Maximum Contract Allowances
Maximum contract allowances are the total reimbursement amounts, under the enrollee’s benefit plan, on which Delta Dental calculates its payment and the patient’s financial obligation.
Example: If the dentist submits a fee on a claim for $120, and the maximum contract allowance is $100, Delta Dental will calculate its payment and the patient’s payment based on $100.
How Maximum Contract Allowances are Determined
Depending on the state, maximum contract allowances are derived from a variety of factors, including data from fees on claims, fee filings submitted by dentists (not applicable for Delta Dental of Pennsylvania), current economic factors and/or other data.
Allowances will differ depending on the type of plan. For example, allowances for Delta Dental PPOSM are different in most cases from those for the Delta Dental Premier® plan.
Maximum contract allowances will differ by 5-digit ZIP code. However, contracted Delta Dental dentists may not charge their Delta Dental patients more than the amount determined by Delta Dental to be the patient’s portion.
How Maximum Contract Allowances are Updated
Delta Dental reviews allowances on an ongoing basis. We update them regularly, usually every 6 to 24 months. These updates are required to be filed first for approval by state regulatory agencies in many locales.
For DeltaCare® USA, maximum contract allowances are not applicable. Enrollees have a fixed copayment for all covered services and cannot be balance billed.