You can choose any dentist to provide dental services. However, the Dentist you choose will affect the total amount you pay under this policy.
Delta Dental of Virginia (Delta Dental) has a Maximum Plan Allowance (MPA) for benefits, which represents the highest amount Delta Dental will pay for dental procedures. Delta Dental PPOTM and Delta Dental Premier® dentists will not charge you more than the MPA for any covered procedure.
Delta Dental PPO and Delta Dental Premier participating dentists have agreed to accept our MPA as payment in full for your covered benefits. You are responsible for any deductible and/or coinsurance that may apply. You may visit an out-of-network dentist; however, your out-of-pocket costs will likely be higher since the dentist may balance bill you for additional charges above our MPA, in addition to your deductible and coinsurance.
Your total out-of-pocket costs for services rendered to an individual pediatric enrollee from a Delta Dental PPO or Delta Dental Premier provider will not exceed $350 per benefit accumulation period. If there are two or more pediatric enrollees receiving benefits under this policy, the out-of-pocket maximum for those Enrollees will not exceed $700 per benefit accumulation period. Only deductibles and coinsurance paid for pediatric enrollees will count toward the out-of-pocket maximum. Amounts paid for optional procedures, non-covered benefits, balance billing or any amounts paid to non-participating providers do not count toward the out-of-pocket maximum.
To file a claim with us, simply present your identification card to the receptionist at your dentist’s office. Claims should be filed with us within 90 days after you receive dental services or supplies. Dental procedures are considered for benefits if they are incurred during the policy term and a claim is filed within fifteen (15) months from the date of service.
Participating dentists file all claims to us directly; however, some non-participating dentists may not file a claim on your behalf. If that is the case, please mail a copy of the itemized claim form to the following address:
P.O. Box 103
Stevens Point, WI 54481-0103
(Policy management and service for individual coverage is provided by Delta Dental of Wisconsin, Inc.)
You have a grace period of thirty (30) days past the date when your premium is due to pay your subscription charges under the policy. However, if you have received an advance payment of the premium tax credit (“APTC”) and have previously paid at least one month of subscription charges during the coverage year, you have a grace period of ninety (90) days past the date when your premium is due to pay your subscription charges under the policy. If you do not make payment when the grace period expires, Delta Dental will end your policy.
Your policy stays in force during the grace period. If you fail to pay the subscription charges during the grace period, our subsequent acceptance of a payment from you for coverage prior to the coverage expiration date shall reinstate your coverage, but such reinstatement shall not provide coverage for the period between the end of the grace period through the date we accepted your payment. Your policy ends if you have not paid the full amount of the subscription charges due by the end of the grace period.
If you receive an APTC and are subject to a ninety (90) day grace period, Delta Dental will pay claims for covered services rendered to the covered person during the first thirty (30) days of the grace period. Thereafter, Delta Dental may pend claims for covered dental services rendered to the covered person during the remaining sixty (60) days of the grace period. Claims pending is a process by which claims are held (not paid) because a premium payment has not been received.
A retroactive denial is the reversal of a previously paid claim. Through this process the covered person then becomes responsible for payment. Claims may be denied retroactively, even after the covered person has obtained services from the provider or received payment from Delta Dental.
You can limit the possibility of retroactive claim denials by ensuring that:
An overpayment of premium for a month will be automatically applied to the following month’s premium balance. In the event that a covered person terminates coverage, any unused premium will be automatically refunded. To contact Delta Dental regarding overpayments, covered persons may use the following address and telephone number:
PO Box 103
Stevens Point, WI 54481-0103
After an examination, a provider may recommend a treatment plan. If the services involve crowns, fixed bridgework, implants, partial or complete dentures, surgical removal of impacted third molars, or medically-necessary orthodontic services, the covered person should ask the provider to send the treatment plan to Delta Dental. The available coverage will be calculated and printed on a predetermination of benefits form. Copies of the form will be sent to the covered person and the provider.
Predetermination of benefits is required for medically necessary orthodontic services or surgical removal of impacted third molars. If predetermination of benefits is not requested prior to the covered person receiving these services, the claims will be denied and the covered person will be responsible for the charges.
Predetermination of benefits is not required for other services; however, Delta Dental encourages the use of this service as a convenient way to determine what Delta Dental will pay towards the claim, as well as what the covered person will be expected to pay.
Requests for predetermination of benefits forms should be made at least four (4) days prior to the beginning of any treatment plan.
An explanation of benefits (EOB) is a notice that explains the reason(s) for payment or nonpayment of a claim. Delta Dental will send an EOB within thirty (30) days of receipt of the claim unless special circumstances require more time. If a claim is denied because of incomplete information, the EOB will indicate what additional information is needed. The covered person, the person who made the claim or the provider, then has forty-five (45) days to provide Delta Dental with the information requested.
The top portion of EOB contains information such as claim number, subscriber name, subscriber ID#, patient name and date of birth, and the dentist name, along with a customer service phone number, web site address and date.
The middle portion of the EOB contains information related to a particular claim:
The portion of the EOB below this reports the amounts applied to the individual’s benefit year deductible, annual benefit year maximum and the out-of-pocket limit, and reference codes are explained. At the very bottom of the EOB, the covered person’s rights of review and appeal are explained.
For more help with your explanation of benefits, download a guide to your EOB.
Coordination of benefits applies when you have coverage under more than one dental policy. It determines which plan will pay benefits first. Your policy is an individual plan and does not coordinate with other policies, whether a group plan or another individual plan.