Get Started: Our Administrative Overview
This guide puts the most frequently used information about your plan at your fingertips.
Contents
Know Your Plantop
Group contract
When you receive your group contract, please read it carefully. Your contract is the controlling document for your dental benefit plan; however, this guide can be used as a reference document for administrative policies, limitations and exclusions, coverage details and payment agreements. If there are questions about your coverage, please contact your account manager.
Contract changes
Your group contract may change because your organization has requested a modification in your agreement or because of regulatory requirements. If there is a change to the contract, we will either issue a revised contract or an amendment (or renewal letter). New contracts will replace the previous version of the contract. Amendment and renewal letters will be incorporated as part of your existing contract and should be retained as part of the contract documents.
Benefit booklet
One of the quickest ways to review benefits is by logging in to Online Services. However we also provide an Evidence of Coverage or Certificate of Coverage that details the main contract provisions, including plan benefits, limitations and exclusions of your dental benefit plan.
Your account manager will coordinate the process to provide your organization with an electronic copy for distribution to your covered enrollees.
Handling Enrollmenttop
Our groups handle eligibility changes in a variety of formats. We accept secure electronic file transfer and eligibility changes through our web eligibility tool as well as hard copy enrollment forms.
Adding enrollment
You may add enrollees and dependents at open enrollment or due to a qualifying event such as marriage, change of employment for spouse, new child, death of dependent, new hire, etc. Eligibility changes received by the 15th of the month will be effective from the first of the same month. In most cases, eligibility received after the 15th of the month will be effective on the first day of the following month.*
You may also make retroactive additions. The group is responsible for any premiums due for the enrollee starting from the enrollee's beginning effective date.
Terminating enrollment
Retroactive terminations will be accepted for up to the preceding three months, provided that we have not paid any claims for the enrollee during that time frame. If claims have been paid within the previous 60 days, the coverage termination date will be established as of the end of the month in which services were rendered.
Special provisions
Your group contract may also contain special provisions for eligibility additions and terminations, as well as provisions for retroactive changes. If so, your contract will serve as the governing document.
* For DeltaCare USA enrollees, premiums may be adjusted back to the enrollee's enrollment date upon discovery of clerical errors made by the administrator. Upon discovery of clerical errors made by the enrollee with respect to enrollment data, the amount of credit which may be taken shall not exceed the premiums for the current month in which premiums are due, plus two months of retroactive premiums. In addition, the total amount of credit which may be taken on any due date shall not exceed 10% of the billed amount for that due date.
Making Inquiriestop
You can check enrollee eligibility and benefits three ways:
- Go online 24 hours a day, 7 days a week.
- Call our interactive voice response telephone line.
- Call our Customer Service toll-free Monday through Friday.
You will need the enrollee's ID number and date of birth to access this information.
Online
Contact your account manager to register for access to online services as a benefits administrator. Once you've registered and logged in, you can view benefits or check eligibility for employees. To view information, you'll need the primary enrollee's ID number, first name, last name and date of birth.
Phone
Call your local Customer Service telephone number and follow the prompts in English or Spanish to obtain the information that you need. When checking enrollee eligibility, please have the primary enrollee's ID number and date of birth available. (Tip: When entering birth dates, use a two-digit format for the month and day and four digits for the year. For example January 2, 2013 would be entered 01022013.)
Submitting Claimstop
For Delta Dental PPOSM and Delta Dental Premier®
All Delta Dental dentists will submit claims for your enrollees. However, if an enrollee chooses to visit a non-Delta Dental dentist, he or she may need to file the claim themselves.
We accept any standard claim form format, and also provide a printable claim form that you or your enrollees can print from our website. All submitted claims must include the enrollee ID number, date of birth, group number, and the dentist's signature and must be submitted to our claims address.
After we process the claim, we will mail a benefit statement to the enrollee. The explanation will provide detailed information regarding benefits received and payment responsibility.
For DeltaCare® USA
DeltaCare USA has no claim forms to submit. However, if enrollees visit a dentist other than their selected DeltaCare USA dentist for out-of-area emergency care, they will need to submit their own claim form.*
Please refer to your Evidence of Coverage, Certificate of Coverage or Group Dental Service Contract for specific details about the limitations and exclusions of your plan when receiving out-of-area emergency care.
We accept any standard claim form format for out-of-area emergency care, and also provide a printable claim form that you or your enrollees can print from our website. All submitted claims must include the enrollee ID number, date of birth, group number, and the dentist's signature and must be submitted to our claims address.
After we process the claim, we will mail a benefit statement to the enrollee. The explanation will provide detailed information regarding out-of-area emergency benefits received and payment responsibility.
*In some states, DeltaCare USA is offered as an open access plan where enrollees can obtain treatment from any licensed dentist; however, deductibles and maximums may be applied for services provided by an out-of-network dentist. Provisions regarding copayments and in and out-of-network treatment vary in Alaska, Connecticut, Idaho, Louisiana, Maine, Mississippi, Montana, New Hampshire, North Carolina, Oklahoma, South Dakota and Vermont.
Managing Billingtop
Invoicing
Invoices are available electronically through our Online Billing and Reconciliation application and also as hard copies for mailing. They are generated at different intervals depending on the plan and product selected by the group. You may have special billing arrangements as part of your contract. Please talk to your account manager if you have any questions about your billing and payment arrangements.
Payment options
We accept payments made via check, wire transfer and Automatic Clearing House (ACH) credit or debit transactions.* Groups initiate all transactions except the ACH debit transactions, which we initiate. We also offer online payment through our Online Billing and Reconciliation application.
Automatic payments
Ask your account manager about setting up automatic payments. We use an Automatic Clearing House (ACH) for automatic payments. ACH debit transactions are made against a bank account designated and authorized by you through an ACH Agreement Form.
*DeltaCare USA payments cannot be made with ACH debit transactions.
Takeover of Work In Progresstop
For Delta Dental PPOSM and Delta Dental Premier®
Takeover credits for maximums and deductibles
When a group's new coverage becomes effective, enrollees often need to satisfy new deductibles, and they also receive new maximum amounts. However, some groups request that we honor enrollees' deductible amounts for the current year. These are known as takeover credits. We can accommodate this requirement.
If your dental plan provides for takeover credits, we must receive the amounts accrued toward plan maximums in the previous plan. The most efficient way to provide this information is to give us a file from the prior carrier with the patient names, dates of birth, enrollee names and social security numbers, along with the deductible and maximum amounts. Your implementation manager and account manager can assist you with this transition.
Orthodontic work in progress
If your group benefits include orthodontic services, we cover new enrollees currently undergoing orthodontic treatment after the enrollee's effective date.
We require the orthodontist to submit the treatment plan and the status of treatment with the initial claim. We also require evidence of the amount paid to date by the enrollee and/or the prior insurance carrier(s).
We will review the treatment plan and apply benefits to the employee's maximum after subtracting benefits previously covered under the prior plan according to the specific provisions of your group contract.
Other work in progress
We will cover claims for procedures started and completed after the enrollee's coverage effective date. However, we do not cover procedures started prior to the effective date of your plan's coverage.
For DeltaCare® USA
Orthodontic work in progress*
Orthodontic treatment in progress is limited to new DeltaCare USA enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program.
Active treatment means tooth movement has begun. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan. DeltaCare USA is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases.
Other work in progress
Procedures started prior to the enrollee's effective date are not covered. (Please note that this is different than the effective date of the group contract.)
*Please refer to your Evidence of Coverage or Certificate of Coverage. Your DeltaCare USA plan may not provide coverage for orthodontic work in progress.
