Small Business Certified Plan ("ACA") Dental Plans

As required by CMS (Centers for Medicare and Medicaid Services), Delta Dental is providing you the following information regarding your dental plan. Should you have any additional questions, please review your policy or contact Delta Dental Customer Service at 1-888-452-9310.

Out-of-Network Liability and Balance Billing

Your policy lets you get dental services from any dentist. However, you will maximize your benefits under the policy and may be able to reduce your out-of-pocket costs if you choose to get services from a Network Dentist. This applies to both adults as well as pediatric enrollees under age 19. Under your policy, a Network Dentist is a Delta Dental PPO^TM Dentist and a Delta Dental Participating Specialist. When you go to a Network Dentist, you may be responsible for payment of a deductible and the coinsurance amount, but the amount of your payment for Covered Services will be limited to the Delta Dental Allowed Amount. For pediatric enrollees under age 19, dental services provided by Network Dentists are subject to a Cost Share Limit, and once the Cost Share Limit has been met, Covered Services are covered at 100% of Delta Dental’s Allowed Amount.

You may also choose to get services from a Non-Network Dentist. Under your policy, a Non-Network Dentist is a Delta Dental Participating Dentist (one who is not a Delta Dental PPO^TM Dentist or a Delta Dental Participating Specialist) or a Non-Participating Dentist (a Dentist who does not have an agreement with Delta Dental). If you go to a Non-Network Dentist, your out-of-pocket costs may be more. This is because a Non-Participating Dentist may balance bill you. Balance billing occurs when a Non-Network Dentist who is a Non-Participating Dentist bills a covered person for charges – other than copayments, coinsurance, or any amounts that may remain on a deductible. When services are received from a Non-Network Dentist who is a Non-Participating Dentist, you may be responsible for making payment directly to the dentist for the difference between the amount approved for the service(s) by Delta Dental and the Delta Dental benefit amount. For Non-Network Dentists that do not participate with Delta Dental, the amount approved by Delta Dental will be the dentist’s actual charge for the services performed.

Your out-of-pocket costs may also be more when a pediatric enrollee under age 19 receives Dental Services from a Non-Network Dentist. This is because the Cost Share Limit applicable to pediatric enrollees does not apply tor services provided by a Non-Network Dentist. This means that if a pediatric enrollee under age 19 goes to a Non-Network Dentist (which could be a Delta Dental Participating Dentist who is not a Delta Dental PPO^TM Dentist or a Delta Dental Participating Specialist or a Non-Participating Dentist who does not have an agreement with Delta Dental), once the Cost Share Limit has been reached, your responsibility to pay deductibles and coinsurance will continue.

Delta Dental offers two ways to help you find a Network Dentist 24 hours a day, 7 days a week. You can either call 1-800-452-9310 or click on "Find a Dentist" at www.deltadentalnj.com. By calling, you can get a customized list of Network Dentists within the area of your request. By searching on the website, you can get a customized list of Network Dentists in a specific town. The list can be downloaded right away and you can search for as many towns as needed. You can get Network Dentist information for any of the 50 states should you need a dentist when you travel outside of New Jersey.

Please refer to your certificate of coverage or your benefit booklet. If you have further questions, contact Delta Dental Customer Service at 1-800-452-9310.

Enrollee Claim Submission

A claim is a request to Delta Dental to pay a benefit under your policy. The following is a description of how a claim should be filed.

In most cases, a Network Dentist will file a claim with Delta Dental on your behalf. The Network Dentist will receive payment directly from Delta Dental. If you visit a Non-Participating Dentist (a dentist who has no agreement with Delta Dental) in New Jersey, the Non-Participating Dentist is required to send the claim for you unless you choose to file the claim yourself. In other states, you may need to send the claim yourself for dental services performed by a Non-Participating Dentist. Claim forms must be sent to:

Delta Dental of New Jersey, Inc.
P.O. Box 16354
Little Rock, AR 72231


Download dental claim form.

In order to receive a benefit, any claim for a dental service must be filed or submitted to Delta Dental within twelve (12) months of the date the dental service was finished. To be entitled to benefits, therefore, you should check your Explanation of Benefits ("EOB") to be sure a claim is submitted to Delta Dental for all dental services that you receive from Non-Network Dentists within twelve (12) months after all dental services are completed. If your claim is not filed or submitted within 12 months after the service was completed, you may be responsible to your dentist for the full cost of the dental service. You are also responsible to your dentist to pay for any dental services finished after termination of your dental coverage.

Retroactive Denials

A retroactive denial is the reversal of a previously paid claim, through which the covered person then becomes responsible for payment. Claims may be denied retroactively, even after the covered person has obtained services from the dentist or received payment from Delta Dental.

For example, if it is determined that an ineligible person is covered under the policy. Delta Dental will pay back any premium charges paid for ineligible persons. However, if Delta Dental paid claims for an ineligible person, the claims will be denied retroactively and the policyholder must pay back Delta Dental for the amount of all claims paid.

Likewise, if the incorrect dental service is submitted on a claim and is subsequently corrected, the correct service submitted may not be covered and result in a retroactive denial of the original claim. Also, Delta Dental pays benefits for covered dental services based on the date the service is completed. If a claim is submitted with a date of service other than the completion date (for example, the tooth preparation date for a crown), Delta Dental may retroactively deny the claim if it is discovered that the date of service does not reflect the completion date. In all such cases, the dentist or policyholder (depending on who received the payment) is responsible to pay back Delta Dental for the amount it paid inappropriately.

You can help to limit the possibility of retroactive claim denials by:

• Ensuring you pay the full amount of your premium charges on time;
• Ensuring that claims submitted by you or your dentist accurately reflect the dental services rendered;
• Ensuring that claims submitted by you or your dentist reflect the date the service was actually completed.

 

Recoupment of Overpayments

Delta Dental has the right to get back any payment made to a covered person, or dentist which is more than the amount the person was entitled to get under this policy or if the payment was made to the wrong payee. Delta Dental may offset any such overpayment against any amount which otherwise is due to you under the policy.

Enrollment and Termination of Coverage

Your employer will provide us with your employment information for you and your eligible dependents. Your dental coverage will begin after you have met all of the eligibility requirements, including any waiting periods. If you have any questions regarding your eligibility or benefits, contact Delta Dental's Customer Service at 1-800-452-9310.

As long as you continue to be eligible for coverage for you and your covered dependents, and your group continues its coverage through Delta Dental, you will be entitled to the dental benefits described in your benefits booklet.

Your dental benefits will end once you are no longer eligible for coverage through the group or either the group or Delta Dental discontinue or terminate the dental plan. Delta Dental has the right to end coverage for any group or persons found to be ineligible for this policy and/or who have submitted claims with false information on purpose.

 

Requirements Applicable to Under Age 19 Pediatric Enrollees - Medical Necessity, Prior Authorization Timeframes and Enrollee Responsibilities

Prior Authorization

Prior Authorization is a determination by Delta Dental as to whether a service recommended for a pediatric enrollee is a covered service by Delta Dental. It responds to a request for approval of dental services as Dentally Necessary or orthodontic services as Medically Necessary Orthodontic Services. Your policy requires that you obtain Prior Authorization for many dental services performed on covered pediatric enrollees. Those services are listed in the appendix to your policy, but can also be found here.

Dentally Necessary or Dental Necessity means dental services that a dentist, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) in accordance with generally accepted standards of dental practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for successfully treating the patient's illness, injury or disease; and (3) not primarily for the convenience of the patient, dentist or other health care provider, and (4) not more costly than an alternative service or sequence of services fulfilling the requirements of the specific situation or the extenuating circumstances as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this definition, generally accepted standards of dental practice means standards that are based on credible scientific evidence published in peer-reviewed dental literature generally recognized by the relevant dental community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.

Services requiring Prior Authorization are reviewed for Dental Necessity, or in the case of comprehensive orthodontic services, Medical Necessity. Delta Dental will pay no benefit for those dental services rendered to pediatric enrollees before you get a Prior Authorization from Delta Dental. You or your dentist must send a request to Delta Dental showing the dental services he or she recommends for the pediatric enrollee. Delta Dental will provide you and your dentist Delta Dental’s decision as to what benefits, if any, it will pay for those services. Requests for Prior Authorization must be sent to:

Delta Dental of New Jersey, Inc.
P.O. Box 16354
Little Rock, AR 72231

Requests for Prior Authorization must include a narrative from the Dentist. That narrative must explain why the dental service is Dentally Necessary. For orthodontic services, that narrative must explain why the orthodontic services are Medically Necessary Orthodontic Services as defined in the policy. Requests for Prior Authorization must include the diagnostics for the Dental Service required by Delta Dental. Those requirements are found at here. Delta Dental may change those requirements, but changes will apply only to requests submitted after the change.

Medically Necessary Orthodontic Services for Covered Children

Medically Necessary Orthodontic Services means comprehensive orthodontic treatment that meets the criteria for Dental Necessity and also meets at least one of the following criteria:

• The pediatric enrollee’s condition necessitates a core of 26 or more points on a correctly scored modified Salzmann Malocclusion Severity Assessment;
• The pediatric enrollee demonstrates that the requested treatment will significantly ameliorate a mental, emotional, or behavioral condition associated with the Covered Person’s dental condition; or
• The pediatric enrollee presents evidence demonstrating severe functional difficulties, developmental anomalies of facial bones and/or oral structures, or facial trauma resulting in severe functional difficulties.

Coverage for orthodontic services, including all specific and general limitations and exclusions, can be found in your policy. Orthodontic services require Prior Authorization. Delta Dental will pay no benefit for those dental services rendered to pediatric enrollees before you get a Prior Authorization from Delta Dental.

 

Pre-Treatment Estimate

A dentist may send a claim to Delta Dental in advance of providing the dental services to show the dental services he or she recommends in order to receive an estimate of the benefits that are available. Delta Dental will then provide an estimate of benefits under your policy. We call this a Pre-Treatment Estimate. The benefit amount for these dental services will depend on your continued eligibility, and any benefit limitations and exclusions (which can be found in your policy). If your dentist suggests the need for dental services which cost more than $300, Delta Dental recommends that you ask for a Pre-Treatment Estimate before receiving the dental services.

Information on Explanation of Benefits ("EOBs")

An Explanation of Benefits is a computer-generated statement from Delta Dental that you will receive after we process a claim for a covered person describing how Delta Dental determined your benefit for the dental services submitted on the claim or telling you the information Delta Dental requires before a benefit determination can be made. It also contains information on how to appeal a benefit determination if the claim is denied or you do not agree with the benefit determination. We will send an Explanation of Benefits within the time and way required by law and/or regulation. A sample Explanation of Benefits with instructions for how to read to understand it can be found here.

Coordination of Benefits

Coordination of Benefits ("COB") applies when you have coverage under more than one dental policy. It determines which plan will pay benefits first.

For example, if you have dental coverage through two dental plans, COB determines which plan is primary and which plan is secondary. The benefits of the primary plan are determined before those of the secondary plan and may be reduced because of the other primary plan's benefits.

If you have any questions regarding COB, your benefits or this notice, contact Delta Dental Customer Service at 1-800-452-9310.