This information applies to our standard processing policies and contract coverage for PPO plans and is to be used only as a guide. Your group contract serves as the controlling document of your plan.
Delta Dental's preferred provider organization (PPO) plan is a fee-for-service dental plan that gives members access to network dentists who accept a contracted fee (usually lower than the dentist's normal fee) as payment in full for covered services. Members typically save the most with a Delta Dental PPO network dentist, though they have the freedom and flexibility to visit any licensed dentist.
The plan pays a percentage of the contracted fee — or coinsurance — for covered services, and the member pays the rest. The percentage varies with each category of service (such as diagnostic and preventive, basic and major services). Members may need to satisfy a plan deductible for certain covered services before the plan begins to pay benefits. Members are also responsible for the cost of non-covered services and any amount over a plan maximum.
The plan provides access to two networks:
Dentists in both networks meet our strict quality standards and agree to charge PPO members at lower negotiated rates (contracted fees). Also, when members visit a network dentist, they don't need to submit claim forms or wait for reimbursement.
Dentists in the PPO network can't bill members for amounts over members' share of the coinsurance plus the plan's payment — this is known as balance billing. Premier dentists may be able to balance bill members, depending on your group's plan design. For more details and examples, review our comparison of plan designs (PDF, 97 KB).
If members choose to visit a non–Delta Dental dentist, they're still covered, but they'll usually pay the most out of pocket. That's because these dentists can charge any fee since they haven't agreed to contracted fees. With some plan designs, the coinsurance amount the plan pays for out-of-network services may also be lower, which would mean the member's share is higher.
For covered services performed by a PPO or Premier dentist, members pay their coinsurance directly to the dentist at the time of treatment (they may need to satisfy a deductible first). They do not have to file a claim form.
If members visit a non–Delta Dental dentist, they may be responsible for paying the full amount upfront. They'll need to submit a claim form so they can be reimbursed by Delta Dental for the plan's portion of the bill.
They do not need a dental plan ID card to get care — they can simply provide the information the dental office requests to verify coverage. Members who prefer to have an ID card can log in to their online account and select Get ID card to print it. If they want to add their ID card to their digital wallet, they can download the Dental Dental mobile app.
No, members can log in to their online account on their mobile device's browser to get their plan ID card and find detailed information about their benefits and costs.
If members would like to add their ID card to their phone's wallet, they can download the Delta Dental app from the App Store or Google Play. They can also use the app to find a dentist and get certain benefits information, though this information may not be as detailed as what members can find in their online account.
No. Members can visit any licensed dentist that they choose, without preauthorization or referral. If costly treatment is planned, it's a good idea for the dentist to request a pre-treatment estimate from Delta Dental ahead of time to help the member understand what costs to expect. These estimates are not a guarantee of payment.
Depending on the severity, members experiencing a dental emergency may need to call 911 or go to the emergency room, otherwise they should contact their dental office immediately. If members need to go out of network, they may need to pay upfront and submit a claim for reimbursement. For more information and guidelines about emergency care, members can refer to their policy or plan booklet, or they can call us at 888-335-8227.
Delta Dental offers two different methods for members to receive virtual care.
Visit the member virtual dentistry page for more info.
This information applies to our standard processing policies and contract coverage for DeltaCare USA plans and is to be used only as a guide. Your group contract serves as the controlling document of your plan.
DeltaCare USA is a prepaid, fixed copayment dental plan that features set copayments, no annual deductibles and no maximums for covered benefits. Upon enrollment, members receive a plan booklet with set copayments for covered services. In most states, to receive benefits members must select a primary care dental facility in the DeltaCare USA network².
To receive coverage, members must select a primary care dental facility and visit a general dentist at that facility (except in certain states)². The facility and dentist must be part of the DeltaCare USA network.
If members need care from a specialist, their general dentist must refer them and coordinate their care.
To select or change their dental facility, members should create an account and log in, then choose Select facility. If they already have a facility selected, they'll choose Change facility. They can then search for a facility by ZIP code, enter a facility ID or automatically assign the facility nearest to their home address. For assistance with logging in or to submit their selection by phone, they can contact us.
Facility selections and changes submitted from the first through 15th of the month are effective immediately, and those submitted on or after the 16th of the month are effective on the first of the next month.
Members can also search for a DeltaCare USA general dentist using Find a dentist, but they'll still need to select the dentist's primary care dental facility before they visit the dentist.
At the time of service, members pay the dentist only the listed copayment (found in their online account or plan booklet) for covered services. For covered emergency services (and in certain states²), members who visit an out-of-network dentist may need to pay upfront and submit a claim form to Delta Dental for reimbursement. In most states², for non-covered services or when members don't visit a DeltaCare general dentist at their selected facility, members must pay the full amount and are not reimbursed.
They do not need a plan ID card to get care — they can simply provide the information the dental office requests to verify coverage. Members who prefer to have an ID card can log in to their online account and select Get ID card to print it. If they want to add their ID card to their digital wallet, they can download the Dental Dental mobile app.
No, members can log in to their online account on their mobile device's browser to get their plan ID card, find a dentist or dental facility and get detailed information about their benefits and costs.
If members would like to add their ID card to their phone's wallet, they can download the Delta Dental app from the App Store or Google Play. They can also use the app to get certain benefits information, though the information may not be as detailed as what members can find in their online account. The app also doesn't allow members to select a primary care dental facility.
Yes, with certain restrictions. Benefits provided by a pediatric dentist are generally limited to children through age seven following an attempt by the assigned primary dentist to treat the child. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. Children who qualify to visit a pediatric dentist must have a primary care facility assigned to them, and a DeltaCare general dentist at their selected facility must provide a specialist referral.
Orthodontic coverage varies depending on your group's DeltaCare USA plan, so be sure to review your group contract for details. Specific services covered generally include:
Members are responsible for the listed copayment for each covered service. At the first visit with the orthodontist, the member should obtain a detailed treatment plan that includes procedures and costs.
Treatment for pre-existing conditions, such as extracted teeth, is covered under your DeltaCare USA plan.
Orthodontic treatment in progress may be covered for new DeltaCare USA members if banding has already taken place3. If your plan includes this provision, the previous orthodontist must submit the DeltaCare USA continuous orthodontic coverage form (PDF, 27 KB) to the DeltaCare USA Claims department along with the required supporting documents. (Spanish version of the form: Cobertura continua de ortodoncia con su plan DeltaCare USA (PDF, 36 KB)
Any other dental treatment in progress started before the member joined the DeltaCare USA plan (such as teeth prepared for crowns, root canals and impressions for dentures) is not covered.
Most DeltaCare USA plans include limited coverage for emergency dental care if a member needs to go out of network for immediate care. The member may need to pay upfront and submit a claim for reimbursement. For more information and guidelines about seeking emergency dental care, members can review their Evidence of Coverage or plan booklet, or they can call us at 800-422-4234.
Federal and state laws require groups to notify members about their rights and Delta Dental's privacy practices³. These notices address a variety of potential member questions, including Delta Dental privacy practices, language assistance, grievance (complaint) filings and COBRA rights⁴.
Be sure to share the notices with all members annually and with new members within 30 days of eligibility:
Find resources to help you support your employees who are Delta Dental members.
Delta Dental PPO is underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA – Delta Dental of California; PA, MD – Delta Dental of Pennsylvania; NY – Delta Dental of New York, Inc.; DE – Delta Dental of Delaware, Inc.; WV – Delta Dental of West Virginia, Inc. In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.
DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, MA, ME, MI, MN, NC, ND, NE, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS, MT, TN, WV — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York, Inc.; PA — Delta Dental of Pennsylvania; VA – Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.