Claim Completion Instructions

Submit all Your Claims and Attachments Electronically

Use Provider Tools for free real-time claims with digital attachments and pre-treatment estimates. You’ll see Delta Dental’s payment and the patient portion when the claim or pre-treatment estimate processes, often within moments (when clinical review is not necessary). Here’s all you need to do:

  • Register for your secure, free Online Services account (in the Online Services box at the top, right side column).
  • Log in.
  • From the Provider Tools screen, transmit claims, digitized attachments and pre-treatment estimates with either of these tools:
    • “Submit Claim” – transmission is quick and efficient.
    • “My Patients” – your current patients are listed here and we add new patients as their claims are processed. Patient information is automatically entered on your pre-treatment estimate or claim.

You can also use FastAttach®, a service available through National Electronic Attachment, Inc. (NEA), to electronically transmit digitized x-rays, periodontal charts, Explanation of Benefits documents, photos and narratives.

If you are not submitting claims electronically, talk with your practice management system vendor about activating your system’s electronic claims component.

Delta Dental and its affiliate companies use MetaVance Benefit Administration Software as the claims editing software product to provide timely and efficient adjudication for dental claims. This software helps our enterprise streamline many interrelated systems and processes, as well as increase functionality for the benefit of our dentists, enrollees and clients.

Use these tips for clear, complete electronic or paper claims that will move smoothly through our system.

DO use:

  • A laser printer with black ink (if not transmitting electronically)
  • A 10 point font and all capital letters (Courier is a good font choice)
  • Eight-digit dates with no spaces, slashes or dashes (for example, 05032014 for May 3, 2014)
  • Standard size paper (8.5 x 11 inch) for claims and written documentation
  • Fees with decimal points (for example, 100.00; not 100)

DON’T

  • Use free-form text — use the “Tooth number or letter” field to indicate quadrant or arch (UR or L, for example)
  • Use ditto marks or arrows to indicate duplicate information
  • Allow stray marks in spaces that should be left blank
  • Use slashed zeroes and crossed sevens
  • Write on top of lines or outside of boxes
  • Use correction fluid or a highlighter pen
  • Use more than one font style on a claim
  • Use photocopied claims that are blurred or skewed

More Tips for Electronic and Paper Claims

Claim form completion

  • Thoroughly complete the claim with clear, legible information.
  • Do not use patients’ nicknames.
  • Document exceptional or unusual circumstances only in the “Remarks” or “Comments” field of the claim. Better yet, send the documentation on a separate attachment (8.5 x 11 inch paper) or transmit it digitally(submit digitized attachments free with Provider Tools; use the “Submit Claim” or “My Patients” tool).
  • Indicate a quantity (the number of x-rays, for example) in the field on the claim specifically for this purpose. If the claim does not have this field, please list each item on a separate line.
  • Be sure to enter the name of the dental plan enrollee in the space provided at the top of the form and in the dual coverage section, if applicable. (The enrollee is the person who has the dental plan through his/her employment. In dual coverage cases, there will usually be two different enrollees within a family.) With Provider Tools, patient information is entered for you. Use the “My Patients” tool to submit free real-time claims.
  • Enter a valid National Provider Identifier (NPI). If you enter two NPIs (one for the billing dentist and another for the treating dentist, if it is different from the billing entity’s NPI), please verify that they are both valid.

Dual Coverage

  • Indicate if the patient has (or does not have) dual coverage with another dental plan (or sometimes, in oral surgery cases for example, with a medical plan) by checking the specific box, usually found in a field titled “Other insurance coverage” or something similar. If there is dual coverage, be sure to include all the requested information.
  • Always include the primary carrier’s Explanation of Benefits or remittance advice document when Delta Dental is the secondary carrier. You can transmit digitized documents for free with Provider Tools – use the ”Submit Claim“ or “My Patients” tool.
  • If dual coverage is through the same Delta Dental company, submit one claim with information entered about both enrollees. We will process the primary and secondary benefits from that one claim. NOTE: You may not receive payment for both coverages on the same check because the secondary coverage may be processed a few days after the primary coverage. See “Dual Coverage” for more information.

Orthodontic Claims

Please don’t send claims for monthly orthodontic visits. To make it easier for you, your fees for these visits are included in the total fee you submit on the claim for banding and in the periodic payments you automatically receive from Delta Dental. See “Orthodontics” for more information.

Pre-treatment Estimates

You can get free pre-treatment estimates often within minutes (when clinical review isn’t necessary) with Provider Tools. Use the “Submit Claim” or “My Patients” tool to find out what’s covered while your patient is in the office.

Send a new claim for payment after services are provided (do not date and return the pre-treatment estimate). In the “Remarks” or “Comments” section, include the Delta Dental reference number found on the original pre-treatment estimate, or write “Pre-treatment estimate on file” if you no longer have the reference number. See “Pre-treatment estimates” for more information.

Documentation

  • X-rays for your for your Delta Dental Premier® and Delta Dental PPOSM claims are necessary only for these procedures:
    • Restorative: D2710-D2794, crowns — laboratory processed, and D2950, core buildup, including any pins
    • Implant services: D6055-D6077, implant supported prosthetics
    • Prosthodontics, fixed: D6710-D6794, fixed partial denture retainers, crowns
  • X-ray copies submitted with paper claims must be of diagnostic quality. We will accept duplicate films and paper copies of digital images.
  • We do not return x-rays or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.
  • Periodontal charting is necessary for osseous and other periodontal surgery procedures in these procedure codes: D4210-D4212, D4240-D4245, D4260- D4278 and D4381.
  • A copy of the pathology report is needed for hard and soft tissue biopsies: D7285-D7286.
  • Please submit the operative and pathology reports for procedures D7410-D7415, D7440-D7461 and D7465.
  • A copy of the operative report is needed for procedures D7490-D7521, D7610-D7780, D7910-D7912, D7980-D7983 and D7998.
  • Narratives need to be included for procedures: D2950, D2980 (with copy of lab bill), D4249, D4320, D4321, D4920, D5620, D7260, D7530, D7540, D8210, D8680 and D9930 as well as any exceptional cases and the unspecified codes in all categories of service (D##99). Enter the information in the “Remarks” or “Comments” field.

Dependents Age 19 and Over

For full time students, enter the name of the school and the city in which it is located on the claim. If the patient is a dependent with a disability, enter the nature of the disability.

Tax Identification Number (TIN)

Enter the TIN of the billing dentist or dental entity. Inform your local Dentist Network Administration and Contracting department if your TIN or the name associated with that TIN changes. Important note: if your TIN changes, you will need to re-register for Online Services with your new TIN.

National Provider Identifier (NPI)

Use claim forms that accommodate the NPI by providing a specific space for it. (This might require you to upgrade your software.) Enter the NPI of the billing dentist or dental entity, as well as the treating dentist's NPI (if they are different). Verify that the NPIs are valid.

Electronic Encounter Forms for DeltaCare® USA

You can save time and money while helping the environment by electronically submitting your encounter forms to DeltaCare USA.

  • Saving money by eliminating printing, copying and mailing costs.
  • Saving time by submitting electronic encounter forms daily, which can eliminate the need to spend more time running monthly reports.
  • Receiving prompt notification of any invalid data, allowing you to make the necessary corrections and re-submit right away.
  • Receiving reports of all successfully transmitted encounter forms, reducing follow-up on unpaid submissions.

DeltaCare USA's payer identification number for encounter forms is DDCA3.

For more information about electronic encounter form submission, please email our Encounters department.

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