Members

Frequently Asked Questions


 


Web Registration

Can I manage my Delta Dental plan online?

Yes, registering to use our online services is fast, secure and the best way to manage your Delta Dental plan. Our web services provide the most immediate access to benefits, eligibility and claims information. Plus, you can sign up to receive e-notifications whenever you have claims activity on your account.

To get started, you’ll need to enter your first and last name, and your Delta Dental identification number as it appears on your ID card. For privacy purposes, we do not accept Social Security numbers as a form of identification. Click here to register.

If you don’t have an ID card, you can provide us with the following information as an alternate registration option:

  • First/last name
  • Date of birth
  • Number of people who are covered on your plan

Please note: Only the Delta Dental policyholder (subscriber) can register, and only one registration is allowed per subscriber ID number.

What type of browser do I need to view my account?
Our online services are compatible with multiple browser platforms, including: Internet Explorer versions 9, 10 and 11, Safari, Chrome and Firefox. We recommend using the latest version of your browser to get the most from our website features.

I lost my password/username. How can I access my online account?

Our web self-service feature allows you to quickly reset your password and/or username. Just click on the “Forgot username” or “Forgot password” link on the log-in page and follow the instructions.


Eligibility

Who is eligible under my dental plan?

Your employer determines eligibility requirements and the type of coverage available to you - typically, an individual membership covers only you. A standard family membership covers you, your spouse, dependent children until they turn age 19 (or age 26, depending on your plan), and handicapped dependent children over age 19, who are mentally or physically incapable of earning their own living.

Is my dependent child covered after age 19?
Dependent coverage varies based on the eligibility requirements established by your employer group. Some employers have elected to follow the new health care reform requirements and extended dependent coverage to age 26. In this situation, we do not need any additional documentation for dependents over age 19.

Student Coverage
Some employee groups may offer dependent coverage up to age 26. Other groups require student certification of dependents over the age of 19.

Please note: You may be required to re-certify your dependent on an annual or semi-annual basis. Check with your Plan Administrator for program requirements. If your group has coverage for dependents over age 19, no documentation is required.

Student Certification Form (Use this form to certify dependents as college students)
Student Certification Form for State of Rhode Island Employees (To be used for State of Rhode Island Employees only)

As a reminder, your Plan Administrator is the best source to answer any questions you may have about who is covered under your plan and if you have coverage for students or dependents over age 19.


Benefits

What does my plan cover?

View detailed benefits online by logging into your account
One of the benefits of Delta Dental is our total flexibility in plan design, so there isn’t a generic answer to this question. The best way to find out complete details about your specific dental coverage is to set up an account online. Once you register, you can view a comprehensive breakdown of your benefits, including the following coverage details:

  • Benefits & Eligibility: View a detailed summary of your benefits, including coverage, eligibility dates and who is covered under your plan. You can also verify your plan type (e.g. Delta Dental PPO, Delta Dental Premier, etc.) and confirm whether or not deductibles apply to a particular service.
  • Time & Frequency: View a “summary of usage” for benefits with time and/or frequency limitations (e.g. how many cleanings or x-rays you’ve had to date and the next time you’re eligible for this service).
  • Deductibles & Maximums: Confirm deductible and maximum amounts, as well as remaining balances (e.g. Annual Maximums and Orthodontic Maximums).
  • Plus, you can print or order a new ID card, check the status of a claim in progress and more!

Automated Phone System/Benefits Fax Back (800-843-3582)
Available 24 hours a day, our automated phone system provides the same information available on the web. You can also request a “fax back” to receive a detailed breakdown of benefits and claim payments. For more complex issues, you can always reach one of our knowledgeable Customer Service Representatives Monday through Thursday from 8 a.m. to 7 p.m. (ET) and Friday from 8 a.m. to 5 p.m.

What happens when I reach the annual maximum on my dental coverage?
If you or any covered dependent receives covered services after you have exceeded the annual maximum amount, your participating dentist may charge you more than the Delta Dental approved allowance for the specified service. However, if Delta Dental makes even a partial payment for a covered service before you exceed the maximum, then a participating dentist cannot bill you more than the Delta Dental allowance for that particular service.

What if I don’t use my entire annual maximum in a given year?
All services must be accrued to your annual maximum within a calendar or policy year, depending on your plan guidelines. Any remaining balances on your annual maximum will not be applied in the following calendar/policy year.

What is the difference between a lifetime maximum and an annual maximum?
A lifetime maximum is a specific one-time allowance that will not renew. Annual maximums – which are based on a calendar year or policy year – renew each year on your group’s anniversary date. Orthodontic and implant coverage are the types of benefits that have a lifetime maximum. Check your specific coverage details online.

How do you cover white (also called composite) fillings on back teeth?
Coverage for white – or composite – fillings on back teeth is based on your group’s policy. If your group has coverage, we will pay for a composite filling based on the coverage level determined by your plan. If you do not have coverage for composite fillings on back teeth, we will pay up to what we would have paid for the silver – or amalgam – filling. You are responsible for the balance up to the dentist’s submitted charge.


Orthodontic Benefits

Please explain how you cover orthodontic (braces) services.

Not all plans cover orthodontic services, so please check with your Plan Administrator to see if this is a covered benefit under your plan. If you do have orthodontic coverage, please log in to your online account to read the Orthodontics section of our Utilization Review Guidelines for a complete overview of our Orthodontic Payment Schedule. Please note that a pre-treatment estimate is recommended for all orthodontic treatment plans, and the fee for orthodontic treatment includes all diagnostic procedures (exams, photographs, appliances, post-treatment stabilization, etc.)

Orthodontic benefits are only available for members under age 19, unless your employer group has purchased coverage for adult orthodontics. Orthodontic coverage ends on the day before the member’s 19th birthday. Benefits are not payable for orthodontic services received prior to the effective date and/or after the termination date.


Participating vs. Non-Participating Dentists

Do I have to go to a particular dentist?

You have the freedom to choose any dentist, however your out-of-pocket costs will be higher when you visit a dentist who does “not participate” with Delta Dental. In Rhode Island, nine out of 10 dentists participate with us. And, more than three out of four dentists nationwide participate. As a member of Delta Dental, you enjoy distinct advantages when you visit a participating dentist, including:

  • Protection against “balance billing:” Participating dentists agree to accept our payment as payment in full – minus any applicable deductibles or co-insurances – so you won’t be billed for any remaining balances.
  • Direct claim submission: A participating dentist will also file your claims directly with us and handle any paperwork.

Please note: Exams and consultations by some specialty dentists may not be covered by your plan, so please be sure to check your benefits for full coverage details.

How do I find a participating dentist?

If you’d like to see if your current dentist participates or find a new dentist who is conveniently located near your home or office, just click on Find A Dentist from our home page. To get started on your search, you’ll need your Delta Dental identification card to determine if you have “Local” or “National” coverage.

Our online dentist search will provide you with the name, address and phone number of participating dentists within your geographic location, as well as hours of operation, whether the dentist/dental office is accepting new patients, languages spoken and whether the office is handicapped accessible.

What happens if I visit a non-participating dentist?

If you choose to visit a non-participating dentist, it will cost you more money because the dentist hasn’t agreed to accept the Delta Dental allowance as full payment. You may also have to pay the dentist upfront and file the claim yourself. You should ask the dentist to complete a standard American Dental Association (ADA) claim form.

Claims should be sent to:              
Delta Dental of Rhode Island
10 Charles Street
Providence, RI, 02901-1517

Will my Delta Dental plan cover me if I need care outside of the country?

If you experience a dental emergency when you are out of the country, you may choose to have dental services provided by any licensed dentist. You will typically need to pay at the time of the service, and we will reimburse you directly based on the current rate of exchange. To help us process your claim in a timely manner, please ask the dentist for a billing statement that includes the treatment you received, the tooth number, the date of service, and the total cost of the service. If possible, have the billing statement translated into English.


Claims

Do I need to submit a claim form?

Participating dentists will take care of filing claims for you. Some non-participating dentists may submit them on your behalf. Call the dentist’s office before you visit to make sure.

If you need to submit a claim form, please send to:
Delta Dental of Rhode Island
10 Charles Street
Providence, RI 02901-1517

Do any dental procedures require prior authorization?

Referrals and prior authorization are not required, however, we strongly recommend that your dentist file what’s known as a “pre-treatment estimate” with us for any service that is expected to cost $300 or more. We will review the treatment plan and let you and your dentist know, in advance, whether or not a particular service will be covered under your plan.

For services that your dental plan does not cover at 100% (e.g. crowns, bridges, certain surgical procedures), having a pre-treatment estimate lets you know what your out-of-pocket costs will be.  The treatment plans for major restorative services like crowns and bridges need to be reviewed and approved to make sure that the service meets our Utilization Review Guidelines, so it’s always in your best interest to have your dentist obtain a pre-treatment estimate in advance.

Please note: Pre-treatment estimates are guaranteed for up to one year of receipt, and only apply to the dentist who submitted the pre-treatment request.

How can I check to see if my claim was paid?

Just log in to your online account to check on the status of a claim, or view a claim in progress. You can also look up the following information online:

  • Pre-treatment estimates for the last three months
  • Explanation of Benefits (EOB) for any processed claim
  • Summary of paid or in-process claims for the last six months

Or, call our Automated InfoLine at 800-843-3582 for a “fax back” summary of claims paid or in-process for the past six months, as well as pre-treatment estimates for the last three months.

I received an Explanation of Benefits (EOB) in the mail and I’m not sure if I owe any money to the dentist.
An EOB is a detailed description of the dental service(s) you received, the date it was provided, the dentist’s charge, what Delta Dental will pay and what – if any – payment responsibility you may have. In particular, you should check the “Processing Policies” field for special messaging explaining the reason(s) for any action we may have taken to approve or deny a procedure.  You should always check with your dentist to determine if you owe additional payment.  Finally, you should review the information on the EOB carefully to ensure that it accurately reflects the services you received.

To save time and paper, you can also sign up to receive regular email notifications from us whenever you have claims activity on your account. By signing up for our paperless program, you’ll receive an e-notification whenever an EOB is processed and available to review online. Click here to register and opt-in to our paperless e-notification service.


Appeals Process

My claim submission was denied. How do I appeal this decision?
There are two types of appeals – Administrative Appeals and Utilization Review Appeals.

Administrative Appeal is a request for reconsideration of a claim that was denied based on the provisions of your group's contract.

Click here for a complete description of our Consumer Rights and Appeals process.

Utilization Review Appeal is a request for reconsideration of a procedure that was denied or disallowed based on dental necessity and in accordance with Delta Dental's policies regarding utilization review determination.

How do I appeal an adverse determination based on your Utilization Review guidelines?

Click here for a complete description of our Consumer Rights and Appeals process.


Coordination of Benefits (COB)

Do you coordinate benefits?
Yes, we coordinate benefits using the National Association of Insurance Commissioners (NAIC) guidelines. These industry-standard guidelines are used by insurers to determine the order of benefit payments whenever a patient is covered by more than one employer-sponsored insurance plan. Coordination between benefit programs is designed to assist in meeting your financial responsibilities (e.g. co-insurance, deductibles, etc.). As a general rule, the secondary carrier will not make a benefit payment if there is no patient responsibility remaining after the primary plan has made its benefit payment.

Do you coordinate benefits for pre-treatment estimates?
No, we do not coordinate benefits for a pre-treatment estimate because this estimate is subject to change. Coordination of benefits occurs after the service is rendered, based on the evidence of payment made by the primary plan.

What is a “non-duplication of benefits” clause?
Some employer group contracts include a “non-duplication of benefits” provision which specifies the integration of benefits, rather than coordination of benefits. In applying this provision, the total payments from both plans will not be more than the amount the dental plan would pay if it were your only coverage. This also means that benefits are never duplicated. For example, if you and/or your spouse's dental policy cover two dental exams, you are not entitled to two exams from the primary plan, and two from the secondary plan. You are only entitled to two exams in total.

Another example of non-duplication of benefits would be if your primary dental policy covers crowns at 50%, and the secondary plan also covers crowns at 50%. In this situation, no additional payment would be made. However, if the primary plan covers crowns at 50% and the secondary plan covers crowns at 80%, then benefits would be coordinated to pay the additional 30%.


Individual Coverage

Does Delta Dental sell individual policies?
Delta Dental sells group programs to Rhode Island-based employers. Members of certain other organizations, such as a Chamber of Commerce, AAA Northeast and HealthSource RI can also purchase dental coverage with us. Companies with fewer than three employees can contact their local Chamber of Commerce for more information. Members of AAA Northeast who live in Rhode Island can click here for details about our AAA Dental plan. HealthSource RI offers an individual plan that includes coverage for preventive and diagnostic benefits (e.g. cleanings, exams and x-rays). Plus, fillings, root canals, extractions and more are covered with co-insurance, after a deductible is met.


Ordering ID cards

I've lost my Delta Dental identification card. How can I order a replacement?
Once you've registered online, you can easily re-order a lost or misplaced identification card. You can either print a paper copy of the card from the website, or re-order a replacement card by mail. Please allow five to 10 business days for processing and mailing. We provide one card for individuals and two cards for family plans. All cards are issued in the subscriber's, not the member's, name.


Affordable Care Act

What are Essential Health Benefits under the Affordable Care Act (ACA)?
The ACA contains 10 health benefits that all health insurance plans are required to cover for both individuals and small groups (employers with 50 or fewer full-time equivalent employees).

Essential health benefits must include items and services within the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

What does the Pediatric Essential Dental benefit cover?
The Affordable Care Act contains 10 essential health benefits that all health insurance plans are required to cover for individuals and small group markets. Pediatric dental benefits are one of the 10 essential health benefits. For more information, click here.

Who is eligible for Medically Necessary Orthodontia under the ACA?
This unique benefit provides orthodontic services for children with serious orthodontic impairment resulting from congenital abnormalities that affect their daily ability to function, e.g. eating, speaking, etc. Under the ACA provisions, there are no lifetime or annual maximum limitations for medically necessary orthodontia, which is covered at 50%.  Click here for more details.