Download Dental Benefits at a Glance - May Insurance Services, Inc.

Understanding your Dental Plan
Delta Dental of Ohio will be your dental provider effective on your enrollment date. You will have access to two of the
nation’s largest networks of participating dentists: our Delta Dental PPOSM network and our Delta Dental Premier®
network. Although you can visit any licensed dentist, you are likely to save more money by visiting a dentist who
participates in one of these networks.
Frequently Asked Questions
When is the new plan effective?
Delta Dental of Ohio will be your new plan administrator beginning on your enrollment
effective date.
Do I need to tell my dentist that my insurance has
changed?
Yes. Once your coverage becomes effective, you should either tell your dentist that you
have Delta Dental PPO (Point-of-Service) coverage or show your ID card at the time of
service.
Do I need an ID card to receive treatment?
No. Your dentist can verify your coverage 24 hours a day, seven days a week, by checking
the online Dental Office Toolkit or calling our Customer Service department.
Why isn’t my Social Security number on my ID
card?
What is the difference between a Delta Dental PPO
and a Delta Dental Premier dentist?
How can I find out if my dentist participates or
find a participating dentist?
What if my dentist does not participate?
Can I obtain information about my own eligibility
and claims?
Is a predetermination required prior to receiving
dental services?
Where should claims be submitted for services
rendered prior to my enrollment date with Delta
Dental?
Where should claims be submitted for services
rendered after my enrollment date with Delta
Dental?
What if I’m in the middle of treatment?
How will current orthodontic treatment claims be
processed?
In order to protect your personal information, your ID card includes a nine-digit subscriber
identification number instead of your Social Security number. This number will be used to
identify you under the plan. Please give this number to your dentist at your next appointment.
Delta Dental PPO providers accept a lower fee than Delta Dental Premier dentists. This
lower fee schedule will likely reduce your out-of-pocket costs (see pricing examples on the
next page).
You can find out if your dentist participates or find participating dentists by calling Delta
Dental’s Customer Service department at (800) 524-0149 or by visiting our website at
www.deltadentaloh.com.
You can still visit a nonparticipating dentist, but you will likely pay more money out of pocket.
Delta Dental’s payment will be sent to you, and you will need to reimburse your dentist.
Yes. You can review your own claims, print an ID card, access a searchable dentist
directory and more by visiting the Consumer Toolkit® located on our website at
www.deltadentaloh.com.
Delta Dental recommends predetermination before your dentist provides any services where
the total charges will exceed $200. Predetermination is not a prerequisite to payment, but it
allows claims to be processed more efficiently and allows you to know what services will be
covered before your dentist provides them.
Claims for dental services rendered prior to your enrollment date must be submitted to your
previous dental administrator for reimbursement.
Claims for dental services rendered after your enrollment date should be sent to the
address listed below.
We encourage you to complete multi-step procedures (like crowns, bridges, or dentures)
started prior to your effective date with Delta Dental. Delta Dental will cover services that are
completed after your effective date where applicable.
If one of your family members is in the middle of orthodontic treatment and has not yet
reached his or her lifetime orthodontic maximum, ask the dentist to submit a claim with the
complete treatment plan to us as if he or she were submitting the claim for the first time. We
will use the information on this claim to calculate the remaining liability based on the number
of months left in the treatment plan. We will then make monthly payments until treatment
ends or until your family member reaches his or her lifetime orthodontic maximum.
Your dentist should send all dental claims for services rendered after your enrollment date to
Delta Dental at the following address:
Delta Dental
P.O. Box 9085
Farmington Hills, MI 48333-9085
Delta Dental
P.O. Box 9085
Farmington Hills, MI
48333-9085
(800) 524-0149
www.deltadentaloh.com
Pricing Examples
PPO Dentist
Class II payment example for:
Filling - Amalgam
Restoration/One Surface
(assuming any applicable
deductible has been met)
Class III payment example for:
Crown - Full cast high noble
metal (assuming any applicable
deductible has been met)
Submitted Fee:
PPO Fee Schedule amount:
Delta Dental pays 80% of the
PPO Fee Schedule amount:
Premier Dentist
$120.00
$64.00
$51.20
2.
3.
$120.00
$102.00
$81.60
Submitted Fee:
Nonparticipating Dentist Fee:
Delta Dental pays 80% of the
Nonparticipating Dentist Fee:
$120.00
$104.00
$83.20
Member pays:
$12.80
The PPO dentist cannot charge the $56
difference between the PPO Fee Schedule
amount and his/ her fee.
Member pays:
$20.40
The Premier dentist cannot charge the $18
difference between the Maximum Approved
Fee and his/her fee.
Member pays:
$36.80
Because the dentist does not participate, you
are responsible for the difference between
Delta Dental’s payment and his/her fee.
Submitted Fee:
PPO Fee Schedule amount:
Delta Dental pays 50% of the
PPO Fee Schedule amount:
Submitted Fee:
$1,000.00
Maximum Approved Fee:
$905.00
Delta Dental pays 50% of the
Maximum Approved Fee:
$452.50
Submitted Fee:
Nonparticipating Dentist Fee:
Delta Dental pays 50% of the
Nonparticipating Dentist Fee:
Member pays:
$452.50
The Premier dentist cannot charge the $95
difference between the Maximum Approved
Fee and his/her fee.
Member pays:
$576.50
Because the dentist does not participate, you
are responsible for the difference between
Delta Dental’s payment and his/her fee.
$1,000.00
$745.00
$372.50
Member pays:
$372.50
The PPO dentist cannot charge the $255
difference between the PPO Fee Schedule
amount and his/her fee.
1.
Submitted Fee:
Maximum Approved Fee:
Delta Dental pays 80% of the
Maximum Approved Fee:
Nonparticipating Dentist
$1,000.00
$847.00
$423.50
A Delta Dental PPO Dentist is one who has agreed to accept the Delta Dental PPO Fee Schedule amount as payment in full. The Delta Dental PPO Fee Schedule amount is
generally lower than the Maximum Approved Fee used for a dentist who participates in Delta Dental Premier.
The Maximum Approved Fee is the maximum amount Delta Dental has approved for a specific procedure performed by a Delta Dental Premier dentist. Premier dentists agree to
accept this amount as payment in full.
The Nonparticipating Dentist Fee is the maximum amount Delta Dental has approved for a specific procedure performed by a dentist who does not participate in either Delta
Dental PPO or Delta Dental Premier.