Benefit administrator FAQs

Delta Dental PPO™ is one of our five contracted national network-based programs. Participating dentists agree to scheduled fees as payment in full.

As with all of the Delta Dental networks, dentists agree to processing policies and are prohibited from billing and collecting charges in excess of the agreed-upon fee. This plan allows enrolled patients to visit any dentist, but offers additional savings when a patient sees a Delta Dental PPO-network 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:
 

• Delta Dental PPO network: Lowest out-of-pocket costs
• Delta Dental Premier® network: Access to one of the largest dentist networks in the nation (member out-of-pocket costs may be higher)

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.

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 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.

If you're outside of the country and you have a dental emergency, seek treatment immediately. You can visit any licensed dentist for emergency dental services.

You should pay the dentist for the services you receive at your appointment. Ask the dentist for a detailed receipt or billing statement for the services rendered. It should contain the following:
 

• The amount paid in original currency (the currency will be converted into U.S. dollars when the claim is processed)
• A list of all the services and procedures provided, including the teeth treated
• Name and address of your dentist
• Date of service

If possible, have the receipt or billing statement translated into English to facilitate claim processing in a timely matter. As soon as you return to the U.S., submit your claim.

Members can find more information and file an appeal using our online grievance form.

DeltaCare® USA is Delta Dental's national Dental Health Maintenance Organization (DHMO). Enrolled patients must select from the DeltaCare® network of primary care dentists. These dentists manage their patients' comprehensive dental needs, including referrals to specialists, and each dentist receives a monthly capitation amount.

If you have coverage through DeltaCare® USA, our dental health maintenance organization (DHMO) plan, you will need to choose a primary care dentist (general dentist) from our DeltaCare® USA network. Use our Find a Dentist tool to find a DeltaCare® USA dentist near you.

The plan gives you a broad range of coverage with no waiting period, annual maximum or deductible. You'll have a list of copayments for every covered procedure so you know all your costs — for preventive, basic and major services — up front.

Many Delta Dental companies offer printable ID cards on their websites, through the Delta Dental mobile app or by mail. In most cases, you do not need an ID card to visit the dentist. Connect with your Delta Dental to find out more.

If you have a Delta Dental PPO plan, you can visit any licensed dentist. There’s no need to tell us if you decide to change dentists. If you visit a dentist outside of the Delta Dental network, though, you may have to submit claims yourself and pay for care up front.

If you have a DeltaCare USA plan, please call 800-422-4234 or visit your online account to change your primary care dentist. Changes requested between the first and 15th of the month are effective immediately; changes received on or after the 16th of the month will be effective on the first of the next month.

Pediatric dentists are trained two or three years beyond dental school to treat infants, children, and persons with special health care needs. These oral health care providers have specialized training in growth and development, psychology, and behavior management that helps them treat children from infancy through adolescence.

A family or general dentist may recommend a pediatric dentist for a variety of reasons. The child might need extensive or specialized treatment, or the dentist may find children (especially very young ones) difficult to treat. In any event, children should visit a dentist within six months of the eruption of their first tooth and no later than their first birthday.

Dependent children covered under a DeltaCare USA plan have the option to seek dental care from a pediatric dentist through the age of 13, whether or not the child has an assigned general dentist. Referrals to visit a pediatric specialist are not required. If the pediatric dentist determines that additional specialty care is needed, they may refer pediatric patients directly to other specialists, such as an orthodontist. At age 14, covered dependent children must obtain care from their assigned DeltaCare USA general dentist.

The first thing you should do is contact your dentist: they will be able to advise you on what to do. Since you never know when an accident will occur, we recommend reviewing and being familiar with your dental insurance plan, which will have information about how dental emergencies are covered.

You can appeal by calling or writing to us within 60 calendar days after you receive the denial, reduction or failure to pay notice. You must follow up a call with a written appeal.

We will let you know we got your appeal and give you a summary of the process and timetable for resolving the appeal. This will include information on the following:
 

• The time for you to present evidence or testimony and to make legal and factual arguments.
• Your right to request records from the file relating to your appeal. This may include dental records and other evidence used by Delta Dental or its representatives.
• The timetable we will follow until we send the final decision.