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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.

About Exempt Dental Coverage
General Contact

Department of Administrative Services
30 East Broad Street, 27th Floor
Columbus, Ohio 43215
614-466-8857 Local
800-409-1205 Toll Free

Driving Directions

Benefits Administration Services Home Page

Claims Accordion

Claims Process

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.

  • Dental claims should be filed within 12 months of the date of service.
  • All of your benefits will be processed by Delta Dental immediately upon receipt of your claims.
  • If you fail to file a claim within the time specified, you will not receive any payment for your treatment.

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.  

Delta Dental
PO Box 30416
Lansing, MI 48909-7916

Disputed Claims Procedure

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.

Formal Claims Appeal Procedure

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:

Dental Director
Delta Dental
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.

Manner and Content of Notice

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.

Coordination of Benefits

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.

  • Under COB, the plan that pays first is the primary plan.
  • The secondary plan pays after the primary plan.
  • When you or your family members are covered by another group plan in addition to this one, Delta Dental will follow Ohio coordination of benefit rules to determine which plan is primary and which is secondary. You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then submit the balance to the secondary plan.

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:

  • Medicaid
  • Group hospital indemnity plans that pay less than $100 per day
  • School accident coverage
  • Some supplemental sickness and accident policies

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.

  • Delta Dental will pay only for health care expenses that are covered by Delta Dental.
  • Delta Dental will pay only if you have followed all of the procedural requirements, including care obtained from or arranged by your Dentist, Predeterminations, etc.
  • Delta Dental will pay no more than the "allowable expenses" for the health care involved. If the allowable expense is lower than the primary plan's, Delta Dental will use the primary plan's allowable expense. That may be less than the actual bill.

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.

2. Employee
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.

Coordination Disputes

If you believe Delta Dental has not paid a claim properly, you should first attempt to resolve the problem by contacting Delta Dental.

Termination Accordion

Continuation Coverage (COBRA)

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.

Termination of Coverage

Your Delta Dental coverage may be automatically terminated:

  • When your employer or organization advises Delta Dental to terminate your coverage; or
  • On the last day of the month for which your employer or organization has failed to pay Delta Dental, or for any other reason stated in the Summary Plan Description.

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.

Change in Status

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.

Assignment

Services and/or benefit payments to subscribers and eligible dependents are for the personal benefit of those people and cannot be transferred or assigned.

Subrogation

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.

Dentist-Patient Relationship

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.

Governing Law

The group contract and/or Certificate will be governed by and interpreted under the laws of the State of Ohio.

Your Rights in The Event of Insolvency

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
800-524-0147

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.