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.
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.
- 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:
- 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.
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.