Out-of-network liability
If an out-of-network dentist charges more than Delta Dental’s allowed amount, the member pays the percentage listed in the policy plus the difference between the submitted and allowed amounts.
If no in-network dentist is available nearby, members may qualify for in-network reimbursement for out-of-network care. Call customer service to discuss options before visiting an out-of-network dentist.
- Customer service for individual plans: 800-971-4108 (TTY users call 711)
- Customer service for group plans: 800-524-0149 (TTY users call 711)
Emergency care from out-of-network dentists is treated as if it was provided by an in-network dentist.
Balance-billing
Balance-billing is when a dentist bills a member for charges other than copayments, coinsurance or any amounts that may remain on a deductible after Delta Dental’s payment on a claim. Our network dentists agree to accept Delta Dental’s contracted fees as full payment and to not bill the member above that amount. Balance-billing is not allowed within the Delta Dental network.
Claim submission
In-network dentist will submit claims on your behalf. Out-of-network visits require self-submission of claims within 12 months of service to:
Delta Dental
PO Box 9085
Farmington Hills, MI 48333-9085
Need a claim form?
- Contact customer service
- Log in to Member Portal
- ADA claim form
Learn more about the Affordable Care Act
ACA basics
Prior authorization is the process through which an issuer approves a request to access a covered benefit before the member accesses the benefit. Delta Dental does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a pre-treatment estimate.
A claim is pending when it has been submitted to Delta Dental and is still being processed by the claims department.
If a member fails to pay the full premium by the due date, a grace period allows extra time to pay without losing coverage.
General grace period (31 days): Applies to members not receiving advance payments of premium tax credit. This means that if a premium, other than the initial premium, is not paid by the date it is due, it can be paid during the 31-day period. Coverage remains active during this period. However, if Delta Dental notifies the member at least 30 days before the due date of its intent not to renew the policy, the grace period does not apply.
Three-month grace period: Applies to members receiving advance payments of premium tax credits who have paid at least one full month’s premium during the benefit year. Coverage remains active during the grace period. If premium payment is not received within the three-month period, coverage will terminate on the last day of the first month of the grace period. Delta Dental will pay claims for services rendered during the first month of the grace period and may pend claims for the second and third months.
Retroactive denial occurs when a previously paid claim is reversed, making the member responsible for payment. This can happen, for example, if a claim is paid during the grace period but the policy was terminated before services were provided.
To help prevent retroactive denials:
- Pay your premium on time (online or by phone)
- Keep your account information up to date
- Confirm coverage before receiving services
To update your account information, visit the Member Portal.
Overpayments are automatically credited toward the next month’s premium. If you prefer a refund, contact customer service at 800-971-4108 (TTY users call 711). Refunds will be issued using the original payment method or by check request.
Essential Health Benefits (EHB) for pediatric oral care services (up to age 19) may limit coverage of certain services, such as orthodontia, to those deemed medically necessary. This means treatment must meet evidence-based clinical standards to be considered an EHB. Since federal law doesn’t define “medically necessary orthodontia,” criteria may vary by state.
Coordination of benefits (COB) ensures that dental expenses are covered appropriately when a person is insured under multiple dental plans. The goal is to avoid paying more than the actual cost of the procedure.
If you or your dependent have coverage under more than one dental plan, benefits will be coordinated according to the rules outlined in your policies.
After you visit your dentist, you will receive an Explanation of Benefits (EOB), which will display the fee your dentist submitted, the amount Delta Dental will cover and the amount you owe for the service. Learn more about your Explanation of Benefits.