FYI

As a valued participating provider in our DeltaCare USA network, you play a critical role in delivering quality oral health care to our members. While reimbursement under DeltaCare USA plans is based on capitation rather than fee-for-service payments, the submission of encounter claims remains an essential requirement of your participation.

Encounter claims are more than administrative tasks, they are a cornerstone of how we support you, serve your patients and meet contractual and regulatory obligations.
 

Here’s why timely and accurate encounter claim submission is important:

Supports patient grievances and appeals
When a patient raises a concern, files a grievance or submits an appeal, encounter claims are the primary source we rely on to understand the care that was provided.
These claims allow us to:

• Confirm services rendered and dates of treatment
• Validate coverage and benefit application
• Resolve patient concerns accurately and efficiently

Without encounter claims, we may not have the documentation needed to fully support your care decisions or respond effectively on your behalf.

Ensures accurate provider-to-patient assignment
Encounter claims allow us to accurately assign patients to their treating dentists through claim-based adjudication if a patient did not select their preferred dentist via our online portal. This process is critical to:

• Maintaining correct provider-patient relationships
• Ensuring appropriate attribution and payment for care delivered
• Supporting continuity of care and accurate provider records

Consistent encounter submission helps ensure our records reflect the care you provide and the patients you serve.

Improves communication with patients about their care
Encounter claims support clear and transparent communication with patients regarding their dental visits. This information helps us explain:

• What services were provided
• Why the visit occurred
• How the services relate to the patient’s benefits

Accurate encounter data reduces confusion, supports patient understanding and helps minimize follow-up inquiries to your office.
 
Fulfills required part of your Provider Agreement
Submission of encounter claims is a contractual requirement outlined in your provider agreement and provider handbook. This requirement allows us to:

• Maintain accurate utilization and quality reporting
• Ensure compliance across our provider network

Each contracted dentist is required to submit completed encounter data. You may submit your encounter data throughout each day at your convenience, but it should be sent no later than 30 days from the date of service. Please note that encounter forms should not be sent for broken or canceled appointments as you will not be reimbursed for the missed appointment.

Supports quality, reporting and population health
Encounter claims provide essential insight into utilization patterns and care delivery across our patient population. This data allows us to:

• Monitor preventive care and treatment trends
• Identify gaps in care
• Develop programs and initiatives that better support providers and patients

Your participation in encounter reporting directly contributes to improving oral health outcomes across the communities we serve.

Protects providers and reduces future administrative requests
Timely encounter submission creates a complete and reliable record of services rendered. This helps:

• Support providers during audits or reviews
• Reduce requests for retroactive documentation
• Streamline responses to patient or regulatory inquiries
   

Submitting encounters promptly after each visit helps minimize administrative burden over time.

How to submit encounter data:

• Online via Provider Tools: Remember you can submit multiple encounters simultaneously by using the "Submit multiple encounters" option in Provider Tools.
• Clearinghouse: If you currently submit claims through a clearinghouse for other fee-for-service plans, you may want to submit your encounters via a clearinghouse as well. DeltaCare USA’s payer ID for encounters is DDCA3. For this option, check with your current clearinghouse vendor for any associated fees.
• Encounter/universal claim form: You can use a paper encounter form or a universal claim form. Please do not include the encounter itself as a line item on universal claim forms. Also, on universal claims forms, do not list the copayment amount from the patient in the “Fee” column (no fee should be listed).

Encounter claim submission is a shared responsibility and a key component of our DeltaCare USA model. By submitting accurate and timely encounter claims, you help ensure transparency, continuity of care, regulatory compliance and effective communication with patients.

We appreciate your partnership and your continued commitment to providing high-quality dental care.