Dentist FAQs

For Delta Dental PPO™ and Delta Dental Premier® networks:
Request a network participation packet or email providerconcierge@delta.org. Learn more about Delta Dental PPO and Delta Dental Premier.

For DeltaCare® USA networks:
Request a network participation packet or email:

PR-DCUSA-West@delta.org (for AK, AR, AZ, CA, CO, HI, IA, ID, KS, LA, MO, MT, ND, NE, NM, NV, OK, OR, SD, TX, UT, WA, WY)

PR-DCUSA-East@delta.org (for AL, CT, DC, DE, FL, GA, IL, IN, KY, MA, MD, ME, MI, MN, MS, NC, NH, NJ, NY, OH, PA, RI, SC, TN, VA, VT, WI, WV)

Medicare Advantage network:

Email: medadv@delta.org

Yes, by signing a Delta Dental Participating Provider Agreement with your local Delta Dental, your participation is honored throughout the national Delta Dental system.

Please keep in mind that patient claims must be submitted to the appropriate Delta Dental company for processing. You can determine eligibility for all Delta Dental enrollees by logging in to Provider Tools.

Delta Dental focuses on getting patients into your office as an essential part of achieving and maintaining good oral health.

Other advantages include:
 

• Exposure to the nation's largest dental insurance customer base.
• A listing in our national dentist directory, where patients have an incentive to visit an in-network dentist.
• Easy administration, including a local presence and provider relations teams.
• As a Delta Dental dentist, you’ll be paid directly when treating Delta Dental patients.
• Quick, accurate claims processing—so you'll be paid promptly and easily.
  

1. Log in and select Eligibility & Benefits. Enter the patient’s name and choose Existing or New.

For new patients you now have two new search options:

• First and Last name and date of birth
• Member ID and date of birth
   

2. Link to more details
Use the links in the left-hand menu to quickly access:
 

• Payer ID Claims mailing address
• Benefit Details: Get benefit levels for procedures by category, such as Preventive, Restorative, Endodontics, etc.

Benefit Search: Enter up to ten procedure codes, keyword or tooth number for more specific information. Treatment History: Review benefit limitations and dates of service from claims we’ve paid from any dentist.

3. Or click on My Patients
After logging in, select My Patients for a list of your existing patients. Under Actions, select the Eligibility & Benefits link to view that patient’s Eligibility & Benefits summary.

Our automated voice response telephone service is a convenient way to obtain eligibility and benefits information and more for your Delta Dental PPO™, Delta Dental Premier® and DeltaCare® USA patients.

Some tips for using the service:
 

• Use the service during business hours, as well as extended hours during the week and on weekends.
• Before you call, have all of the following items ready:
• Your tax ID number (TIN) that is on file with Delta Dental
• The subscriber's ID number and date of birth and the patient's date of birth (the ID may be the subscriber's social security number or another number, such as an employee ID or alternate ID assigned by the subscriber's employer)
• Your fax number, if you will be requesting a faxed summary
• Return to the main menu any time by pressing "9".
• Move quickly through the system. As soon as you know your response choice to the automated question, you may say or enter it. You don't need to wait until all options are offered.
• Say "claim status" for the amount Delta Dental paid on a specific claim.
• Say "claim details" for the amount Delta Dental paid per procedure.
• To hear the benefit summary, stay on the line after eligibility is played, or just press pound (#).
  

Fast Fax is an eligibility and benefits summary that is faxed to your office. Follow the steps on this PDF to use the automated telephone service and obtain Fast Fax.

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).
  
  

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.
  
  

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).

The patient will be displayed twice, with primary coverage first (when both coverages are within our group of Delta Dental companies).

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 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

Stay connected with Provider Tools, a one-stop shop that allows you to access eligibility and benefits information, remaining maximum and deductible amounts, claim submission with attachments, claim status, treatment history and more.

Learn more about Provider Tools

Provider Tools allows to you access the following tools and information:

• My Patients: A comprehensive list of your Delta Dental patients for whom you’ve submitted claims.
• Submit Claim: Free, real-time claim and pretreatment estimate submission. Upload attachments at no charge. See Delta Dental’s payment and the patient’s payment portion often within moments (for claims that don’t require clinical review).
• National Search: Find a patient's eligibility, benefits and claims history from any of the 39 Delta Dental member companies.
• Reference Library: Access your Dentist Handbook and other resources to help answer all your questions.
• EFT and ERA: Sign up for direct deposit (electronic funds transfer/EFT) of all your Delta Dental payments. You can also sign up for electronic remittance advice (ERA).
• Perks at Work: Discounts and special offers on products and services for Delta Dental PPO™ and DeltaCare® USA dentists.
• Eligibility & Benefits: Summaries and benefit details per procedure for the network(s) in which you participate. Obtain this information through My Patients, too, for your established patients.
• My Claims: Your electronic and paper claims from receipt to completion.
• My Documents: Review your claim statements (including details of each processed claim) and pre-treatment estimates.
• My Profile: Go paperless by selecting "Online with email alerts" in the Preferences menu within your profile.
• Treatment History: Procedures provided for your patients from claims we’ve processed from any dentist.
• My Payments: Your Delta Dental payments (direct deposit and/or paper checks), listed by payment date. See whether the payment has cleared your account or is outstanding.
   

Learn more about Provider Tools

Registering for Provider Tools is a simple process. Here's how to get started:

1. Register for your Provider Tools account. Make sure to enter the information that matches what we have on file for your practice:

• Dentist's first and last names
• Dentist's taxpayer identification number (TIN), without hyphens or spaces
• Practice's five-digit ZIP code
• Dentist's license number (without leading zeros, if any). In addition, your National Provider Identifier (NPI) must be registered with us.

2. Log in for immediate access to certain Provider Tools. From the Authorization Code page, select Continue to use My Account, My Claim Documents and Reference Library right away.

3. Activate for access to all Provider Tools. After registration, an email will be sent to the practice location's email on file containing an authorization code. As soon as you receive it, log in and enter the code using uppercase letters. A letter containing the authorization code will also be sent in the mail to the practice location.

Don't forget to have each user in your practice register separately. Any person authorized by the dentist may register for Provider Tools. We encourage each person to register separately so that if someone leaves the practice, that person’s username and password can be deleted while leaving the others intact and usable.

Enter the following information, which must match our records exactly:
 

• The dentist’s first and last names
• The dentist’s tax identification number (TIN), without hyphens or spaces
• The practice’s five-digit ZIP code
• The dentist’s license number (letters or preceding zeros are usually not included). In addition, your National Provider Identifier (NPI) must be registered with us.
  

Any person authorized by the dentist may register. We encourage each person to register separately so that if someone leaves the practice, that person’s username and password can be deleted while leaving the others intact and usable.

Provider Tools works best with current versions of Internet Explorer, Chrome, Firefox and Safari (be sure to keep your browser updated.)

Generally, your online account access will expire in 30 minutes. You’ll receive a warning message two minutes before this occurs, asking you to select OK to continue. If your session expires, you’ll be redirected to our website to log in again.

Yes, by using the Eligibility & Benefits tool. First, verify the patient’s eligibility. Then, select the option to add the patient. You can submit a real-time claim or pre-treatment estimate for patients using the link in the My Patients tool.

Apply online at the National Plan & Provider Enumeration System (NPPES) website. When you receive a confirmation from the NPPES containing your NPI (National Provider Identifier), please email it to us at npi@delta.org (It is not enough to simply use your NPI on claims — we must be notified separately).

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.

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.

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.
  

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.

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).
  

On average, claims that are adjudicated automatically will be processed in less than three business days from the date the claim is received. However, claims that require reviews by a claim examiner or dental consultant, as well as adjusted claims, may take longer.

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.

For x-rays and some other procedures, you’ll need to include specific documentation when you submit the claim. Find a list of procedures that require additional documentation on the Claims and payments page. Be sure to follow all requirements for submitting the documentation.

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 select 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.

Up to five attachments per claim or pre-treatment estimate. The total size limit for all attachments combined is 5 MB. The file types that may be attached are PDF, JPG, GIF and TIF.

Submitting a monthly claim for orthodontics is not necessary. Normally, the claim is filed for the entire treatment, and Delta Dental automatically makes a payment each month until the treatment is completed, terminated or the patient is no longer eligible. Contact the patient's Delta Dental with payment questions.

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.

You will not see this type of adjustment in the payment’s list but you will find it on your claim statement using the My Claim Documents tool.

A 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.

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.

Electronic funds transfer (EFT) functions like direct deposit and allows payments to be deposited directly into your bank account. This offers more security and quicker access to your funds. In addition, claim payment details and pre-treatment estimates are safely stored and accessible online. You can enroll in direct deposit by logging in to your Provider Tools account.

Direct deposit (EFT) is available to any dentist who receives payments from our group of Delta Dental companies. ERA (Electronic Remittance Advice) is available if you use a clearinghouse to submit claims. To see the list of clearinghouses we work with, review the ERA page.

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
  
  

All payments issued to you by Delta Dental companies will be received when you sign up for Electronic Funds Transfer.

If you suspect that fraud has occurred, contact us. You can remain anonymous.
 

• Call our toll-free hotline: 800-526-1852
• Complete the Fraud Report Form
  

Virtual dentistry visits work on any computer, tablet or phone with a camera and an internet connection.