Patient rights and responsibilities

Delta Dental is committed to protecting patient rights. We believe that you, as a Delta Dental enrollee, have the right to expect quality, affordable care that protects not only your dental health, but also your privacy and ability to make informed choices. We also believe that you have certain responsibilities to help protect these rights.

The Right to Choose
The Right to Quality Assurance
The Right to Affordability
The Right to Full Disclosure
The Right to Fair Review and Appeal
The Right to Privacy
The Right to Security
The Responsibility to Protect these Rights

The Right to Choose

Delta Dental maintains some of the largest "traditional," PPO and HMO dentist networks in the industry — each with a full range of specialists — to give you the widest possible choice of dentists. Dentists are never penalized for referring you to a specialist.

Our traditional and PPO programs allow you to visit any dentist at any time, without prior notification or authorization from Delta Dental. Our dental HMO programs do require you to choose a network dentist, but allow you to change dentists with an easy toll-free call; immediate treatment for emergency or urgent care is always available.

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The Right to Quality Assurance

While we support the right of patients to choose their dentist, we recognize our responsibility to provide some assurances of quality care.

Therefore, each of the three out of four dentists nationwide who have contracted with Delta Dental agree to provide care that meets the high standards of the dental profession. Dentist contracts allow Delta Dental to audit dental offices in person -- at random and for cause -- to help ensure that these standards are met. If you should ever receive substandard care, Delta Dental will fully investigate the matter and can arrange for you to be reimbursed and/or retreated.

We recognize that our responsibility to assure quality increases with any limitation on the freedom to choose your dentist. That's why dentists participating in our smaller dental HMO network undergo even more detailed checks of their credentials and procedures.

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The Right to Affordability

Delta Dental negotiates with dentists to establish fair and reasonable compensation. Delta Dental contracts prohibit dentists from billing you for charges in excess of these negotiated amounts, for "add-on" procedures that should be included, or for any amount that is Delta Dental's responsibility.

Delta Dental benefit programs are designed to promote preventive care, avoiding dental disease before more costly treatment becomes necessary.

Because you are entitled to have a maximum portion of your benefit dollars spent directly on the delivery of appropriate dental care, Delta Dental spends on average 89 cents of every premium dollar for such care. The remaining eight cents is directed to administrative activities such as claims processing and quality review.

Delta Dental is a nonprofit health care service corporation, so our focus is on delivering quality, affordable benefits — not shareholder profits.

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The Right to Full Disclosure

You have the right to clear and complete information about your dental benefits, including treatment that is subject to limitations or not covered. You are entitled to know what your share of costs will be before you receive treatment ("predetermination"), and how your dentist is compensated by Delta Dental. Delta Dental provides materials to explain these features to you.

Delta Dental dentists are not subject to policies sometimes called "gag clauses." You are entitled to hear about all treatment options your dentist may recommend, whether covered or not, and to obtain a second opinion if you choose.

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The Right to Fair Review and Appeal

Delta Dental supports your right, as well as your dentist's, to a fair and prompt review of any of Delta Dental's coverage decisions. We maintain effective complaint resolution systems in the event of disagreement over coverage or concern about the quality of care. The review is done internally, but may be escalated to outside parties if warranted.

To submit a grievance to Delta Dental, use one of these secure forms:

Delta Dental Premier and Delta Dental PPO
Patient grievance form

DeltaCare USA
Enrollee assistance forms

Denti-Cal/State, County and Local Dental Programs
Patient grievance form

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The Right to Privacy

Delta Dental vigorously supports and protects the privacy of patient records and dental histories. Delta Dental also supports your right to gain access to all information pertaining to claims submitted on your behalf.

Data are used only for the purposes of designing and administering effective dental programs — information isn't sold, bartered or used for third party marketing efforts.

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The Right to Security

You are entitled to a dental program backed by a financially stable institution. Delta Dental's current reserve (several months of claims payments) helps to ensure the corporation can meet its expected financial obligations, as well as to withstand unforeseen business developments without risk to you, your dentist or employer.

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The Responsibility to Protect These Rights

Protection of the rights described above is possible only with your cooperation. In order to ensure the continued enjoyment of these rights, you share:

• The responsibility to participate in your own dental health — practicing personal dental hygiene and receiving regular professional care. You should avoid substances and behaviors that could jeopardize your oral health, and should cooperate with your dentist on his or her recommended treatment plans.
  
  
• The responsibility to become familiar with your coverage. This includes meeting any financial obligation incurred as a result of treatment (including the appropriate copayments or deductibles required by the program). It means cooperation with Delta Dental policies designed to protect against health care fraud schemes by fellow enrollees or dentists. It also means taking advantage of the information available on dental health and your dental program so that you can become a more informed consumer.

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