The Delta Dental PPO plan, offered through Delta Dental of Ohio, provides exempt employees with access to two networks of dentists – the Delta Dental PPO network and the Delta Dental Premier network. In addition, you can go to any licensed dentist of your choice and receive benefits. However, you will generally pay less when you go to a dentist within the Delta Dental PPO or Delta Dental Premier network. For most covered services, Delta Dental pays a higher percentage if you go to a dentist in its PPO network over its Premier network. Delta Dental pays the least for out-of-network dentists. Check with your dentist to determine whether he/she belongs to the Delta Dental PPO or Delta Dental Premier network.
Click here to see Dental information prior to July 1, 2013.
Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease.
Major Services (such as bridges, partial dentures and complete dentures)
Services, treatment and procedures to correct malposed teeth; no age limit.
The individual yearly deductible is $25; it will be applied to your covered dental expenses once during each benefit year. No deductible will be applied to Diagnostic and Preventive Services or Orthodontic Services.
For information regarding the dental networks, see the Exempt Dental Plan chart below.
Click image to enlarge.
A type of plastic used for dentures and some kinds of crowns.
One of the most common filling materials; usually soft silver that hardens after it is packed into the cavity.
An X-ray showing exposed portions of the back teeth. Primarily used for early detection of hidden decay between teeth.
Portion of a tooth destroyed by decay. Requires filling or sometimes more extensive treatment.
This document is the certificate of coverage. Delta Dental will provide benefits as described in this certificate. Any changes in this certificate will be based on changes to the plan.
Some procedures may require more than one appointment. Treatment is complete:
The Delta Dental Plan that contracts with your group. The Control Plan will provide all claims processing, service and administration for a multi-state group. Your Control Plan is Delta Dental Plan of Ohio and is referred to as Delta Dental.
The percentage of covered services that you will have to pay toward treatment.
The unique benefits selected in your plan. The Summary of Dental Plan Benefits lists your covered services.
A dental restoration usually covering the whole exposed portion of a tooth. Most often made of porcelain, gold or acrylic. Frequently used in bridgework or to restore a badly-broken tooth.
The amount an individual and/or a family must pay toward covered services before Delta Dental begins paying for services. The Summary of Dental Plan Benefits lists the deductible that applies to you, if any.
Delta Dental Plan
An individual state dental benefit plan that is a member of the Delta Dental Plans Association, a nationwide system of dental health plans offering employers, large and small, custom programs and reporting systems.
Delta Dental's Nonparticipating Dentist Fee
The maximum amount allowed per procedure for services rendered by a nonparticipating dentist.
Delta Dental PPO (Point-of-Service)
A preferred provider organization program that can reduce your out-of-pocket expenses if you receive care from one of Delta Dental's Dentists. This program has back-up coverage through Delta Dental Premier when treatment is received from a Non-PPO Dentist.
Delta Dental PPO Dentist (“PPO Dentist”) – a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in the Delta Dental PPO. PPO Dentists agree to accept Delta Dental’s payment and your Copayment, if any, as payment in full for Covered Services.
Delta Dental Premier Dentist (“Premier Dentist”) – a Dentist who has signed an agreement with the Delta Dental Plan in his or her state to participate in Delta Dental Premier. Premier Dentists agree to accept Delta Dental’s payment and your Copayment, if any, as payment in full for Covered Services.
Nonparticipating Dentist – a Dentist who has not signed an agreement with any Delta Dental Plan to participate in Delta Dental PPO or Delta Dental Premier.
A person licensed to practice dentistry in the state or country in which dental services are rendered.
A removable replacement for a natural tooth or teeth.
Treatments of diseases within the tooth, primarily root canal therapy.
The removal of a natural tooth or teeth.
Material used to fill a cavity that is inserted in a tooth as opposed to one which covers it (crown).
A non-removable replacement for natural tooth or teeth. It is cemented to natural teeth on either side which are used as abutments.
A topically-applied chemical used to prevent tooth decay.
Soft tissue adjacent to your teeth; your gums.
A tooth partly- or wholly-buried under the gum by bone or tissue.
The maximum dollar amount Delta Dental will pay in any benefit year or lifetime for covered dental services (see the Summary of Dental Plan Benefits).
The contact position of the teeth when the upper and lower jaws are closed, sometimes called "bite."
Surgery of the oral mouth cavity, including teeth, tongue and gums. May be dental or non-dental in nature.
Teeth straightening or repositioning.
Treatment of the gum and tissue around the teeth.
An artificial replacement of a missing tooth; part of a fixed bridge.
An estimate of covered services. Dentists may submit their treatment plans and X-rays to Delta Dental before procedures are started. Delta Dental reviews the treatment plan and advises the patient and dentist of what services are covered by your plan and what Delta Dental's payment may be. Delta Dental's payment for predetermined services depends on continued eligibility and the annual or lifetime maximum payment available.
Professional cleaning and polishing of the teeth.
Delta Dental's policies and guidelines used for predetermination and payment of claims. The Processing Policies may be amended from time to time.
Artificial replacement of natural teeth (bridges and dentures).
A partial denture normally held by clasps to the natural teeth, permitting removal if desired.
A filling or crown that restores a natural tooth.
Root Canal Therapy
Treatment of the pulp of the tooth.
Sodium Fluoride Application
A mild decay prevention dental treatment applied to the outer surface of the teeth.
The fee the dentist bills to Delta Dental for a specific treatment.
You, when the State of Ohio notifies Delta Dental that you are eligible to receive dental benefits.
Summary of Dental Plan Benefits
A list of the specific provisions of your group dental plan and is a part of the Dental Care Certificate.
A term which refers to one of the four sides of your tooth or a chewing area of the tooth. A one-surface filling is inserted in only one surface of a tooth; a two-surface filling includes two adjoining surfaces of the same tooth in a single filling.
No payment will be made by Delta Dental and all charges for the following services will be the responsibility of the subscriber:
1. Services for injuries or conditions payable under Workers' Compensation or Employer's Liability laws. Benefits or services that are available from any government agency, political subdivision, community agency, foundation or similar entity.
NOTE: This provision does not apply to any programs provided under Title XIX Social Security Act, that is, Medicaid.
2. Services, as determined by Delta Dental, for correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons.
3. Services or appliances started before an individual became eligible under this plan. This exclusion does not apply to orthodontic treatment in progress
4. Prescription medications, premedications and relative analgesia. General anesthesia and/or intravenous sedation for restorative dentistry or for surgical procedures, unless medically necessary. Charges for hospitalization, laboratory tests and examinations.
5. Preventive control programs including home care items.
6. Charges for failure to keep a scheduled visit with a dentist.
7. Replacement, repair, relines or adjustments of occlusal guards.
8. Charges for completion of forms. A participating dentist may not make these charges to a subscriber/eligible dependent.
10. Lost, missing or stolen appliances of any type and replacement or repair of orthodontic appliances.
11. Services for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental in nature as determined by the standards of generally accepted dental practice.
12. Appliances, surgical procedures and restorations for increasing vertical dimension; for altering, restoring or maintaining occlusion; for replacing tooth structure loss resulting from attrition, abrasion, abfraction or erosion or for periodontal splinting. If orthodontic benefits have been selected, this exclusion will not apply to those benefits as limited by the terms and conditions of the plan.
13. Treatment by someone other than a dentist, except for services performed by a licensed dental hygienist or dental professional under the scope of his or her license as permitted by applicable state law.
14. Those benefits excluded by the policies and procedures of Delta Dental including the Processing Policies.
15. Services or supplies for which no charge is made, for which the patient is not legally obligated to pay, or for which no charge would be made in the absence of Delta Dental coverage.
16. Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared.
17. Services that are covered under a hospital, surgical/medical or prescription medication program.
18. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint (TMJ).
19. Services that are not within the classes of benefits that have been selected and are not in the contract.
The benefits for the following services are limited as follows, unless specified in the Summary of Dental Plan Benefits. All time limitations are measured from the last date of service in any Delta Dental Plan record or, at the request of your group, any dental plan record.
1. Prophylaxes and oral exams are payable twice in a contract period.
2. Bitewing X-rays are payable once in a contract period. Full-mouth X-rays, which include bitewing X-rays, are payable once in any five-year period. A panographic X-ray, including bitewings, is considered a full-mouth X-ray.
3. Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.
4. Cast restorations (including jackets, crowns and onlays) and associated procedures (such as cores and post substructures) on the same tooth are payable once in any five-year period.
5. Porcelain, porcelain substrate and cast restorations are not payable for children less than 12 years of age.
6. Optional treatment: If you select a more expensive service than is customarily provided, or for which Delta Dental does not determine a valid dental need is shown, Delta Dental can make an allowance based on the fee for the customarily-provided service.
7. Benefits for root planing are payable once in any two-year period. Periodontal surgery, including subgingival curettage, is payable once in any three-year period.
8. Prosthodontic (Major Services) benefit limitations:
a. One complete upper and one complete lower denture are covered once in any five-year period for any individual.
b. A partial denture, fixed bridge or removable bridge for any individual can be covered once in any five-year period unless the loss of additional teeth requires the construction of a new appliance.
c. Fixed bridges and removable cast partials are not payable for individuals less than 16 years of age.
d. A reline or the complete replacement of denture base material is limited to once in any three-
year period per appliance.
9. Preventive fluoride treatments are payable for children until their 19th birthday and for adults older than age 55.
10. Orthodontic Services benefit limitations:
a. Orthodontic benefits are payable at any age of a subscriber/eligible dependent.
b. If the treatment plan is terminated before completion of the case for any reason, Delta Dental's obligation will cease with payment to the date of termination.
c. The dentist may terminate treatment, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. In those cases, Delta Dental's obligation for payment of benefits ends on the last day of the month in which the patient was last treated.
d. Any charge for the replacement or repair of an orthodontic appliance furnished under any Delta Dental Plan will not be paid by Delta Dental and will be the responsibility of the patient.
11. Delta Dental's obligation for payment of benefits ends on the last day of the month in which coverage is terminated.
12. When services in progress are interrupted and completed later by another dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each dentist.
13. Care terminated due to the death of a subscriber or eligible dependent will be paid to the limit of Delta Dental's liability for the services completed or in progress.
14. Maximum Payment:
a. The maximum benefit payable in any one benefit year will be limited to the amount specified in the Benefit Feature Sheet.
b. Delta Dental's payment for Orthodontic Services will be limited to the lifetime maximum per person specified in the Benefit Feature Sheet.
15. There is a $25 annual deductible on Basic Services and Major Services. Delta Dental will not be obligated to pay for, in whole or in part, any service to which the deductible applies until the plan deductible amount is met.
16. Sealants are payable once per tooth per lifetime and only for the occlusal surface of first and second permanent molars for patients up to age 19.
17. Processing Policies may limit treatment.
For questions about dental benefits, contact Delta Dental at 800-524-0149.
Delta Dental PPO Plan
Group Number: 9273-0001
Visit the Delta Dental website at deltadentaloh.com.
For first time users, log in using your Employee ID number and date of birth.
If you are an exempt full-time or part-time permanent employee with one year of continuous state service, the state pays the full cost for you and your eligible dependents to participate in the dental plan.
Service time for employees classified as student help, college interns or whose appointments are temporary, seasonal or intermittent may count toward one year of continuous state service if such employees are hired on a permanent, full-time basis or permanent part-time basis with no break in service. Contact your payroll/personnel officer to confirm your eligibility.
If you are eligible for dental benefits, your dependents also may be eligible to receive dental benefits under your coverage. Review dependent eligibility at das.ohio.gov/eligibilityrequirements.
If you are an eligible employee, you will be able to enroll in dental coverage through Delta Dental after one year of continuous state service. Prior to the end of your first year of service, you should receive notification that you soon will become eligible for dental coverage.
Enrollment in the state’s dental plan is not automatic. Instead, you may complete your dental plan enrollment in one of two ways:
• You may enroll on-line at myOhio.gov beginning the second business day following your one-year anniversary date.
• You may submit the Benefit Enrollment & Change Form (ADM 4717) to your agency human resources office.
Your dental coverage will be effective the first day of your 13th month of state service. If you do not enroll within 31 days of your anniversary date, you must wait until the annual open enrollment period to obtain dental coverage.
Once you are enrolled, you can go to deltadentaloh.com and sign up for access to the Consumer Toolkit. The Consumer Toolkit allows you to check your eligibility, claims status and benefits; print a customized ID card; and locate participating dentists near you.
You must notify Delta Dental, through your employer or organization, of any event causing a change in the status of an eligible dependent. Events that can affect the status of an eligible dependent include, but are not limited to, marriage, birth, death, divorce and entrance into military service.
Services and/or benefit payments to subscribers and eligible dependents are for the personal benefit of those people and cannot be transferred or assigned.
If Delta Dental pays a claim for which another person or company is liable, Delta Dental has the right to recover its payment from the other person or company.
Obtaining And Releasing Information
While you are covered by Delta Dental, you agree to provide Delta Dental with any information it needs to process your claims and administer your benefits. This includes allowing Delta Dental to have access to your dental records.
You and your eligible dependents have the freedom to choose any dentist. Each dentist maintains the dentist-patient relationship with the patient and is solely responsible to the patient for dental advice and treatment and any resulting liability.
Loss of Eligibility During Treatment
If you or your eligible dependent lose eligibility while receiving dental treatment, only covered services received while you or your eligible dependent were covered under the plan will be payable.
Certain procedures begun before the loss of eligibility may be covered if the services were completed within a 60-day period measured from the date of termination. In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. The balance of the total fee is your responsibility.
Late Claims Submission
Delta Dental will not honor, and no payment will be made for, services if a claim for those services has not been received by Delta Dental within one year following the year in which the services were completed.
The group contract and/or Certificate will be governed by and interpreted under the laws of the State of Ohio.
Once you are covered by a dental plan, you will be able to receive dental treatments and have a portion of the cost covered by your dental plan. If you seek care from a Delta Dental PPO or Delta Dental Premier dentist, your dentist will fill out and file claims for you. If you seek care from a dentist who does not participate in a Delta Dental network, you may need to fill out and file your own claim form. Claim forms are available to download.
If you have any questions about your benefits or a claim payment problem, you should call Delta Dental's Customer Service department at 800.524.0149, visit Delta Dental's website at deltadentaloh.com or send a written inquiry to the below address.
PO Box 30416
Lansing, MI 48909-7916
If you receive notice of an Adverse Benefit Determination and you think that Delta Dental incorrectly denied all or part of your claim, you or your Dentist should contact Delta Dental’s Customer Service department and ask them to check the claim to make sure it was processed correctly. You may do this by calling the toll-free number, (800) 524-0149, and speaking to a telephone advisor. You also may mail your inquiry to the Customer Service Department at P.O. Box 9089, Farmington Hills, MI, 48333-9089.
When writing, please enclose a copy of your explanation of benefits and describe the problem. Be sure to include your name, telephone number, the date and any information you would like considered about your claim. This inquiry is not required and should not be considered a formal request for review of a denied claim. Delta Dental provides this opportunity for you to describe problems, or submit an explanation or additional information that might indicate your claim was improperly denied, and allow Delta Dental to correct any errors quickly and immediately.
Whether or not you have asked Delta Dental informally to recheck its initial determination, you can request a formal review within the Formal Claims Appeal Procedure section below.
If you receive notice of an Adverse Benefit Determination, you, or your authorized representative, should seek a review as soon as possible, but you must file your request for review within 180 days of the date that you received that Adverse Benefit Determination.
To request a formal review of your claim, send your request in writing to:
P.O. Box 30416
Lansing, MI 48909-7916
Please include your name and address, the Subscriber’s Member ID, the reason why you believe your claim was wrongly denied and any other information you believe supports your claim. You also have the right to review the contract between Delta Dental and your employer or organization and any documents related to it. If you would like a record of your request and proof that Delta Dental received it, mail your request certified mail, return receipt requested.
The dental director or any person reviewing your claim will not be the same as, nor subordinate to, the person(s) who initially decided your claim. The reviewer will grant no deference to the prior decision about your claim. The reviewer will assess the information, including any additional information that you have provided, as if he or she were deciding the claim for the first time. The reviewer's decision will take into account all comments, documents, records and other information relating to your claim even if the information was not available when your claim was initially decided.
If the decision is based, in whole or in part, on a dental or medical judgment (including determinations with respect to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate), the reviewer will consult a dental health care professional with appropriate training and experience, if necessary. The dental health care professional will not be the same individual or that person's subordinate consulted during the initial determination.
The reviewer will make a determination within 60 days of receipt of your request. If your claim is denied on review (in whole or in part), you will be notified in writing. The notice of an Adverse Benefit Determination during the Formal Claims Appeal Procedure will meet the requirements described the Manner and Content of Notice section below.
Your notice of an Adverse Benefit Determination will inform you of the specific reasons(s) for the denial, the pertinent plan provisions(s) on which the denial is based, the applicable review procedures for dental claims, including time limits and that, upon request, you are entitled to access all documents, records and other information relevant to your claim free of charge. This notice also will contain a description of any additional materials necessary to complete your claim, an explanation of why such materials are necessary, and a statement that you have a right to bring a civil action in court if you receive an Adverse Benefit Determination after your claim has been completely reviewed according to this Formal Claims Appeal Procedure. The notice also will reference any internal rule, guideline, protocol or similar document or criteria relied on in making the Adverse Benefit Determination, and will include a statement that a copy of such rule, guideline or protocol may be obtained upon request at no charge.
If the Adverse Benefit Determination is based on a matter of medical judgment or medical necessity, the notice also will contain an explanation of the scientific or clinical judgment on which the determination was based, or a statement that a copy of the basis for the scientific or clinical judgment can be obtained upon request at no charge.
If you are still not satisfied, you may contact the Ohio Department of Insurance for instructions on filing a consumer complaint by calling (614) 644-2673 or (800) 686-1526. You also may write to the Consumer Services Division of the Ohio Department of Insurance, 50 W. Town St., Third Floor, Suite 300, Columbus, Ohio, 43215.
You and your family members may have coverage under more than one health plan. Coordination of benefits (COB) is the procedure used to determine the amount of a claim that each plan should pay and to eliminate duplication of payment for services.
Delta Dental pays for health care only when you follow the rules and procedures. If the rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use.
Plans That Do Not Coordinate
Delta Dental will pay benefits without regard to benefits paid by the following kinds of coverage:
How Delta Dental Pays as Primary Plan
When Delta Dental is primary, Delta Dental will pay the full benefit allowed by your contract as if you had no other coverage.
How Delta Dental Pays as Secondary Plan
When Delta Dental is secondary, it will use the carve-out method of coordinating benefits. If the patient has other coverage and that coverage has a higher priority than this plan, this plan’s payment for covered services will equal the amount payable under this plan minus the amount paid by the primary carrier. This plan’s payment will not exceed the amount that would have been paid in the absence of the other plan.
For example, if the primary plan pays an amount higher than Delta Dental would have paid, no payment will be made by Delta Dental. If the primary plan pays less than Delta Dental allows, Delta Dental will pay the difference up to Delta Dental's allowed amount minus the amount paid by the primary plan.
Which Plan Is Primary?
To decide which plan is primary, Delta Dental has to consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The primary plan will be determined by the first of the following, which applies:
1. Non-coordinating Plan
If you have another group plan that does not coordinate benefits, it will always be primary.
The plan, which covers you as an employee (neither laid off nor retired), is always primary.
3. Children (Parents Divorced or Separated)
If the court decree makes one parent responsible for health care expenses, that parent's plan is primary.
If the court decree gives joint custody and does not mention health care, Delta Dental follows the birthday rule (see below).
If neither of those rules applies, the order will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.
4. Children and the Birthday Rule
When your children's health care expenses are involved, Delta Dental follows the "birthday rule." The plan of the parent with the first birthday in a calendar year is always primary for the children. If your birthday is in January and your spouse's birthday is in March, your plan will be primary for all of your children.
However, if your spouse's plan has some other coordination rule (for example, a "gender rule" which says the father's plan is always primary), Delta Dental will follow the rules of that plan.
5. Other Situations
For all other situations not described above, the order of benefits will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.
If you believe Delta Dental has not paid a claim properly, you should first attempt to resolve the problem by contacting Delta Dental.
If you or one of your dependents become ineligible for employer-paid dental coverage, you may be eligible to continue your coverage under the federal COBRA program. Contact your agency for more details.
Your Delta Dental coverage may be automatically terminated:
In no event will eligibility for any person covered under this program continue beyond the date your employer advises Delta Dental or organization to terminate eligibility, except to the extent that COBRA is applicable.
Ohio law requires Delta Dental to make the following statements:
As a licensed health-insuring corporation (HIC) Delta Dental is not a member of a Guarantee Fund. In the event of Delta Dental's insolvency, you are protected only to the extent that the provision in the contracts between Delta Dental and its dentists in which providers agree not to bill members, applies to the dental services you receive.
In addition, in the event of Delta Dental's discontinuance of operations, dentists are required to provide covered dental services that are medically necessary to complete previously initiated treatment, but this is limited to the thirty-day period following discontinuance of operations.
Participating dentists are not required to continue to provide covered dental services past the occurrence of the earliest of the following events.
1. The end of the thirty-day period following the filing of the liquidation order per Ohio law;
2. The end of the member's contract year;
3. The date the member obtains equivalent coverage;
4. The end of the member's period of coverage for a contractual prepayment of premium; or
5. Legal transfer of Delta Dental's obligations.
In the event of Delta Dental becoming insolvent, you may be financially responsible for dental services rendered by a provider or facility that is not under contract with Delta Dental whether or not Delta Dental authorized the use of the provider or health care facility.
In addition, in the event of Delta Dental's discontinuance of operations, as required by Ohio law, Delta Dental is required to submit to the Ohio Superintendent, documentation of an arrangement to provide medically necessary health care services to members until the expiration of the member's contract year. As required by Ohio law, this arrangement to provide medically necessary health care services may be made by using any one, or any combination of the following methods.
1. The maintenance of insolvency coverage;
2. A provision in participating providers' contracts with Delta Dental, provided such provision is not solely relied upon for more than thirty days;
3. In agreement with any other health insuring corporations or insurers, providing members with automatic conversion rights upon the discontinuance of Delta Dental's operations; or
4. Such other methods as approved by the Superintendent of Insurance.
In the event any of the foregoing situations applies to you, please contact Delta Dental at 800-524-0149.
Anti-Fraud Toll-Free Hotline
Insurance fraud significantly increases the cost of health care. If you are aware of any false information submitted to Delta Dental, you could help lower these costs by calling the toll-free hotline. Only ANTI-FRAUD calls can be accepted on this line. The following statement is required for this document by Ohio law:
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
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