This guide is designed to help you get the most from your dental plan. It highlights the key things you need to know as an enrollee. This information is intended to answer general questions you may have about your Covered Benefits and is not specific to each employer group’s coverage. For information specific to your employer’s group coverage, please consult your Evidence of Coverage (EOC).

Your EOC is your actual explanation of your Covered Benefits as an enrollee. While this guide includes general information about using your benefits, your EOC is always the ultimate source of information about Covered Benefits, Exclusions, Limitations, Membership provisions and is a part of your group’s contract. Please review your Evidence of Coverage.

For more information, please click on the links below:

How to Contact Us
How to Use Your Benefits
Eligible Dependents
Visiting the Dentist
Understanding the Delta Dental Networks
Pre-determination of Benefits
Notice of Payment (Explanation of Benefits)
Filing Claims
Complaint and Appeals Procedures
Coordination of Benefits
Common Dental Terminology

How to Contact Us

ON THE WEB

We encourage you to visit us on the web at www.deltadentalva.com. As a new member you should register to use our secured information center. Once registered, you can review benefits and eligibility information, specifics on any claims filed and remaining benefit balances for all the individuals covered under your policy. You can also print additional copies of your ID card to use when visiting your dentist.

BY PHONE

Call Delta Dental’s Benefit Services whenever you have a question about your dental plan. You can reach us by calling 800-237-6060 or the toll-free number on the bottom of your Delta Dental of Virginia ID card. Benefit Services representatives are available Monday through Thursday from 8:15 am to 6:00 pm and Friday 8:15 am to 4:45 pm to help with:

• General questions
• Claims questions
• Information about network dentists and specialists
• Complaints and problem resolution

Delta Dental also offers a 24-hour automated phone system which can be used to:

• Check the status of a claim
• Determine how much of your deductible has been satisfied
• Locate a provider
• Get updates on available benefits

BY MAIL

Correspondence should be addressed to:
Delta Dental of Virginia
ATTN: Benefit Services
4818 Starkey Road
Roanoke, VA 24018

How to Use Your Benefits

You and your family members are covered for dental services when enrolled in one of Delta Dental’s plans. Our plans are designed to make Covered Benefits more affordable. In most cases, this plan will pay a portion of the cost of your Covered Benefits (up to any plan maximums). You may be responsible for deductibles, coinsurance and in some cases, dentists charges that exceed what Delta Dental covers. Please see your schedule of benefits for more details about what is covered under your plan. In most cases where you choose to have a more expensive service or benefit than is normally provided, or for which Delta Dental does not believe a “valid need” is shown, Delta Dental will pay the applicable percentage of the fee for the service which is adequate to restore the tooth or dental arch to proper function. You may be responsible for the difference between what Delta Dental pays and the dentist’s fee for the optional treatment.

Eligible Dependents

An employee’s spouse (or domestic partner) and unmarried, dependent children (please see your Schedule of Benefits for details on the dependent age limits) are eligible to be covered under your plan. If you need to add dependents to your coverage, please see your benefit administrator. Generally, dependents can be added to your coverage on the first day of the month immediately following a Qualifying Event as long as Delta Dental is notified in writing no later than 30 days after the qualifying event.

For full details regarding eligibility please refer to your EOC or contact Benefit Services at the toll-free number on your ID card.

Visiting the Dentist

You may choose to go to any licensed dentist when you need dental care. Whatever dentist you choose, you will receive some level of coverage for Covered Benefits. However, there are advantages when you receive treatment from a dentist participating in one of the Delta Dental networks. Please consult Delta Dental’s website at www.deltadentalva.com for the most up-to-date information on participating dentists or call our Benefit Services department at 800-237-6060 or the toll-free number listed on the bottom of your ID card.

Understanding the Delta Dental Networks

DELTA DENTAL PREMIER PLANS

If you are enrolled in a Delta Dental Premier plan, to receive the highest level of benefits you should choose a dentist who participates in the Delta Dental Premier Network. These dentists participate in our largest network and also reduce your out-of-pocket costs by agreeing to accept our Delta Dental Premier Plan Allowance as full payment for Covered Benefits. You will be responsible for any deductible and co-insurance due at the time of service. There is absolutely no balance billing. We pay the dentist directly, so you do not have to pay the whole bill up front and wait for reimbursement.

Of course, as stated earlier, you may select any licensed dentist to provide your dental care. For Covered Benefits provided by non-participating dentists, our payment is based on the Plan Allowance for non-participating dentists, which may be lower than the Delta Dental Premier Plan Allowance. Non-participating dentists have not agreed to accept our discounted reimbursement as payment in full. Meaning that in addition to what Delta Dental pays, you must pay any deductible, co-insurance, and the difference between our non-participating dentist allowance and the charges submitted by this dentist. Therefore, the amount you would owe a non-participating dentist is typically higher than if you chose a Delta Dental Premier dentist. If you do decide on a non-participating dentist, in most cases, we will pay you directly for Covered Benefits unless an assignment of benefits is made with Delta Dental.

See the illustration below for an example of how payments are made between participating and non-participating dentists.

DELTA DENTAL PPO PLANS*

If your plan is a PPO plan, you can enjoy the ultimate balance of cost and flexibility. Just choose a dentist who participates in the Delta Dental PPO network, and you will receive the greatest level of savings on your out-of-pocket costs. PPO dentists have agreed to accept a greater discount (The Delta Dental PPO Plan Allowance) as payment in full for covered procedures. This means that you only pay your deductible and any co-insurance for Covered Benefits. We pay PPO dentists directly, so you do not have to pay the whole bill up front and wait for reimbursement.

Of course, as stated earlier, you may select any licensed dentist to provide your dental care. For Covered Benefits provided by non-participating dentists, our payment is based on the Delta Dental PPO Plan Allowance. Non-participating and Delta Dental Premier dentists have not agreed to accept our discounted PPO Plan Allowance as payment in full. This means that in addition to what Delta Dental pays, you must pay any deductible and co-insurance. For a non-participating dentist you may also have to pay the difference between our Delta Dental PPO Plan Allowance and the charges submitted by this dentist. For a Delta Dental Premier dentist you must also pay the difference between our Delta Dental PPO Plan Allowance and Delta Dental Premier Plan Allowance. Therefore, the amount you would owe a non-participating or Delta Dental Premier Dentist is typically higher than if you chose a Delta Dental PPO dentist. If you go to a non-participating dentist, in most cases, we will pay you directly for Covered Benefits unless an assignment of benefits is made with Delta Dental. We pay PPO dentists directly, so you do not have to pay the whole bill up front and wait for reimbursement.

See the illustration below for an example of how payments are made between participating and non-participating dentists.

*The Delta Dental PPO network is not available in all areas. Please consult our website at www.deltadentalva.com and go to the Find a Dentist link for details and to check dentist participation.

DELTA DENTAL PPO/PREMIER PLANS*

With these plans you are provided with a unique opportunity we call the ‘safety-net’ feature. This feature allows you to select a dentist from either the Delta Dental PPO or the Delta Premier network with no balance-billing. These participating dentists have agreed to accept our Plan Allowance as payment in full for your Covered Benefits. This means that you pay your deductible and any co-insurance for Covered Benefits. We pay the dentist directly, so you do not have to pay the whole bill up front and wait for reimbursement.

Of course, as stated earlier, you may select any licensed dentist to provide your dental care. For Covered Benefits provided by non-participating dentists, our payment is based on the Delta Dental PPO Plan Allowance. Non-participating dentists have not agreed to accept our discounted PPO Plan Allowance as payment in full. This means that in addition to what Delta Dental pays, you must pay any deductible and co-insurance. In addition, for a non-participating dentist you must also pay the difference between our non-participating dentist allowance and the charges submitted by this dentist. Therefore, the amount you would owe a non-participating is typically higher than if you chose a Delta Dental PPO or Delta Dental Premier Dentist. If you go to a non-participating dentist, in most cases, we will pay you directly for Covered Benefits unless an assignment of benefits is made with Delta Dental. We pay PPO dentists directly, so you do not have to pay the whole bill up front and wait for reimbursement.

See the illustration below for an example of how payments are made between participating and non-participating dentists.

*The Delta Dental PPO network is not available in all areas. Please consult our website at www.deltadentalva.com and go to the Find a Dentist link for details and to check dentist participation.

Pre-determination of Benefits

Another aspect of Delta Dental’s quality assurance is cost management. It’s a responsibility we have to you, our customer. To fulfill that responsibility, we’re tracking and analyzing costs at every step of the process. Delta Dental’s close relationship with our participating dentists goes along way toward achieving cost-conscious coverage for you.

To assist you in managing your total costs, Delta Dental also offers what’s called “Pre-determination of Benefits”. Dentists may submit their treatment plan to Delta Dental for review and estimation of coverage before procedures are started. Delta Dental advises the patient and the dentist of what services are covered and what the payment would be. The actual payment for these pre-determined services depends on eligibility, any plan limitations, coordination of benefits and the remaining maximum at the time services are performed. A pre-determination plan is subject to change based on the dentist’s participation status at the time of treatment and does not guarantee direct payment. A predetermination plan is valid for 90 days once issued. Of course, pre-determination is optional, but it is strongly recommended for dental services expected to exceed $250. Once the service is completed, the claim should be submitted to Delta Dental for prompt payment.

Notice of Payment

Use this reference to better understand your Notice of Payment (sometimes called an Explanation of Benefits). If you need further explanation, please call our Benefit Services at the toll-free number listed on your ID card.

Filing Claims

Most dentists file claims electronically or have claim forms on hand. If they don’t, you may obtain one by visiting our website at www.deltadentalva.com. In some cases your human resources office may have a supply, or you can call Benefit Services at 800-237-6060 or the toll-free number listed on the bottom of your ID card.

If you use a Delta Dental participating dentist, your claim will be submitted for you. If you visit a non-participating dentist, you may need to submit your own claim. Just follow these easy steps to ensure efficient processing:

Complete your portion of the claim form (Sections 1-17) and present the form to the dentist for completion. If you visit a non-participating dentist you may need to mail your completed claim form to the address below.

Delta Dental will notify you in writing of the amount of benefits which are paid on your behalf and the amount which you must pay. This is called a Explanation of Benefits.

All claims are processed at Delta Dental of Virginia’s headquarters in Roanoke, Virginia. Our mailing address is:
Delta Dental of Virginia
4818 Starkey Road
Roanoke, VA 24018

All claims must be submitted within twelve (12) months of the date services are completed. This is called the timely filing limitation. If the claim is for Orthodontic services, the claim should be filed at the time of the banding. For new enrollee’s who are already in Orthodontic treatment when this coverage becomes effective or after a Benefit Waiting Period (if applicable) is met, should file a claim upon enrollment or once the Benefit Waiting Period has been satisfied.

Complaint and Appeals Procedures

You have the right to file a complaint or appeal a denied claim. Please consult the EOC at the end of this handbook for details.

Coordination of Benefits

If you are covered under another dental plan, Delta Dental will coordinate your Covered Benefits as described in your EOC. Among other things, Coordination of Benefits eliminates duplicate payments for the same Dental or Orthodontic services. Please see the EOC at the end of this handbook for details on the rules regarding which insurance plan would be considered primary and which would be considered secondary for payment purposes.

Common Dental Terminology

Click here for a list of definitions for commonly used dental terms.