How to file a DHMO claim
DeltaCare* USA network dentists will handle all claims and paperwork for you.
If you visit an out-of-network dentist,* you might need to file the claim yourself. We usually process claims within two weeks unless additional information is required from you or the dentist.
If you need to file a claim
- Download the form: DeltaCare USA (DHMO) (PDF, 183 KB). Use this form to request reimbursement for emergency (pain-relief) care not provided by your DeltaCare USA primary care dentist (PCD).
*Please note: Your DHMO plan requires that you visit a DeltaCare USA network dentist, who will handle your claims. If you need urgent palliative care (emergency treatment of dental pain) and are away from your designated DeltaCare USA PCD, you will have to pay for services and submit a claim form to request reimbursement. Please refer to your Evidence of Coverage (EOC) (PDF, 2.3 MB) for specific coverage details and procedures.
- Complete the patient and subscriber information on the claim form, and provide a copy of the dentist's Statement of Treatment or a detailed receipt that includes:
- Name, address and complete phone number of dentist
- Date each service was performed
- Description, procedure code and fee of each service performed
- List of affected teeth
- Total cost of services performed
- Dentist's National Provider Identifier (NPI)
- Dentist’s Tax Identification Number (TIN)
- State license number
- Specialty code
Important note: If the Statement of Treatment or similar document you receive from your dentist is missing any of the information listed in Step 2, please enter it on the claim form. A dental office staff member can provide you with the dentist and treatment information.
- Make a copy of the completed claim form and the dentist’s Statement of Treatment or detailed receipt for your records.
Mail the original copies of the completed claim form and the dentist’s Statement of Treatment or detailed receipt to:
Delta Dental Insurance Company
P.O. Box 1810
Alpharetta, GA 30023-1810
DeltaCare USA is underwritten in Texas by Alpha Dental Programs, Inc. and administered by Delta Dental Insurance Company.