Dual coverage:
Tips for coordinating claims submission
and claims processing
What to include when submitting dual coverage claims
To help Delta Dental pay the claim correctly, without having to return it for more information, be sure to:
- Include ID numbers for both covered subscribers
- Indicate the patient's relationship to each subscriber
- Provide the birth date of each patient
- For a divorce situation, indicate the parent with whom the child lives
- When Delta Dental is the secondary carrier, include the Explanation of Benefits (EOB) from the primary carrier.
In cases of dual coverage, groups follow the birthday rule, not the gender rule
The birthday rules states that the parent whose birthday falls earlier in the year holds the primary coverage for dependent children. The year is not relevant. For example, if the father's birth date is 5/10/57 and the mother's birth date is 4/13/58, the mother's coverage is primary. These rules may be superseded by a court order that establishes the responsible party for the child's coverage.
To ensure timely processing of dual coverage for dependent children whose parents are divorced and possibly remarried
Please use the following general claims submission guidelines (unless there are other circumstances, such as a court order that specifies primary coverage):
- Primary coverage -- natural parent with custody
- Secondary coverage -- step parent with custody
- Third coverage -- natural parent without custody
- Fourth coverage -- step parent without custody
Be sure to advise Delta Dental of any change in dual coverage status
When submitting claims, be sure to review and update your patients' dual coverage status. Many patients change their coverage in the fall when a large number of groups conduct open enrollment; while other groups will have open enrollment in late spring/early summer for a July 1 contract effective date.
If a patient no longer has dual coverage, please write "patient no longer covered by another program" on the treatment form (or in the comments/remarks field of an electronic claim) to help ensure correct payment and updating of Delta Dental's records.
When Delta Dental is the secondary carrier and is subject to the provisions of California Assembly Bill 895
When Delta Dental is secondary, we pay the lesser of: (1) the amount we would have paid in the absence of any other dental benefit coverage; or (2) the enrollee’s out-of-pocket cost payable under the primary plan. .
Please indicate the total amount paid by the primary carrier on the face of the claim or in the comments/notes section of an electronic claim and attach a copy of the Explanation of Benefits from the primary carrier.
The combined payments by all programs may not exceed the total fee for the treatment. If you or the patient receives more than 100% of the fee, the amount in excess should be refunded to the secondary carrier.
When a patient is covered by two Delta Dental programs
Please submit only one claim. Delta Dental will process the primary benefits, even if processing the secondary coverage must be delayed (for lack of eligibility data, for example). There is no need to resubmit the claim. You will be notified separately when processing of secondary coverage is completed.
Orthodontic services
Dental offices that provide orthodontic services should be sure to submit dual coverage information on any claims for orthodontic procedures, even when the other insurance does not cover orthodontics.
Some Delta Dental groups that are not subject to the provisions of California Assembly Bill 895 have a non-duplication of benefits clause in their contract.
In cases where the non-duplication of benefits rule applies, the secondary carrier pays only the difference, if any, between what the primary carrier actually paid and what the secondary carrier would have paid if it had been the primary carrier.
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