How to file an out-of-network claim

Delta Dental dentists who are not in your Delta network will handle all claims and paperwork for you.

If you visit a dentist not in any Delta Dental network, 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

  1. Download the form. (PDF, 343 KB). Use this form to request reimbursement if you visit a non-participating dentist not in any Delta Dental network or want to request a pre-treatment estimate before visiting a non-participating dentist.


  2. Complete the policyholder/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 the 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 dental claim form. A dental office staff member can provide you with the dentist and treatment information.


  3. 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 of Pennsylvania
    One Delta Drive
    Mechanicsburg, PA 17055-6999