Member: Frequently Asked Questions

Find the answer to some of the most common Delta Dental member questions

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Benefits and Coverage


What changes can I make at open enrollment?
Your company benefits administrator can give you more details and advise you when your company's open enrollment will occur.

I am divorced. If my former spouse and I both have dental coverage, whose insurance covers our children first?
The parent named responsible for maintaining insurance would be primary and the other parent would be secondary. If the divorce decree or custodial agreement is silent regarding responsibility, the order of benefit determination is:
(1) the plan of the custodial parent;

(2) the plan of the spouse of the custodial parent;
(3) the plan of the noncustodial parent;
(4) the plan of the spouse of the noncustodial parent.

If the parents have joint custody, then the parent with the birthday (month/day) earliest in the calendar year usually has primary coverage.

What is an alternate benefit and how does it work?
In cases where alternative methods of treatment exist, benefits are provided for the least costly professionally accepted treatment. This determination is not intended to reflect negatively on the dentist's treatment plan or to recommend which treatment should be provided. It is a determination of benefits under terms of the patient's coverage. The dentist and patient should decide the course of treatment. If the treatment rendered is other than the one benefited, the difference between Delta Dental's allowance and the approved amount for the actual treatment rendered is collectible from the patient.

 

I participate in the DeltaCare managed care program. Once I have selected a dentist, may I change my primary care dentist?
Yes. You may change your eligibility from one primary care dentist to another.

If you are located in New Jersey, please call 800-722-3524.

If you are located outside of New Jersey or writing Flagship Dental Plans by the 15th of the month, please call 800-848-3524.

The change will be effective on the first day of the following month. However, requests to change dentists should not be made if a patient is in the middle of treatment. If necessary, a Flagship Dental Plans representative can advise you on the definition of "middle of treatment."

If my dependent child is eligible for benefits as a full time student, what documentation does Delta Dental require?
Please use the Student Documentation Verification form.

What happens when I'm covered by two dental plans (coordination of benefits)?
Having two dental programs (called "dual coverage") does not "double" your coverage. However, it may mean that you will have lower out-of-pocket costs. Usually, one program will be considered primary (usually the one through your job) and the other will be secondary (the one through your spouse's employer). The total payments of both the primary and secondary carrier cannot exceed the total approved amount or the total of what Delta Dental would have paid as primary. As an example, if your dental program covers 80% for fillings, and so does your spouse's, your program would cover the first 80% and your spouse's program would cover the remaining 20%. Some dental benefit plans have "non-duplication of benefits" provisions. This means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist. For example, if both the primary and secondary carrier pay for the service at 80 percent level, but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50 percent of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80 percent - $50 = $14).

Do I have to see a primary care dentist to get a referral to a specialist?
Referrals are not required if you have Delta Dental Premier®, Delta Dental PPOSM or Advantage Program. If you have chosen the DeltaCare plan, you will need to select a primary care dentist, who will coordinate a referral to the appropriate DeltaCare specialist.

How do I know which dentists participate in my plan in my particular area?
Use our Find a Dentist tool to find a participating dentist near your home or office.

How do I check if I have met my deductible and/or what is remaining on my maximum?
You can verify your deductibles and maximums my visiting your MySmile account. First-time users need to register. You also can call our Customer Service department at 800-452-9310 and follow the voice prompts for the remaining maximum/deductible option.

I don't understand my Explanation of Benefits (EOB). Whom should I talk to?
If you have a question about your Explanation of Benefits (EOB), (also known as a Notification of Benefits, NOB; and Notification of Payment, NOP), you can view an easy-to-read description of Delta Dental of New Jersey's Explanation of Benefits statement. You can also call Customer Service at 800-452-9310.

Does Delta Dental offer individual plans/policies?
Delta Dental of New Jersey now offers affordable dental coverage for those without access to a group dental plan. Currently available to New Jersey residents only, our plans provide access to a broad array of dental services through our vast network of participating dentists. Our plans offer quality coverage options at competitive rates with automatic monthly payments. Learn more about our individual dental plans.

Do I need an ID card?
ID cards are not required and many employers do not issue them. Dental offices can verify your eligibility by logging into the secure area of our website. As a member, you can print an ID card by logging in to your MySmile account. First-time users must register for an account. 

Can I find out what my treatment will cost before I have it?
Yes, your dentist can submit a pre-treatment estimate, or pre-determination of benefits of your proposed treatment plan to Delta Dental. We will process it and send your dentist an Explanation of Benefits that shows what would be covered and how much you would have to pay. Please keep in mind that although a pre-treatment estimate may state Delta Dental will pay a certain amount for a procedure, it is not a guarantee of payment, as circumstances may change (e.g., your annual maximum could be met between the date the pre-treatment estimate was submitted and the actual date the service was performed; your coverage could be changed or terminated; you may obtain treatment from a different dental office).

What does my plan cover? How can I verify dental coverage?
You can retrieve information about coverage for yourself and your covered dependents from your MySmile account. First-time users need to register. If you prefer, you can also call our Customer Service department at 800-452-9310.

How can I get a Delta Dental benefits booklet?
To obtain a benefits booklet, please contact your employer. You can retrieve information about your coverage from your MySmile account. First-time users will need to register.

Why did Delta Dental pay less for white fillings on my back teeth?
White fillings, or fillings made of composite resin, are considered to be optional. Dental amalgams, or what we normally think of as silver fillings, are less expensive and clinically equivalent to composite resins. Because of this, your plan pays for the least costly clinically equivalent fillings in back (posterior) molars.

What if a participating dentist charges me up front?
We suggest our participating dentists not charge patients any more than their co-payment and deductible before Delta Dental has processed their claims. However, if a participating dentist does charge you up front, he or she is obligated by his or her agreement with Delta Dental to reimburse you anything over and above what Delta Dental determines the patient payment to be.

How often can I have cleanings and exams, and are these services included in my plan maximum?
Each plan specifies how often cleanings and exams are eligible. You can check your benefits frequency limitations in your MySmile account. First-time users will need to register. You can also check with your benefits administrator or your plan booklet for the specific frequency limitation or call our Customer Service department at 800-452-9310. All procedures paid by Delta Dental are included in the plan maximum.

When can I switch plans?
Usually only during your company's open enrollment period. However, it is best to contact your employer's benefits department.


Claims


Where do I mail claims?
Mail all claims to:
Delta Dental of New Jersey
P.O. Box 222
Parsippany, New Jersey 07054-0222.

Fax claims to: 800-DAISYFX (800-324-7939).

If you are a member of DeltaCare, address your correspondence to:
Flagship Dental Plans
P.O. Box 369
Parsippany, New Jersey 07054.

If you have DeltaUSA coverage through another Delta Dental Plan, please visit DeltaDental.com  and use the Find you Delta Dental tool for the correct mailing address.

How can I verify the status of a claim? Can I verify claim status on a patient?
You and your dentist can verify the status of your dental claims in your MySmile account. All first-time users must register. You can also call Customer Service at 800-452-9310, and follow the prompts. Note: there is a 10-day waiting period for claims inquiries after your initial registration. If you are having difficulty viewing or verifying claims in MySmile, please call Customer Service at 800-452-9310.

Is there a time limit for sending in claims?
Claims are payable up to one year from the date of service. Delta Dental must receive the claim one year from the date of service.

 

Where can I get claim forms?
You can download a copy from MySmile. The dental office may also use standard ADA forms.

 


COBRA


If a person is on Medicare or becomes eligible for Medicare, is he/she still entitled to COBRA coverage?
If the person qualifies for Medicare prior to becoming effective for COBRA, the person is entitled to COBRA coverage. If a person with existing COBRA coverage becomes eligible for Medicare during this time, the COBRA coverage ends.

Do my benefits start over when I go on COBRA?
No. COBRA is a continuation of existing coverage. Maximums, deductibles, and tooth history carry over. Benefits remain the same.

Where do the rates for COBRA come from?
If payment is to be made to Delta Dental of New Jersey, the rates may be obtained from the Delta Dental COBRA Department at 973-285-4145. If the payment is to be made to a different entity, rates may be obtained from the employer.

When an employee's children reach the maximum age under the plan, how do the children switch to COBRA?
The employee must notify his/her benefits department, who will provide the necessary paperwork to enroll dependents.

After I enroll in COBRA, will I need to give the dentist an identification card?
No. When a member goes to the dentist, the member should provide his/her Member ID number and COBRA policy number.

How do I make COBRA payments and where should I send the payments?
Payments are made on a monthly basis. Depending on who administers COBRA, payments will be sent to the administrator. The benefits administrator will be able to guide employees as to who collects the premiums.

How long is a person covered under COBRA?
Depending on the circumstances of the qualifying event, coverage is 18, 29, or 36 months. Employees should ask their benefits manager.

Can I be covered under COBRA and a second plan at the same time, and can benefits be coordinated?
Yes, you can be covered under COBRA and a second plan at the same time, but only if the second plan was in effect prior to the qualifying event for COBRA.

Where do I get an application for COBRA?
All paperwork pertaining to COBRA must come from your employer.

If I become disabled during the COBRA coverage period of 18 months, is the coverage period extended?
Yes. Disabled individuals are entitled to a total of 29 months of coverage. A member must provide the COBRA administrator with the proper documentation from a doctor.

What happens if I return to work while on COBRA and receive benefits through the new employer?
Once someone becomes eligible for benefits through a new employer, the person is no longer eligible for COBRA coverage. If Delta Dental is administering COBRA, the notification must be sent in writing to:

COBRA Department
Delta Dental of New Jersey
P.O. Box 219
Parsippany, NJ 07054.


General Account Questions


How do I create a MySmile account?
To create a MySmile account click the “Sign in or Register” button at the top of the page and then “Register now.” You will need to enter your first and last name, date of birth, email address and the subscriber’s member id number. If you don’t know the subscriber’s member id number, check your id card if you have one, look at a recent explanation of benefits (EOB) statement or call customer service (1-800-452-9310).

How do I change my email preferences, including the email address I provided upon initial registration?
To change your email preferences follow these steps. Sign in with your username and password, then under “My account” choose “Email & communications.” From there you will be able to update your email address, paperless options and change email preferences.

How do I change my password and/or security question?
To change your password and/or security question follow these steps. Sign in with your username and current password, then under “My account” choose “Password & security.” From there you will be able to change your password and update your security question.

 

I forgot my username and/or password. How can I sign in?
To retrieve your username and/or reset your password follow these steps. Click either forgot username or password adjacent to the Sign in button. Follow the three step process. You will need to enter your first and last name, date of birth, the subscriber’s member id number and the security question associated with your MySmile account. For username, you will also need to enter the email address on file.

I did not get an ID card. How will my dentist know I have coverage through Delta Dental?
An ID card is not necessary to present at your dentist office. Provide your name and subscriber ID number, which the dental office will use to verify eligibility and submit claims. Note your group number is helpful to provide, but is not mandatory.
To obtain a copy of your ID card, you can sign into your MySmile account and print a paper version, email an electronic copy to yourself, send to your iPhone passbook or view on our mobile app.

Why is there only one ID card available in MySmile account?
The ID card available in your MySmile account only lists the primary subscriber on the card, but can be used for all individuals included on the benefit plan

What is my member ID number?
Your member ID number is a unique number that identifies you as a Delta Dental subscriber under your dental plan. It may be your Social Security Number or a randomly selected identification number that has been assigned.

Does it matter if I use all CAPS when creating a MySmile account?
No, you shouldn’t have to use all CAPS to register. However, if you're having difficulty registering, you may try using all CAPS.

How do I change my address?
There are two ways Delta Dental will accept a member change of address: (1) via notification by the U.S. Postal Service when you file a change of address form with them; (2) by submitting in writing a signed letter indicating your new address to our Correspondence Department. Please note: if you send employee address information to Delta Dental of New Jersey electronically, your employer will need to be notified of the address change.


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