Transparency in Individual ACA-compliant Dental Plans

As required by CMS (Centers for Medicare and Medicaid Services), Delta Dental is providing you the following information regarding your dental plan. Should you have any additional questions, please review your policy or contact Delta Dental Customer Service at 1-888-899-3734.

Out-of-Network Liability and Balance Billing

Your policy lets you get dental services from any dentist. However, you will maximize your benefits under the policy and may be able to reduce your out-of-pocket costs if you choose to get services for from a Network Dentist. This applies to both adults as well as pediatric enrollees under age 19. Under your policy, a Network Dentist is a Delta Dental PPO℠ Dentist and a Delta Dental Participating Specialist. When you go to a Network Dentist, you may be responsible for payment of a deductible and the coinsurance amount, but the amount of your payment for Covered Services will be limited to the Delta Dental allowed amount. And, once the cost share limit for pediatric enrollees under age 19 has been met, services are covered at 100% of Delta Dental’s allowed amount.

You may also get dental services from a Non-Network Dentist. If you visit a Non-Network Dentist, you may be balanced billed. Balance billing occurs when a Non-Network Dentist bills a covered person for charges – other than co-payments, coinsurance, or any amounts that may remain on a deductible. Also, the Cost Share Limit does not apply for services provided by a Non-Network Dentist for covered pediatric enrollees under age 19. This means that if you go to a Non-Network Dentist, once you have reached the Cost Share Limit, your responsibility to pay deductibles and coinsurance will continue.

When services are received from a Non-Network Dentist, you will be responsible for making payment directly to the dentist for the difference between the amount approved for the service(s) by Delta Dental and the Delta Dental benefit amount. For Non-Network Dentists, the amount approved by Delta Dental will be the dentist’s actual charge for the services performed.

Your policy includes examples of your potential out-of-pocket costs when receiving services from both Network and Non-Network Dentists. Please refer to your policy or if you have further questions, contact Delta Dental Customer Service at 1-888-899-3734.

Because claims must be submitted to Delta Dental within twelve (12) months of the date dental services are completed to be entitled to benefits, you should check your Explanation of Benefits to be sure a claim is submitted to Delta Dental for all dental services that you receive from Non-Network Dentists within twelve (12) months after all Dental Services are completed.

Delta Dental offers two ways to find a Network Dentist 24 hours a day, 7 days a week. You can either call 1-888-899-3734 or access www.deltadentalcoversme.com. By calling, you can get a customized list of Network Dentists within the area of your request. By searching on the website, you can get a customized list of Network Dentists in a specific town. The list can be downloaded right away and you can search for as many towns as needed. You can get Network Dentist information for any of the 50 states should you need a dentist when you travel outside of New Jersey.


Enrollee Claim Submission

A claim is a request to Delta Dental to pay a benefit under your policy. The following is a description of how a claim should be filed.

In most cases, a Network Dentist will file a claim with Delta Dental on your behalf and will receive payment directly from Delta Dental. If you visit a Non-Participating Dentist (a dentist which has no agreement with Delta Dental) in New Jersey, the Non-Participating Dentist is required to send the claim for you unless you choose to file the claim yourself. In other states, you may need to send the claim yourself for dental services performed by a Non-Participating Dentist. Claim forms must be sent to:

Delta Dental of Wisconsin, Inc. 
P.O. Box 103
Stevens Point, WI 54481-0828
(Policy management and service for individual coverage is provided by Delta Dental of Wisconsin, Inc.)

Download dental claim form.

A claim for a dental service must be filed within twelve (12) months after the date the dental service was finished. You will also be responsible for any dental service if the claim was not filed within 12 months after the service was provided. You will also be responsible for payment of any dental services finished after termination of your coverage.

Grace Periods and Claims Pending Policies During the Grace Period

You have a grace period of thirty (30) days past the date when your premium is due to pay your subscription charges under the policy. However, if you have received an advance payment of the premium tax credit (“APTC”) and have previously paid at least one month of subscription charges during the coverage year, you have a grace period of ninety (90) days past the date when your premium is due to pay your subscription charges under the policy. If you do not make payment when the grace period expires, Delta Dental will end your policy.

Your policy stays in force during the grace period. If you fail to pay the subscription charges during the grace period, our subsequent acceptance of a payment from you for coverage prior to the coverage expiration date shall reinstate your coverage, but such reinstatement shall not provide coverage for the period between the end of the grace period through the date we accepted your payment. Your policy ends if you have not paid the full amount of the Subscription Charges due by the end of the grace period.

If you receive an APTC and are subject to a ninety (90) day grace period, Delta Dental will pay claims for covered services rendered to the covered person during the first thirty (30) days of the grace period. Thereafter, Delta Dental may pend claims for covered dental services rendered to the covered person during the remaining sixty (60) days of the grace period. A “pending” claim is one that has been set aside and will not be processed until the premium due is paid.

Retroactive Denials 

A retroactive denial is the reversal of a previously paid claim, through which the covered person then becomes responsible for payment. Claims may be denied retroactively, even after the covered person has obtained services from the dentist or received payment from Delta Dental.

For example, if you receive services during the grace period and Delta Dental makes payment for those services but you don’t pay the premium, Delta Dental may retroactively deny the claim. If the claim is denied retroactively, you will be responsible to pay for the dental services.

Another example is if it is determined that an ineligible person is covered under the policy, Delta Dental will pay back any subscription charges paid for ineligible persons. However, if Delta Dental paid claims for an ineligible person, the claims will be denied retroactively and the policy holder must pay back Delta Dental for the amount of all claims paid.

Likewise, if the incorrect dental service is submitted on a claim and is subsequently corrected, the correct service submitted may not be covered and result in a retroactive denial of the original claim. Also, Delta Dental pays benefits for covered dental services based on the date the service is completed. If a claim is submitted with a date of service other than the completion date (for example, the tooth preparation date for a crown), Delta Dental may retroactively deny the claim if it is discovered that the date of service does not reflect the completion date. In all such cases, the dentist or policyholder (depending on who received the payment) is responsible to pay back Delta Dental for the amount it paid inappropriately.

You can help to limit the possibility of retroactive claim denials by:

• Ensuring you pay the full amount of your subscription charges on time
• Ensuring that claims submitted by yourself or your dentist accurately reflect the dental services rendered
• Ensuring that claims submitted by yourself or your dentist reflect the date the service was actually completed

Recoupment of Subscription Charge Over payments 

In the event that Delta Dental over-bills a policy holder for subscription charges, we will issue a refund of the subscription charges paid in excess of the amount actually due, if any. Delta Dental will pay you back any subscription charges paid in advance for periods after the termination date of you policy. Delta Dental has the right to end coverage for any persons found to be ineligible for this policy and/or who have submitted claims with false information on purpose. In the case of ineligible persons signed up for in the policy, Delta Dental will pay back any subscription charges paid for ineligible persons. If Delta Dental has paid claims for an ineligible person, the policy holder, must pay back Delta Dental for the amount of all claims paid. Delta Dental may reduce any refund for the amount of any known over payment.

Delta Dental has the right to get back any payment made to a subscriber, covered child, or dentist which is more than the amount the person was entitled to get under this policy or if the payment was made to the wrong payee. Delta Dental may offset any such over payment against any amount which otherwise is due to you under the policy.

If you think you are due a refund of subscription charges, contact Delta Dental Customer Service at 1-888-899-3734. You may also write to: 

Delta Dental of Wisconsin, Inc.
P.O. Box 103
Stevens Point, WI 54481-0828

Be sure to include your member identification number, the reason you believe you are due a refund of subscription charges, and any other supporting documentation.

Medical Necessity, Prior Authorization Time frames and Enrollee Responsibilities

Prior Authorization
Prior Authorization is a determination whether a service to be rendered to a covered pediatric enrollee under age 19 is a covered service by Delta Dental. It responds to a request for approval of dental services as Dentally Necessary or orthodontic services as Medically Necessary Orthodontic Services. Your policy requires that you obtain Prior Authorization for many dental services performed on covered pediatric enrollees up to age 19. These services are listed in the appendix to your policy, but can also be found here.

Dentally Necessary or Dental Necessity means dental services that a dentist, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) in accordance with generally accepted standards of dental practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for successfully treating the patient's illness, injury or disease; and (3) not primarily for the convenience of the patient, dentist or other health care provider, and (4) not more costly than an alternative service or sequence of services fulfilling the requirements of the specific situation or the extenuating circumstances as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this definition, generally accepted standards of dental practice means standards that are based on credible scientific evidence published in peer-reviewed dental literature generally recognized by the relevant dental community or otherwise consistent with the standards set forth in policy issues involving clinical judgment. Services requiring Prior Authorization are reviewed for Dental Necessity, or in the case of comprehensive orthodontic services, Medical Necessity. Delta Dental will pay no benefit for those dental services rendered to covered pediatric enrollees before you get a Prior Authorization from Delta Dental. You or your dentist must send a request to Delta Dental showing the dental services he or she recommends for the covered pediatric enrollee. Delta Dental will provide you and your dentist Delta Dental’s decision as to what benefits, if any, it will pay for those services. Requests for Prior Authorization must be sent to:

Delta Dental of Wisconsin, Inc.
P.O. Box 103
Stevens Point, WI 54481-0828

Requests for Prior Authorization must include a narrative from the Dentist. That narrative must explain why the dental service is Dentally Necessary. For orthodontic services, that narrative must explain why the orthodontic services are Medically Necessary Orthodontic Services as defined in the policy. Requests for Prior Authorization must include the diagnostics for the Dental Service required by Delta Dental. Those requirements are found at here. Delta Dental may change those requirements, but changes will apply only to requests submitted after the change.

Medically Necessary Orthodontic Services for Covered Pediatric Enrollees

Medically Necessary Orthodontic Services means comprehensive orthodontic treatment that meets the criteria for Dental Necessity and also meets at least one of the following criteria:

• The Covered Person’s condition necessitates a core of 26 or more points on a correctly scored modified Salzmann Malocclusion Severity Assessment; or
• The Covered Person demonstrates that the requested treatment will significantly ameliorate a mental, emotional, or behavioral condition associated with the Covered Person’s dental condition; or
• The Covered Person presents evidence demonstrating severe functional difficulties, developmental anomalies of facial bones and/or oral structures, or facial trauma resulting in severe functional difficulties.

Coverage for orthodontic services, including all specific and general limitations and exclusions, can be found in your policy. Orthodontic services require Prior Authorization. Delta Dental will pay no benefit for those dental services rendered to covered pediatric enrollees before you get a Prior Authorization from Delta Dental.

To be entitled to a benefit under this policy, the claim must be submitted by you or your Dentist within twelve (12) months of the date dental services are completed and dental services must have been performed after any required Prior Authorization was issued. Delta Dental must approve the claim or request for Prior Authorization, deny the claim or request for Prior Authorization, or ask for more information within the time frames prescribed by law and/or regulation.

Pre-Treatment Estimate 

A dentist may also send a claim to Delta Dental showing the dental services he or she recommends for even if no Prior Authorization is required by the policy. Delta Dental will then provide an estimate of benefits under your policy. We call this a Pre-Treatment Estimate. The benefit amount for these dental services will depend on eligibility, and any benefit limitations and exclusions (which can be found in your policy). If your dentist suggests the need for dental services which cost more than $300, Delta Dental recommends that you ask for a Pre-Treatment Estimate before receiving the dental services.

Information on Explanation of Benefits (EOBs) 

An Explanation of Benefits (EOB) is a computer-generated statement from Delta Dental that you will receive after we process a claim for a covered person describing how Delta Dental determined your benefit for the dental services submitted on the claim or telling you the information Delta Dental requires before a benefit determination can be made. It also contains information on how to appeal a benefit determination if the claim is denied or you do not agree with the benefit determination. We will send an Explanation of Benefits within the time and way required by law and/or regulation. A sample Explanation of Benefits with instructions for how to read to understand it can be found here.

Coordination of Benefits 

Coordination of benefits applies when you have coverage under more than one dental policy. It determines which plan will pay benefits first. Your policy is an individual plan and does not coordinate with other policies, whether a group plan or another individual plan.