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Help Enrollees Use Delta Dental PPOSM

The information below applies to our standard processing policies and contract coverage, and is to be used only as a guide. Your group contract serves as the controlling document of your plan.

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Plan basics

What is Delta Dental PPO?

PPO stands for preferred provider organization. This means Delta Dental network providers accept a contracted fee as payment in full. (The contracted fee is usually lower than the provider’s normal fee.) While enrollees will usually save the most with a Delta Dental network dentist, they are free to visit any licensed dentist.

How does Delta Dental PPO work?

Patients pay a percentage of the contracted fee — called coinsurance — and we pay the rest. The percentage varies with each category of service (diagnostic and preventive, basic, major, etc.). The plan deductible must be satisfied for certain covered services before we begin paying benefits; enrollees will have to pay any amount over their plan maximum.

How do enrollees pay for services?

Enrollees pay coinsurance directly to the dentist at the time of treatment. They will not have to file a claim form if they use a Delta Dental dentist.

Do enrollees need an ID card?

No. Enrollees can simply provide their dentist with their name, date of birth and social security number or enrollee ID to verify coverage. They can also display ID cards on their mobile device by logging in to Online Services. (Enrollees can print their ID card if they prefer a hard copy by logging in to Online Services, or they can request a card from customer service.)

Is pre-authorization required for treatment?

No. Enrollees can visit any licensed dentist that they choose, without pre-authorization or referral. However, dentists can provide enrollees a “what if” claim before performing treatment (so enrollees know the cost of service up front).

Finding a dentist

How do enrollees find a network dentist?

Enrollees can log in to Online Services and use our Find a Dentist tool. Enrollees can find a network provider close to home, the office or any location they choose. They can even search by specialty. If enrollees know their network they can also use the Find a Dentist tool on the right side navigation on deltadentalins.com without logging in. Enrollees without internet access can call customer service.

Can enrollees change their dentist?

Enrollees can change their dentist at any time — there’s no need to notify us.

Do enrollees’ dependents receive treatment from the same dentist?

They can, but it’s completely their choice. Enrollees can keep it in the family, or choose a different dentist for each family member.

What’s the difference between a Delta Dental PPO dentist and a Delta Dental Premier dentist?

Both Delta Dental PPO and Delta Dental Premier dentists are contracting network dentists. Delta Dental PPO dentists are the “in-network” choice for a PPO plan, and usually offer the deepest discounts. Delta Dental Premier dentists offer moderate savings if an enrollee chooses to go outside the PPO network.

Pre-existing conditions

Are pre-existing dental conditions covered?

Most pre-existing conditions are usually covered. The exceptions would be for congenital conditions and cosmetic treatment. Often, missing teeth are excluded as well. Coverage is generally provided on a no-loss/no-gain basis; however, any expenses for treatment started before an enrollee’s eligibility are the responsibility of the previous carrier. Since each contract can vary, it's best to verify coverage through your contract.

Is treatment-in-progress covered?

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. See the Orthodontics section for information on orthodontic treatment-in-progress.

Specialty and emergency care

How does out-of-area/emergency coverage work?

Enrollees can visit any licensed dentist in the world. If traveling outside the US, enrollees should ask for a detailed billing statement that includes treatment provided, tooth number, date of service and the cost of the service (translated into English, if possible). We’ll convert any currency.

Can enrollees visit a specialist? Can children visit a pediatric dentist?

Yes. Enrollees and dependents can visit any licensed dentist without referral, and can locate network specialists and pediatric dentists online. See Finding a dentist.

Orthodontics

Are orthodontics covered?

Orthodontics are an optional benefit, so if your group purchased this benefit, enrollees will have orthodontic coverage. To find out what procedures are covered, and at what coinsurance level, refer to your contract. You can also direct enrollees to find this information online or in their benefits booklet.

How does orthodontic treatment-in-progress work?

If your group’s dental benefits include orthodontic services, we cover new enrollees currently undergoing orthodontic treatment after the enrollee’s effective date. The current orthodontist must submit the treatment plan and the treatment status with the initial claim. We also require evidence of the amount paid to date by the enrollee and/or prior insurance carrier(s).

We will review the treatment plan and apply benefits to the enrollee's maximum after subtracting benefits previously covered under the prior plan according to the specific provisions of your group contract.

Miscellaneous

How does coordination of benefits work for spouses/partners and dependents with dual coverage?

Adults

  • Primary: If the adult is the primary Delta Dental enrollee and he/she has only one job, Delta Dental is the primary carrier. If the primary adult holds more than one job, the primary carrier is whichever employer has covered them longer.

  • Dependent: If the adult is a dependent Delta Dental enrollee, the primary carrier is the one provided by his/her employer.

Dependent children

  • The primary carrier is through the parent whose birthday (month, day) falls earlier in the year.

  • If the parents are not married and do not have joint custody, coverage is usually determined in this order: Custodial parent, custodial stepparent, non-custodial parent, non-custodial stepparent.

Your group contract may dictate a different rule for coordination of benefits, so be sure to check your benefits as well.

Are implants covered?

Implants are generally covered as an alternate benefit. This means we’ll base payment for an implant on the contracted fee for a comparable lower-cost service, like a denture or bridge. The enrollee will pay the difference between the Delta Dental contracted fee and the dentist’s submitted fee.

Up to what age are sealants covered?

Age limitations vary by plan, but sealants are generally covered as a pediatric benefit up to age 15.

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