SummaHealthDeltaDentalHighPlan
WelcometoDeltaDentalofOhio!
Beginningonyoureffectivedate,youwillbecoveredunderDeltaDentalHighPlanPPOSM(Point-of-Service)andwillhaveaccesstotwoofthenation’slargestnetworksofparticipatingdentists:DeltaDentalPPOSMandDeltaDentalPremier®network.DeltaDentalishonoredthatyouhavechosenus,andwelookforwardtoservingyou.Formoredetails,pleasereviewtheenclosedSummaryofBenefits.
HowcanIsave?
DeltaDentalPPOandDeltaDentalPremierDentists§ Submitsclaimsforyou
§ Onlychargesyouforyourcopaymentanddeductible,ifany;nobalancebilling
§ Out-of-pocketcostsarelikelytobelower
NonparticipatingDentists§ Mayrequireyoutosubmityourownclaims§ Maychargeyouthefullcostofaprocedure§ Mayaskforpaymentinfullupfront
Howwillthedentistreceivepayment?
DeltaDentalPPOandDeltaDentalPremierDentistsPaymentwillbesentdirectlytoyourdentist.
NonparticipatingDentistsYouwillberesponsibleformakingfullpaymenttoyourdentistandthenDeltaDentalwillsendyouthecheckforcoveredservice.
WhatisthedifferencebetweenaDeltaDentalPPOandaDeltaDentalPremierdentist?
Thoughyourbenefitlevelfordentalserviceswillremainthesameregardlessoftheparticipatingstatusofthedentist,yourout-of-pocketcostswilllikelybethelowestifyouuseaDeltaDentalPPOprovider.ThisisbecauseDeltaDentalPPOprovidershaveagreedtoacceptalowerfee(inotherwords,they'veagreedtoalargerclaimdiscount)thanDeltaDentalPremierdentistswouldaccept.Becauseyourcopayments(ifany)arebasedonapercentageofthisfee,thedollaramountofthecopaymentwillbelowerifthedentistacceptsalowerfee.Pleaseseeourattachedpricingsamplesforadetailedexample.
HowcanIfindaparticipatingdentistorfindoutifmydentistparticipates?
Youcanfindparticipatingdentistsbyvisitingourwebsiteatwww.deltadentaloh.comorbycallingDeltaDental’sCustomerServicedepartmentat(800)524-0149.
WhatifmydentistdoesnotparticipateandIwouldlikeDeltaDentaltorecruithim/her?
Ifyourdentistisnotaparticipatingdentistyoucanrequestthatwerecruitthembyvisitingourwebsiteatwww.deltadentaloh.comandcompletingthe“ReferYourDentist”formorbycallingoremailingourCustomerServicedepartment.YoucanalsotalktoyourdentistaboutjoiningaDeltaDentalnetwork.
ShouldItellmydentistmycoveragechanged?
Yes!PleasetellyourdentistthatDeltaDentalofOhioisprovidingyouwithcoverageunderaDeltaDentalPPOplan.Seeenclosedbenefithighlightsforyourdentalplanbenefits.
WherecanIfindinformationaboutmyeligibilityandclaims?
OnceyouareenrolledwithDeltaDental,youcanreviewyoureligibilitystatus,claimsinformation,andbenefitsbyvisitingourConsumerToolkit®atwww.deltadentaloh.com.ThistoolkitwillalsoenableyoutoprintyourownIDcardsandcanprovideyouwithoralhealthtips.
WhatifIaminthemiddleoftreatment?
Weencourageyoutocompletemultiple-stepproceduresinprogress(likecrowns,bridges,ordentures)priortoyoureffectivedatewithDeltaDental.However,DeltaDentalwillcoverservicesthatarecompletedafteryoureffectivedatewhereapplicable.
Tofindaproviderusethecodebelow.
www.deltadentaloh.com
Howwillorthodonticclaimsbeprocessed?
Iforthodontictreatmentiscurrentlyinprogressforyouoroneofyourdependents,pleaseaskyourdentisttosubmitanewtreatmentplantoDeltaDental.Theremainingliabilityoftheclaimwillberecalculatedbasedonthenumberofmonthsleftinthetreatmentplan.DeltaDentalwillalsoreceivetheorthodonticlifetimemaximumhistoryfromyourpreviouscarrier.Yourorthodonticmaximumbenefitavailableunderyournewplanwillbereducedbythebenefitamountusedunderyourpreviousplan.
Whereshouldclaimsbesubmittedforservicesrenderedpriortomyeffectivedate?
Claimsfordentalservicesrenderedpriortoyoureffectivedatemustbesubmittedtoyourpreviousdentalcarriertoreceivereimbursement.
WhatifIhaveotherquestions?
Ifyouhaveotherquestionsaboutyourdentalbenefits,pleasecontactDeltaDental’sCustomerServicedepartmentat(800)524-0149.
PricingExampleDeltaDentalHighPlanPPO(PointofService)
DeltaDentalPPODentist1
DeltaDentalPremierDentist2
Out-Of-NetworkDentist3
ADULTCLEANING
Submittedfee: $80.00 $80.00 $80.00MaximumApprovedFee: $54.00 $77.00 $63.00Coveragelevel: 100% 100% 100%AmountDeltaDentalPays: $54.00 $77.00 $63.00AMOUNTYOUPAY: $0.00 $0.00 $17.00
CROWN
Submittedfee: $950.00 $950.00 $950.00MaximumApprovedFee: $675.00 $898.00 $744.00Coveragelevel: 60% 60% 60%AmountDeltaDentalPays: $405.00 $538.80 $446.40AMOUNTYOUPAY: $270.00 $359.20 $503.60
1. ADeltaDentalPPODentistisonewhohasagreedtoaccepttheDeltaDentalPPOFeeScheduleamountaspaymentinfull.TheDeltaDentalPPOFeeScheduleamountisgenerallylowerthantheMaximumApprovedFeeusedforadentistwhoparticipatesinDeltaDentalPremier.
2. TheMaximumApprovedFeeisthemaximumamountDeltaDentalhasapprovedforaspecificprocedureperformedbyaDeltaDentalPremierdentist.DeltaDentalPremierdentistsagreetoacceptthisamountaspaymentinfull.
3. TheNonparticipatingDentistFeeisthemaximumamountDeltaDentalhasapprovedforaspecificprocedureperformedbyadentistwhodoesnotparticipateineitherDeltaDentalPPOorDeltaDentalPremier.
Fordentalservicesrenderedafteryoureffectivedate,yourdentistshouldsendallclaimsto:
DeltaDentalP.O.Box9085
FarmingtonHills,MI48333-9085
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