If there is an extenuating circumstance not evident from the documentation listed below, a narrative and any available corroborating diagnostics must be submitted. As part of the re-review process Delta Dental may require documentation (e.g., photographs) in addition to that listed in this chart.
All radiographic images are pretreatment unless otherwise indicated. Any radiographic image submitted must be of diagnostic quality and substantiate the need and appropriateness of the service submitted for predetermination or payment. In order to do so, the dentist may need to submit radiographic images in addition to those listed in this chart.
Submission Requirements - Radiographic Images
Whenever a participating dentist submits a claim that includes any combination of intraoral radiographic images whose combined fee equals or is greater than a complete series (D0210), the fee allowed will be limited to that of a complete series. Also, a panoramic radiographic image submitted together with supplemental radiographic images will be handled in the same manner.
If a participating or non-participating dentist submits eight or more intraoral radiographic images and/or a panoramic radiographic image with supplemental bitewings or periapical radiographic images, the dentist must submit a brief narrative as to the reason for taking the radiographic images and also identify the tooth numbers of the periapical radiographic images if the radiographic images are not part of a complete series or are not intended to function as a complete series. Delta Dental will consider that supplemental information in determining whether the radiographic images will be subject to the limitations for individual radiographic images rather than for a complete series.
All procedures listed on this chart are not necessarily covered benefits, and all benefits are not necessarily listed.
Unless otherwise noted:
Yes = Documentation Required
Blank = Documentation Not Required
PA = Periapical Radiographic Image (may require more than one for diagnostic purposes)
FMX = Full Mouth Series
Pano = Panorex
DDNJ = Delta Dental of New Jersey
Medical EOB Requirements
Medical plans may cover some dental procedures, such as oral surgery. This chart indicates if a procedure requires a medical EOB for processing. If a Medical EOB is required for an oral surgery procedure on a claim, a medical EOB is also required for related exams, x-rays and anesthesia.
Some groups have elected Delta Dental as the primary plan for oral surgery. A list of these groups is available in Benefits Connection. A medical EOB is not required for the groups on the list.