Dentists

Frequently Asked Questions

How to Join Our Network Changes to Your Practice
Web Registration Claims Review
Direct Deposit Coordination of Benefits
Appeal Process Overpayments and Refunds
Orthodontic Payment Schedule Affordable Care Act

How to Join Our Network

Who is Eligible to Join?
Any actively licensed dentist practicing in the state of Rhode Island is eligible to join our network.

For out-of-state dentists, please click here to contact your local Delta Dental plan.


How do I Join?
To join, simply complete our credentialing application packet, which includes the following documents and forms:

  • Dentist Application
  • Participating Dentist Agreement
  • IRS W-9
  • Participating Dentist Checklist

Please click here to download the required application packet. After completing and signing the forms, please fax, email or mail your completed application packet to:

How long will it take for my application to be approved?
Our Credentialing Committee meets every 30 days. Completed applications must be received seven (7) days prior to the scheduled meeting date. Only completed applications will be reviewed. Click here to view our Credentialing Committee Meeting Schedule.


How often do you re-credential?
We re-credential network dentist every three (3) years. We will send you a Dentist Profile with the information we have on file for you.  You’ll need to verify and/or update and then sign your profile. You can fax, email, or mail the updated profile to us to complete the process.


Changes to Your Practice

How do I add a new dentist to my practice?
To ensure timely and accurate claims processing, please notify us as soon as a new dentist joins your practice. Just complete the “Add Location” form by clicking here.   Please submit the completed form by email, fax or mail.

If a dentist leaves your practice, please complete the “Remove Location” form , and submit to us as soon as possible.


How do I make changes to my business information?
Please complete and sign a new W-9 form whenever you need to change the following information:

  • Your office changes its Business Name or Payment Address
  • Your office changes its Tax Identification Number (TIN)

If you are retiring or selling your practice, you must complete the “Office Closed” form. Both forms are available on our Forms and Resources page.


Web Registration

How do I register to use your online services?
Registering for our online services is easy and fast. You’ll just need your tax identification number (TIN), license number and business address to register. We offer several levels of access to our web services, depending on the needs of your practice. Click here to get started.

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.

Can I check a patient’s benefits & eligibility online?
Once you’ve registered, you’ll find all the tools you need to manage your Delta Dental patients, including detailed, patient-specific benefits and eligibility information. With our Dentists Online tool, you can:

  • Verify benefits & eligibility (both current and previous), and, if applicable, termination dates
  • Confirm deductibles and maximums usage
  • View time and frequency usage by benefit, including when the patient is next eligible to receive the service
  • Look up tooth history for up to 84 months
  • View benefits at the procedure code level, including percentage of coverage and any applicable deductibles and waiting periods

How can I check on the status of a submitted claim?
With our Claims Lookup tool, you can check on paid claims as well as claims in process. In addition, you can:

  • Access and print patient-specific EOBs
  • View pre-treatment estimates for the last three months
  • Print a summary of paid or in-process claims for the last six months

How do I find out if a specific CDT code is covered under a patient’s plan?
With our Procedure Code Lookup feature, you can search at the procedure code level to determine if a patient is covered for that specific procedure. By entering a valid CDT procedure code, you’ll have access to the following information: co-insurance percentage, deductible and waiting periods, if applicable. You should also review the patient’s benefit summary carefully for additional criteria associated with any procedure code. Please note: To access this feature, you must be registered to use our online services.


What is Delta Dental’s payer ID number?

The payer ID number for Delta Dental is 05029.


Claim Review

What procedures require professional review?
Delta Dental of Rhode Island’s Utilization Review Guidelines explain the criteria used to determine whether or not a procedure qualifies for coverage. The UR Guidelines are organized by dental procedure code and include what – if any – documentation is needed to file a claim for a particular service (e.g. x-rays, periodontal charting, etc.). Please note that while services may be dentally appropriate and necessary, they may not be covered by a patient’s specific dental plan.

Finally, these guidelines are subject to change as new procedure codes are introduced, existing codes are revised, or when materials, techniques and insurance industry practices are updated.


Do any procedures require pre-authorization?
For any treatment that is expected to cost $300 or more, we recommend – but do not require – what we call a “pre-treatment estimate.” The pre-treatment review process lets dentists and patients know about coverage levels and appropriateness of care before services are received. Pre-treatment estimates are also recommended for crowns, bridges, and certain surgical procedures.


What type of supporting documentation may be required as part of the review process?
Since an x-ray does not always depict the entire condition of the tooth or site, any relevant supporting documentation may help a claim process on first submission. We always encourage dental offices to provide additional information – such as the patient’s clinical treatment notes and photographs – along with an x-ray, when submitting a pre-treatment estimate or a claim for procedures that undergo utilization review, such as crowns, bridges, post and core, etc.


Who makes the clinical decisions in the review process?
The responsibility for clinical review of claims lies with our Dental Case Management staff, consisting of licensed, clinically-trained hygienists and dental assistants who are supervised by our Dental Director and highly-regarded general and specialty dental consultants.

Onsite, clinically trained hygienists and dental assistants conduct the first level of clinical review. These professionals are empowered to approve claims that meet our treatment guidelines while referring questionable claims to an in-house dental consultant. The Dental Consultants are all dentists with at least 10 years of clinical practice and most of our consultants have over 20 years of experience. In addition, specialty Dental Consultants (in the areas of oral surgery, periodontics, endodontics and orthodontics) are available on an as needed basis to review the second level of appeals in cases specific to their area of specialization.


Direct Deposit

How do I sign up for direct deposit?
To sign up for direct deposit, you’ll first need to register to use our online services, including electronic funds transfer. Once you register, select the “Direct Deposit” link and complete the online form. You’ll need to provide the name of the bank you would like funds deposited to, the bank account and routing numbers, and your Tax Identification Number (TIN).

If you’ve already registered to use our web services, just log in, select the “Direct Deposit” link, and complete the online form, providing the same information referenced above.

Once you’ve completed the Direct Deposit application form, you’ll receive a confirmation screen that requests your email address and electronic signature to complete the process. Then, you’ll receive an email notification stating that your Direct Deposit request was successfully processed. The email will also let you know when the first payment will be made directly to your account. Please note:  Your electronic fund transfer will usually be deposited to your bank account the day before you would normally receive a paper check by mail. Click here to review the Current Check Run Schedule.


When you enroll in direct deposit with us, we automatically enroll you in the Delta Dental Plans Association’s (DDPA) National EFT File by sharing the banking information you provide through our secure connection with DDPA. Enrollment in the National EFT File allows Rhode Island dentists who treat patients covered by other participating Delta Dental plans to receive payment from those plans by direct deposit. You can disenroll from the National EFT File by:

  • Logging in to your online account
  • Clicking the Direct Deposit/Paperless CEOBs tab in the left menu
  • Clicking the “Manage My EFT” button
  • Clicking “Disenroll from National EFT”

Note: You will remain enrolled in Delta Dental of Rhode Island’s EFT program, even if you disenroll from the National EFT File. If you choose to disenroll from DDRI’s Direct Deposit program, you will be disenrolled automatically from the National EFT File as well.

Can I also receive electronic settlement statements?
Yes, as part of our Direct Deposit program you can also receive your Consolidated Explanation of Benefits (CEOB) electronically Participating Delta Dental of Rhode Island dentists will automatically receive electronic statements once they enroll in our Direct Deposit Program. Out-of-state dentists can opt-in to receive this service.

Once the funds are deposited to the approved bank account, your office will receive an email letting you know that your electronic CEOB is available for review.

 How do I change or update my bank account information?
To edit banking information you select the Direct Deposit/Paperless CEOB's tab and click on Manage My EFT.

  • Bank Account Name
  • Bank Account Number
  • Bank Account Routing Number

Coordination of Benefits

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 the patient in meeting his/her 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. COB is not designed to increase the amount collected by a dental office.


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 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 the patient’s only coverage.  This also means that benefits are never duplicated. For example, if a patient’s and/or spouse’s dental policy covers two dental exams, the patient is not entitled to two exams from the primary plan, and two from the secondary plan. The patient is only entitled to two exams.

Another example of non-duplication of benefits would be if a patient’s primary dental policy covers crowns at 50%, and the secondary plan also covers crowns at 50%, 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%.


Appeals Process

Please describe your Appeals Process.
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 contract provisions.  These types of appeals are typically filed by a member.

Example:  A subscriber appeals the denial of a sealant (CDT code 1351) rendered on tooth number 13. The patient's contract specifically excludes coverage for sealants done on bicuspid teeth.

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 determinations.

Example:  A dentist appeals a Dental Consultant's denial of a crown on tooth number 15 because the tooth lacks the required breakdown to qualify for a crown.

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

Click here for a complete description of the Delta Dental Consumer Rights and Appeals process.


Overpayments and Refunds

A claim was submitted to Delta Dental in error. How will the error be reflected on my settlement statement?
If a claim was submitted by your office in error – and a payment was made – there are two options for correcting the financial mistake:

  1. We can retract the dollars paid from a future settlement check; or
  2. You can send a check back to Delta Dental of Rhode Island with a copy of your Consolidated Explanations of Benefits (CEOB)

If you ask us to retract the money from a future check, it will be reflected in a future settlement with the following processing policy:

PP 506: This amount reflects an overpayment for a previously paid claim. The dollar amount of this claim has been deducted from your check total.

If we receive a check from your office, it will be reflected in your next settlement check with the following processing policy:

PP 505: This amount confirms receipt of a check you sent to us. It has no affect on your payment total.


Orthodontic Payment Schedule

How do you reimburse for orthodontic services?
For a complete overview of our Orthodontic Payment Schedule, please log in to your online account to read the Orthodontics section of our Utilization Review Guidelines. 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, etc.), appliances, post-treatment stabilization, etc.

Orthodontic benefits are only available for members under age 19, unless the 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.


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.