How to file a PPO claim
Delta Dental network dentists will handle all claims and paperwork for you.
If you visit a non-Delta Dental 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: State of Texas Dental ChoiceSM (PPO) (PDF, 343 KB). Use this form to request reimbursement if you visit an out-of-network dentist or want to request a pre-treatment estimate before visiting an out-of-network dentist.
In the Select your Plan drop-down list at the top of the form, choose Delta Dental Insurance Company. The mailing address for claims will be displayed.
- 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 1809
Alpharetta, GA 30023-1809
The State of Texas Dental Choice Plan is offered by Employees Retirement System of Texas and administered by Delta Dental Insurance Company.