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Delta Dental claims and payments

Claims and payments

Everything you need to know about submitting Delta Dental claims.

Claims processing

Everything you need to know about claims and payments. 

Delta Dental Premier® and Delta Dental PPO™ Claims

Mailing addresses for your Delta Dental Premier and Delta Dental PPO claims.

  • Delta Dental of California
    For the state of California

    Delta Dental of California
    PO Box 997330
    Sacramento, CA 95899-7330

  • Delta Dental Insurance Company
    For the states of Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas and Utah

    Delta Dental Insurance Company
    PO Box 1809
    Alpharetta, GA 30023-1809

  • Mid-Atlantic States
    For the states of Delaware, Maryland, New York, Pennsylvania, Washington, D.C., and West Virginia

    Delta Dental
    P.O. Box 2105
    Mechanicsburg, PA 17055.

 


  • DeltaCare® USA Claims

    Mailing addresses for your DeltaCare USA claims.

    DeltaCare USA
    P.O. Box 1810
    Alpharetta, GA 30023

 

  • AARP Dental Insurance Plan Claims

    Mailing addresses for your AARP Dental Insurance Plan claims.

    AARP Dental Insurance Plan c/o Delta Dental Insurance Company
    P.O. Box 2059
    Mechanicsburg, PA 17055-2059

 

Here are some suggestions to speed up claim payments.

Anticipate questions related to policy

Dental consultants look for reasons to approve your claims. Anticipate what questions a dental consultant may have regarding a particular claim and provide the reason it should be paid.

Example: If you replace a crown that is less than five years old, anticipate the obvious question and explain what event or circumstance made the replacement necessary.

Dental consultants are licensed dentists, who share your depth of knowledge about dental treatment and disease. Your knowledge and expertise about dentistry will likely come across clearly if you remember that your audience is a dentist just like you.

Include all patient information on claims

Lack of sufficient information, especially the member’s ID number, is the most common reason for a delayed or denied claim. With electronic claims submission, your claims are automatically edited for missing or invalid information before they are sent to carriers.

Help the dental consultant review your claim

For extensive or unusual services, what would you need to understand why a patient needs a particular treatment? Dental consultants cannot directly observe a patient’s condition, so let them know what cannot be seen on an x-ray and any special circumstances unique to your claim.

Example: If you submit a claim for a crown that was placed to restore a tooth with a fractured cusp, be sure the fractured cusp is visible in the x-ray copy. If it is not, include a written narrative so that the dental consultant will understand the purpose of the crown.

Understand the difference between what is covered and what is needed

Some procedures are not covered under your patient's plan, no matter what documentation is submitted. In such cases, it’s important to understand that a recommended treatment may be perfectly appropriate. It’s just not a payable claim under the terms of the dental benefit contract.

Example: If you provide treatment for erosion, there’s a good chance the claim cannot be paid because erosion is a common exclusion under most dental plans. The same principle applies to treatments that address cosmetic needs rather than dental disease.

Use Provider Tools for free real-time claims with digital attachments and pre-treatment estimates. You’ll see Delta Dental’s payment and the patient portion when the claim or pre-treatment estimate processes, often within moments (when clinical review is not necessary). 

First, log in to Provider Tools. From there, you can transmit claims, digitized attachments and pre-treatment estimates with either of these tools:

  • Submit Claim: transmission is quick and efficient.
  • My Patients: your current patients are listed here and we add new patients as their claims are processed. Patient information is automatically entered on your pre-treatment estimate or claim.

You can also use FastAttach®, a service available through National Electronic Attachment, Inc. (NEA), to electronically transmit digitized x-rays, periodontal charts, Explanation of Benefits documents, photos and narratives.

If you are not submitting claims electronically, talk with your practice management system vendor about activating your system’s electronic claims component.

For full time students, enter the name of the school and the city in which it is located on the claim. If the patient is a dependent with a disability, enter the nature of the disability.

Save time and money while helping the environment by electronically submitting your encounter forms to DeltaCare USA.

  • Saving money by eliminating printing, copying and mailing costs.
  • Saving time by submitting electronic encounter forms daily, which can eliminate the need to spend more time running monthly reports.
  • Receiving prompt notification of any invalid data, allowing you to make the necessary corrections and re-submit right away.
  • Receiving reports of all successfully transmitted encounter forms, reducing follow-up on unpaid submissions.

DeltaCare USA's payer identification number for encounter forms is DDCA3.

For more information about electronic encounter form submission, please email our Encounters department.

When you submit claims as soon as possible after treatment is completed, you help us process claims more efficiently, using the patient’s most current eligibility and benefits to determine payment.

Generally, claims received more than 12 months after the date of treatment may not be paid. However, some programs may require you to submit claims within a shorter period of time (e.g., 90 days for Texas CHIP program). To be sure, please refer to your dentist handbook. If you receive notification that no payment was made because of late submission:

  • The patient is responsible for their coinsurance/copayment portion only. The amount that would have been payable by Delta Dental may not be charged to the patient.
  • If late submission occurred because of extenuating circumstances (for example, the patient did not advise you sooner of the existence of coverage), you may request reevaluation of the decision to disallow payment. Please call or write to our Contact Center (and be sure to include all relevant information).

Payments to professional partnerships

Amounts due from Delta Dental may be paid to your professional corporation, partnership or association. However, you may not assign amounts due from Delta Dental to any other entity, such as an accounts receivable agency. Please make sure we have your correct Tax Identification Number (TIN) on file to facilitate correct payment.

If you have more than one office

Every 12 months you may submit separate Delta Dental Premier® fee updates for each practice location, specialty and TIN. Simply submit a separate Confidential Fee Filing Form for each update. (Note: Fee filings are not used in Texas or by any states administered by Delta Dental of Pennsylvania.)

Learn more:

Your Tax Identification Number (TIN, EIN or SSN). 

Fee discounts (including waiver of copayment/coinsurance) should be reflected in the total fee that is entered on the claim.

Example: If your fee for a service is $100 and you wish to give the patient a 20% discount, then $80 becomes the fee that is actually charged and $80 should be entered on the claim as the total fee.

By entering $80 on the claim, you ensure that Delta Dental calculates its payment based on the fee actually charged, as required under the terms of your agreement with Delta Dental.

Always notify Delta Dental of the actual fee charged. This helps ensure that you don’t contribute to higher costs that can potentially jeopardize patients’ dental benefits plans.

Copayment waiver is when a dentist enters a fee on a claim that includes a copayment that the dentist never intends to collect, which makes the reported fee artificially higher than the dentist's actual fee charged. This causes the dental carrier to cover the patient's share of the fee. Copayment waivers are a form of overbilling the dental carrier.

Example: If a dentist reports a fee for a service as $100, we calculate our payment based on the patient’s dental benefits contract and, for this example, pay $80 (80% benefit, with 20% patient copayment). If the dentist makes no effort to collect the remaining $20 from the patient, then the dentist’s actual fee for the service is $80, not $100. This means Delta Dental has overpaid – we’ve paid 100% of $80 instead of 80% of $80.

Waiving copayments violates the contracted dentist’s participation agreement with Delta Dental as well as the patient’s dental benefits contract. This can jeopardize the stability of the patient’s dental coverage by driving up costs because we assume the overbilled fee to be accurate, then base our premiums on inflated dental costs. When premiums increase, groups may consider dropping dental benefits altogether. Delta Dental may also terminate the dentist’s participation agreement if a dentist regularly waives patient copayments.

To avoid overbilling, always make reasonable efforts to collect patient coinsurance/copayments. Reasonable efforts include:

  • Payment plans: Making arrangements with patients for monthly payments, for example, or offering the option to pay by credit card.
  • Billing statements: Mailing monthly reminders of the balance and the minimum amount due.
  • Collections: Forwarding large, uncollectable balances to a professional collection agency.
  • Discontinuing the relationship with a patient who will not make reasonable efforts to pay his or her portion.

Maximum contract allowances are the total reimbursement amounts, under the member's benefit plan, on which Delta Dental calculates its payment and the patient’s financial obligation. 

Example: If the dentist submits a fee on a claim for $120, and the maximum contract allowance is $100, Delta Dental will calculate its payment and the patient’s payment based on $100.

How maximum contract allowances are determined

  • Depending on the state, maximum contract allowances are derived from a variety of factors, including data from fees on claims, fee filings submitted by dentists (not applicable for Delta Dental of Pennsylvania), current economic factors and/or other data.
  • Allowances will differ depending on the type of plan. For example, allowances for Delta Dental PPO™ are different in most cases from those for the Delta Dental Premier® plan.
  • Maximum contract allowances will differ by 5-digit ZIP code. However, contracted Delta Dental dentists may not charge their Delta Dental patients more than the amount determined by Delta Dental to be the patient’s portion.

How maximum contract allowances are updated

Delta Dental reviews allowances on an ongoing basis. We update them regularly, usually every 6 to 24 months. These updates are required to be filed first for approval by state regulatory agencies in many locales.

For DeltaCare® USA, maximum contract allowances are not applicable. Members have a fixed copayment for all covered services and cannot be balance billed.

If you do not agree with Delta Dental’s determination of benefits, and you have additional information to provide, you may request reevaluation by submitting:

  • Your reason for requesting reevaluation
  • A copy of the claim detail section of the Delta Dental payment summary or the pre-treatment estimate
  • Copies of x-rays, photos and/or clinical comments

Mail this information to the Delta Dental member company that originally processed the claim or pre-treatment estimate. Generally, Delta Dental allows one reevaluation per claim.

Need to make an adjustment on a claim? You can submit a request for a claim adjustment. Simply log in to Provider Tools and select "My claims." Locate your processed claims by entering your claim number and selecting "Search."

Find the claim number you wish to adjust and choose "Submit a request" in the Claim adjustment section. This will lead you to the claim adjustment form, where you can indicate the issue(s) that needs to be addressed with your claim, provide necessary details and upload supporting documentation. 

Once you submit your claim adjustment request, it can take up to 21 calendar days for it to process. 

Delta Dental and its affiliate companies use MetaVance Benefit Administration Software as the claims editing software product to provide timely and efficient adjudication for dental claims. This software helps our enterprise streamline many interrelated systems and processes, as well as increase functionality for the benefit of our dentists, members and clients.

Use these tips for clear, complete paper claims that will move smoothly through our system.

Completing your claim

  • Thoroughly complete the claim with clear, legible information.
  • Do not use patients’ nicknames.
  • Document exceptional or unusual circumstances only in the “Remarks” or “Comments” field of the claim. Better yet, send the documentation on a separate attachment (8.5 x 11 inch paper) or transmit it digitally(submit digitized attachments free with Provider Tools; use the “Submit Claim” or “My Patients” tool).
  • Indicate a quantity (the number of x-rays, for example) in the field on the claim specifically for this purpose. If the claim does not have this field, please list each item on a separate line.
  • Be sure to enter the treating dentist’s license number or National Provider Identifier (NPI). If you enter two NPIs (one for the treating dentist and another for the billing entity), please verify that they are both valid.

Use these tips for clear, complete paper claims that will move smoothly through our system.

Do use:

  • A laser printer with black ink.
  • A 10-point font and all capital letters.
  • Six-digit dates with no spaces, slashes or dashes (for example, 120320 for December 3, 2020).
  • Standard size paper (8.5 x 11 inch) for claims and written documentation.
  • Fees with decimal points (for example, 100.00; not 100).

Avoid

  • Free-form text — use the “Tooth number or letter” field to indicate quadrant or arch (e.g., UR or L) and the “Remarks” box for necessary comments or notes.
  • Stray marks in spaces that should be left blank.
  • Ditto marks or arrows to indicate duplicate information.
  • Slashed zeros and crossed sevens.
  • Writing on top of lines or outside of boxes.
  • Using correction fluid or a highlighter pen.
  • More than one font style on a claim.
  • Photocopied claims that are blurred or skewed.

National Provider Identifier (NPI)

Your National Provider Identifier (NPI) is an important number for all providers to have in order to successfully submit claims with Delta Dental. Here's what you need to know about NPIs. 

Delta Dental recommends that all dentists obtain and use a National Provider Identifier (NPI). This is a 10-digit random number unique to each health care provider or organization.

Who needs an NPI?

Every health care provider transmitting health information in connection with a standard transaction in electronic form must obtain an NPI. An NPI is required by the federal Health Insurance Portability and Accountability Act (HIPAA) for electronic transactions.

All individual health care providers (including dentists) and organizations such as clinics and group practices are eligible to obtain an NPI.

If you answer “yes” to any one of the following questions, you are considered a “covered entity” under the NPI standard and are required by federal law to obtain an NPI.

  • Do you submit claims electronically?
  • Do you use a clearinghouse?
  • Do you submit claims attachments electronically?
  • Do you use the Internet to obtain eligibility and benefits information or check on the status of claims?

Benefits of an NPI

  • Eliminates the need to maintain and match identification numbers to specific payers for transactions
  • Allows you to relocate your practice or change specialties without requiring new identifiers from multiple payers
  • Helps reduce costs and simplify health care transactions
  • Contributes to more efficient coordination of benefits

The federal Health Insurance Portability and Accountability Act (HIPAA) requires you to obtain an NPI if you submit claims electronically or if you check claims status or access patient eligibility and benefits information online. However, some health plans may choose to require NPIs on all transactions.

Obtaining your NPI is simple and once obtained, it stays with you for life. To obtain your NPI, simply go to the National Plan and Provider Enumeration System (NPPES) and follow the instructions to complete the application.

There are two types of NPIs:

  • Type 1 is for individual health care providers, such as dentists and hygienists. This is the only type of NPI you will need if you receive payments in your name or under your social security number as a solo practitioner. For practices with multiple dentists, obtain a Type 1 NPI for each dentist.
  • Type 2 is for incorporated businesses, such as group practices and clinics. This also includes entities paid under their business or corporate name, or under their employer identification number (EIN).

How to tell which NPI you need:

  • Solo practitioner: Type 1 only, if claims are transmitted in the dentist's name and social security number.
  • Individual dentist at one practice location: Type 1 for the dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and Tax Identification Number (TIN).
  • Multiple dentists, one practice location: Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN.
  • Multiple dentists, multiple practices: Type 1 for each dentist and Type 2 for each practice with a separate TIN.

On claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the dentist who provided the treatment.

Example:
On a standard ADA Dental Claim Form (#J400), the treating dentist’s NPI is entered in field 54 and the billing entity’s NPI is entered in field 49.

Applying for an NPI is a simple process:

  1. Visit https://nppes.cms.hhs.gov
  2. Complete the application and follow instructions to submit either online or by mail. Faxes are not accepted.
  3. After confirmation of the receipt of your application, you should receive your NPI via e-mail within one to five business days if you submitted the application online. Mailed applications may require up to 20 days to process.

If any data related to your NPI changes (name, address, etc.), you are responsible for submitting an update to the NPPES within 30 days of the change.

If you need help with your application

The NPI Enumerator will help you with your NPI application and to update your information in the NPPES.

Contact the NPI Enumerator:

E-mail: customerservice@npienumerator.com

Telephone: 800-465-3203 / 800-692-2326 (NPI TTY)

Mail: NPI Enumerator
         P.O. Box 6059
         Fargo, ND 58108-6059

Additional information about NPIs

The information provided here is for educational purposes only and should not be interpreted as legal advice. Dentists are encouraged to seek their own legal advice about how the NPI pertains to their practices and circumstances.

Please register your NPI with Delta Dental by providing us with a copy of the confirmation containing your NPI that you receive from the National Plan & Provider Enumeration System (NPPES). Send it to your local Delta Dental by e-mail, fax or U.S. mail:

California:

E-mail: dentist_services@delta.org
U. S. Mail: Delta Dental of California, ATTN: Provider Onboarding, P.O. Box 997330, Sacramento, CA 95899-7330

Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas, Utah and U.S. Virgin Islands:

E-mail: ProfessionalServices@ddic.delta.org
U. S. Mail: Delta Dental Insurance Company, ATTN: Provider Onboarding, P.O. Box 1826, Alpharetta, GA 30023

Delaware, District of Columbia, Maryland, New York, Pennsylvania and West Virginia:

E-mail: ddpdentist_services@deltadentalpa.org
Fax: 717-774-1770
U. S. Mail: Delta Dental of Pennsylvania, ATTN: Provider Onboarding, P.O. Box 2106, Mechanicsburg, PA 17055

For other Delta Dental member companies, please check how they prefer to register your NPI. Simply submitting it on a claim will not ensure that it's entered into the Delta Dental system.

  • Once you’ve registered your NPI with Delta Dental, you should begin using it on claims. Delta Dental recommends that the NPI be used on all claims.
  • Enter the NPI of the billing dentist or dental entity, as well as the treating dentist’s NPI (if they are different).
  • Use new claim forms that accommodate the NPI by providing a specific space for it. (This might require you to upgrade your software.)

If you don’t conduct any electronic transactions governed by HIPAA, you aren’t required to obtain an NPI. However, we strongly encourage you to get one, because you can use it as a single unique identifier with all payers.

The NPI replaces other identifying numbers used in electronic transactions, such as:

  • Medicaid
  • Blue Cross and Blue Shield
  • UPIN
  • CHAMPUS
  • Certain other legacy numbers

The NPI will not replace these numbers, which are used for purposes other than general identification:

  • Social Security
  • DEA
  • Taxpayer Identification
  • Taxonomy
  • Your state license

NPIs are issued by the National Plan & Provider Enumeration System (NPPES). The NPI contains no embedded intelligence – no coding that would identify the dentist’s state or license number, for example. It is simply a random number that does not expire.

Dual coverage

Dual coverage refers to when a patient's dental treatment is covered by more than one dental benefits plan. Coordination of benefits is the process insurance companies follow to ensure that the combined benefits from all group dental plans do not exceed 100% of the dentist’s fee.

Be sure to include the following information on dual coverage claims:

  • ID numbers for both covered members
  • Patient’s relationship to each member
  • Birth date for the patient and each member
  • If parents are divorced, the parent with whom the child lives
  • When Delta Dental is the secondary carrier, Explanation of Benefits (EOB) from the primary carrier

For adults, the member's plan through his or her employment is primary. A spouse or domestic partner’s plan is secondary.

In less common situations, a member may have two plans, such as a plan through current employment and a retiree plan. In this case, generally, the plan through current employment is primary. If the member has two plans through current employment at two jobs, then the plan that has been in effect the longest is usually primary. However, specific plan provisions may dictate differently how dual coverage will be determined, so it is a good idea to check the member's Evidence of Coverage for details.

Example dual coverage scenarios:

  • A full time job and a part time job: Coverage through the full time job is primary.
  • Two jobs or two retiree plans: The plan that has covered the employee longest is primary.
  • A retiree plan and a spouse’s active plan: Usually, the patient’s retiree plan is primary (a person’s own coverage is primary for himself/herself); however, check the Evidence of Coverage for the retiree plan – there may be a provision making it secondary to an active plan.
  • A current spouse and an ex-spouse: The current spouse’s coverage is primary (unless a court order makes the ex-spouse’s plan primary).

Coverage received as an active employee is primary. For example, if a retiree is employed, the “active” coverage is primary; the coverage resulting from retirement is secondary. However, there are exceptions, such as the TRICARE Retiree Dental Program (TRDP), a federal plan that follows the effective date rule. When a patient has coverage through TRDP and another dental plan, the plan that has covered the member the longest is considered primary.

If a court order makes one parent more financially responsible, that parent provides primary coverage. Otherwise, the natural parent the child lives with provides primary coverage. In joint custody cases, the parent
whose birth date is earlier in the year provides primary coverage. When children are covered through remarriages/domestic partnerships, coverage is determined in this order:

  • Primary coverage: natural parent the child lives with
  • Second: natural parent’s spouse/domestic partner
  • Third: non-custodial natural parent
  • Fourth: non-custodial natural parent’s spouse/domestic partner

In the case of coverage through stepparents only: The stepparent the child lives with provides primary coverage. For joint custody, the plan that has covered either stepparent longest provides primary coverage.

Example:

If the father’s birth date is 10/3/67 and the mother’s birth date is 5/15/68, then the mother’s coverage is primary.

A medical plan may be primary when an accident has caused the need for dental treatment (such as a broken tooth resulting from a fall or a car accident). Also, medical coverage would be primary if the group dental plan contract indicates that specific oral procedures are covered (such as a biopsy, oral surgery provided by a physician or dental treatment provided in a hospital). Checking the patient’s Evidence of Coverage for both plans will help you determine when a medical plan is primary.

A patient may have dual coverage through the same Delta Dental company (for example, your patient may have her own Delta Dental of California coverage and also be covered as a spouse through her husband’s plan, which is also a Delta Dental of California plan).

When this occurs, please submit only one claim to the Delta Dental company. Delta Dental will process the primary benefits, even if processing the secondary coverage must be delayed (for lack of eligibility data, for example). There is no need to resubmit the claim. You will be notified separately when processing of secondary coverage is completed.

Be sure to regularly review and update your patients’ dual coverage status. Patients may change their coverage, usually in the fall or spring, during their open enrollment periods.

It is a good idea to let us know when a patient no longer has dual coverage. You can ask the patient to advise us by calling our Customer Service department, or you can send a copy of the notice from the patient’s former carrier that includes this information.

Be sure to submit dual coverage information on claims for orthodontic procedures, even if the other insurance does not cover orthodontics. This is important because some services may be included in the patient’s basic coverage, even if the patient does not have specific orthodontic coverage. Also, this will help ensure that Delta Dental’s calculation of the patient’s portion takes into account all available benefit information.

When Delta Dental of California is the secondary carrier and is subject to the provisions of the California Health and Safety Code §1374.19, we pay the lesser of: (1) the amount we would have paid in the absence of any other dental benefit coverage; or (2) the member's out-of-pocket cost payable under the primary plan for benefits that are covered by the secondary plan.

Please indicate the total amount paid by the primary carrier on the face of a paper claim or in the comments/notes section of an electronic claim and attach a copy of the Explanation of Benefits from the primary carrier.

The combined payments by all plans may not exceed the total fee for the treatment. If you or the patient receives more than 100 percent of the fee, the amount in excess should be refunded to the secondary carrier.

Some Delta Dental groups that are not subject to the provisions of California Health and Safety Code §1374.19 have a non-duplication of benefits clause in their contract.

Such clauses means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.

For example, if both the primary and secondary carrier pay for the service at 80% level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50% of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80% - $50 = $14).

Pre-treatment estimates

Use Provider Tools to avoid surprises with a free, real-time pre-treatment estimate. Pre-treatment estimates are especially beneficial when expensive or extensive treatment is being considered and/or dental plan annual maximum, limitations and/or exclusions may affect coverage.

Before you start treatment, log in to your Provider Tools account and use the Submit Claim or My Patients tools to request a pre-treatment estimate. Pre-treatment estimates often process within moments (when clinical review isn’t required), so you can talk with your patients about treatment plans while they are still in your office. Pre-treatment estimates tell you about:

  • Contractual limitations or exclusions that apply to your treatment plan
  • Delta Dental’s estimated payment amount
  • The patient’s estimated payment portion

Advantages

  • Determine how best to plan treatment; for example, treatment may be done in segments, over weeks, months or years, to incorporate all available benefits
  • Develop a payment plan for the patient, taking into account what Delta Dental is expected to pay
  • Receive email notifications when new documents are available to review online (when you sign up to go paperless).

Log in to your Provider Tools account and select the My Patients tool or the Submit claim tool.

To use My Patients:

  • First, select the patient. Then, select the Submit Claim icon under Actions.
  • Next, under Type of Transaction, choose Pre-Treatment Estimate.
  • Complete the claim information, select Continue, then Submit Claim.

To use Submit Claim:

  • Enter your patient’s name and choose Existing (or enter a new patient’s information).
  • Select the patient, then select the Submit Claim icon in the Actions menu.
  • Next, in the Type of Transaction menu, choose Pre-Treatment Estimate.
  • Complete the claim information, select Continue, then Submit Claim.

Use the My Claims tool to see Delta Dental’s estimated payment and the patient’s portion (often within moments when clinical review is not necessary).

Or, you may mail a paper claim to Delta Dental. Include all required x-rays, documentation and/or written narratives. You will receive by mail a pre-treatment estimate showing the amount Delta Dental is estimated to pay and the amount of the patient’s responsibility. Unfortunately, we cannot provide pre-treatment estimates by telephone.

Keep in mind, a pre-treatment estimate is not a guarantee of payment and it does not check the patient’s:

  • Eligibility (until the date of service)
  • Incentive levels
  • Maximum or deductible
  • Any additional coverage that may apply

At any time, you can review the patient’s current eligibility and benefits information, including remaining maximum and deductible amounts. Simply log in to your Provider Tools account (or register if you have not already done so) and use the Eligibility and Benefits tool.

When the services are complete and a claim is received for payment, Delta Dental will calculate its payment based on the member's current eligibility, amount remaining in his/her annual maximum and any deductible requirements.

Orthodontics claims

Delta Dental’s allowance for orthodontic procedures includes all appliances, adjustments, insertion, removal and post-treatment stabilization (retention). Please don’t send claims for monthly orthodontic visits. To make it easier for you, your fees for these visits are included in the total fee you submit on the claim for banding and in the periodic payments you automatically receive from Delta Dental.

Be sure to include:

  • Banding date.
  • Estimated treatment length.
  • Amount of down payment.
  • Dual coverage information, including the amount payable by the prime carrier.
  • Monthly payment amount.
  • Appliance name used to control harmful habit.
  • Description of service.
  • Indication if this is an initial claim or a transfer case.
  • Description of any treatment prior to this claim (including treatment outside of Delta Dental coverage).

Dual coverage

When Delta Dental is secondary in dual coverage cases, please include the primary coverage’s total liability including copayment/coinsurance percentage and the explanation of benefits (EOB).

Work-in-progress

Include the amount paid by the previous carrier on the claim.

Charges for clear aligners (e.g., Invisalign®, SureSmile®) should be submitted using the appropriate orthodontic procedure code (D8010-D8090). The benefit is based on the approved fee for conventional orthodontics. Any additional fee for the nontraditional method is not billable to the patient.

X-rays and other documentation

Dual coverage refers to when a patient's dental treatment is covered by more than one dental benefits plan. Coordination of benefits is the process insurance companies follow to ensure that the combined benefits from all group dental plans do not exceed 100% of the dentist’s fee.

Most of the claims we get don't need documentation, but for some procedures, supporting documentation such as x-rays or charts help us determine if treatment is covered under the patient's benefit plan.

For example, a consultant reviews a preoperative x-ray when a claim is received for a cast restoration to see if the contractual criterion has been met for coverage. That so much tooth structure has been lost from caries or fracture that a direct amalgam or resin restoration would not be an adequate restoration.

During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and/or documentation for procedures that otherwise may be identified as not requiring the submission of documentation.

These guidelines apply to your Delta Dental Premier and Delta Dental PPO patients with coverage through or administered by Delta Dental Insurance Company (Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas and Utah) and Delta Dental of California, Delta Dental of Delaware, Delta Dental of the District of Columbia, Delta Dental of New York, Delta Dental of Pennsylvania/ Maryland and Delta Dental of West Virginia.

Current Dental Terminology (CDT) © American Dental Association (ADA). All rights reserved.

X-rays only need to be included for the following procedures:

Restorative

  • (D2710 - D2794) Crowns – laboratory processed
  • (D2950) Core buildup, including any pins

Implant services

  • (D6055 - D6077) Implant supported prosthetics

Prosthodontics, fixed

  • (D6710 - D6794) Fixed partial denture retainers – crowns

Periodontal charting is necessary for osseous and other periodontal surgery procedures in these procedure codes:

  • D4210 - D4212
  • D4240 - D4245
  • D4260 - D4278
  • D4381

A copy of the pathology report is needed for hard and soft tissue biopsies:

  • D7285 - D7286

Please submit the operative and pathology reports for the following procedures:

  • D7410 - D7415
  • D7440 - D7461
  • D7465

A copy of the operative report is needed for procedures:

  • D7490 - D7521
  • D7610 - D7780
  • D7910 - D7912
  • D7980 - D7983 and D7998

Narratives need to be included for procedures: D2950, D2980 (with copy of lab bill), D4249, D4320, D4321, D4920, D5620, D7260, D7530, D7540, D8210, D8680 and D9930 as well as any exceptional cases and the unspecified codes in all categories of service (D##99). Enter the information in the “Remarks” or “Comments” field.

You no longer need to send us paper claims just because you need to send an attachment. Use your FastAttach™ connection, a service available through NEA, to electronically transmit digitized x-rays, narratives, intra-oral pictures, Explanation of Benefits (EOB) Statements or any other document needed to adjudicate the claim.