticipating dentist, you will need to submit your own claims within 12 months of the date of service to:
PO Box 9085
Farmington Hills, MI 48333-9085
Prior authorization is the process through which an issuer approves a request to access a covered benefit before the member accesses the benefit. Delta Dental does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a pre-treatment estimate.
A claim is pending when it has been submitted to Delta Dental and is still being processed by the claims department.
If the member fails to pay the full amount of the premium by the date it is due, a grace period will apply. The grace period allows the member additional time to pay the premium without losing coverage. The grace period refers to either a three-month grace period for members receiving advance payments of premium tax credit, or a general grace period for members not receiving advance payments of premium tax credit.
During the three-month grace period, Delta Dental will pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend claims for services rendered to the member in the second and third months of the grace period.
A retroactive denial is the reversal of a previously paid claim, as a result of which the member then becomes responsible for payment. A claim can be denied retroactively, for example, if Delta Dental pays a claim during the grace period and it is discovered that the member has terminated the policy prior to covered services being rendered.
The best ways to prevent retroactive denials are to:
To update your individual account information, you can visit the Member Portal.
If an overpayment occurs, it will automatically be given as a credit toward the next month's premium unless the member contacts customer service to request a refund. The refund will be issued in the way the premium was paid, or a refund by check can be requested.
The Essential Health Benefits (EHB) requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary. In the case of orthodontia, this means that only orthodontic treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered an EHB. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.
Coordination of benefits is a procedure for paying health care expenses when people are covered by more than one dental plan. The goal of coordinating benefits is to make sure the cost of the dental procedure is covered within the scope of the plans, without exceeding the amount of the actual bill.
If you or your dependent are covered by two or more dental plans, the coverage will be coordinated in accordance with the coordination of benefit rules set forth in your policies.
After you visit your dentist, you will receive an Explanation of Benefits. The Explanation of Benefits will display the fee your dentist submitted, the amount Delta Dental will cover and the amount you owe for the service. If you owe any amount, you will need to pay your dentist the remaining balance. Learn more about how to understand your Explanation of Benefits.