Benefits Administration Manual

Easy dental starts here
:)
Benefits Administration Manual
Dental made simple.
Delta Dental of Tennessee
Mission Statement
The mission of Delta Dental of Tennessee is to improve oral health by being the leading
dental carrier providing programs of demonstrated value that balance the needs of the
customers.
Customers
Because we believe that you, our customer, are one of our most valued stakeholders,
we provide you the highest level of service available. You are the catalyst that inspires
us to become more innovative and progressive.
Enrollees
We treat enrollees with respect in a friendly, courteous manner. We endeavor to assist
them in receiving the full value of their benefits by accurately describing their program.
We address their questions and concerns promptly and thoroughly.
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Table of Contents
Welcome .................................................................................................1
Web-based Services
Benefit Manager Toolkit ................................................................1
e-Billing .........................................................................................1
Online Bill-pay ...............................................................................2
Dentist Search ..............................................................................2
Employer Resources.....................................................................2
EyeMed Vision Care ...............................................................................3
Dental Benefits: Eligibility and Enrollment
Who Can Enroll? .......................................................................... 3
When Coverage Begins ................................................................3
Qualifying Events ......................................................................... 4
Rejoining the Plan ........................................................................ 4
When Coverage Ends ...................................................................4
Member Retroactivity ................................................................... 4
Verifying Eligibility Information ..................................................... 4
Filling out the Enrollment/Change Forms ..................................... 5
ID Cards ...................................................................................... 5
Coordination of Benefits ................................................................5
COBRA ........................................................................................ 5
Billing
e-Billing ....................................................................................... 6
Online Bill-pay .............................................................................. 8
Claims
Claim Filing ...................................................................................9
For Services performed by a participating dentist......................... 9
For services rendered by non-participating dentist ....................... 9
Explanation of Benefits ...............................................................10
Pre-treatment Estimates .............................................................10
Appealing a Claim .......................................................................10
Health and Wellness.............................................................................11
Administrative and Employee Contact Information ...........................11
Forms and Documents
Enrollment Form .........................................................................12
Change Form ..............................................................................13
Claim Form ............................................................................14-15
Sample Invoice ......................................................................16-17
e-Billing Registration Form ..........................................................18
Online Bill-pay Instructions ..........................................................19
Coordination of Benefits ..............................................................20
Sample ID Card ..........................................................................21
Understanding your Explanation of Benefits...........................22-25
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Welcome Employers!
We are pleased to provide your dental
benefits and we look forward to serving
you and your employees.
Client satisfaction comes first at Delta
Dental of Tennessee. So, we have several
resources available to assist you in
managing your dental program and for
helping your employees to make the most
of their dental benefits.
Benefit Manager Toolkit
With the Benefit Manager Toolkit (BMT), benefit managers can:
•
•
•
•
•
•
Get real-time benefit and eligibility information 24/7
Take control of your group’s eligibility
Enter, edit and terminate enrollee eligibility
Download dentist directories in a printable format
Streamline your benefits management process
Access Client Knowledge, our web-based reporting service
e-Billing
e-Billing is a fast and easy way to receive your bill and stay organized. With
e-Billing you can:
•
•
•
•
•
•
•
Receive an email with your monthly invoice attached
View complete subscriber listings online with quick, secure access
Automatically archive bills so they’re always available
Download a list of active subscribers in an Excel format
Receive a higher level of security to maintain Protected Health
Information (PHI)
Combine with ACH or bank draft for the most convenient processing
Reduce unnecessary paper clutter
The Benefit Manager Toolkit and e-Billing give you more control of your benefits. To sign up for e-Billing,
complete the form on page 18 and return it to your Account Manager.
1
Online Bill-pay
This new feature allows you to pay your monthly invoice quickly and securely
through our bank’s online portal. There is a $3.00 processing fee per
transaction, but there is no sign-up process and all you need to make a
payment is your group number and a Visa, MasterCard, or checking account.
Dentist Search
With nearly 3 out of 4 providers nationwide in our networks,
you and your employees have a wide selection of dentists from
which to choose.
To locate a dentist, just access the Dentist Search by visiting
our website at www.DeltaDentalTN.com and clicking on the link
titled Find a Dentist.
Here are a few tips to help you select the right dentist:
•
•
•
Put in a City and a Zip Code to get more accurate results.
Search for locations near both your home and work to
find more options.
If you are unsure about your plan type, you should be
able to find it on the Declaration Page of your group dental contract. You may also contact your Account
Manager for assistance.
Employer Resources
Administrative materials, like the ones listed below, may be downloaded from our website at
www.deltadentaltn.com/Groups/Employer-Resources.
Administrative Manual
As a plan administrator, you are the primary contact between Delta
Dental and your employees. To assist you, we have created this
handbook to serve as a valuable resource to answer your how to or
what if questions.
Claim Form
Download a hard copy of the commonly-used claim form.
Quick Reference Guide to DASI
Get assistance with DASI, Delta Dental's automated inquiry system.
Newsletters
Miss one of our newsletters? View our archived editions.
Online Bill-pay
Pay your monthly invoice quickly and securely.
2
EyeMed Vision Care
The choice is clear. More Choices. Better Quality.
The EyeMed Vision CareSM discount plan provides significant savings on eye care
and eyewear simply by showing a Delta Dental ID card to any EyeMed provider.
Choose from a nationwide network of optometrists, ophthalmologists and opticians,
as well as the nation’s leading optical retailers such as LensCrafters®, Sears
Optical®, Target Optical® and most Pearle Vision® locations.
This is not insurance, so there are no claims to file. Discounts should be given in the
office at the time of the appointment. For more information, visit the website at
www.eyemedvisioncare.com/deltadental or call toll free at 1-866-246-9041.
Dental Benefits: Eligibility and Enrollment
As the Plan Administrator, you may already be familiar with some
of our guidelines for enrolling your company or group in Delta
Dental. However, there are some additional guidelines, such as
ongoing group participation requirements, that you may want to
refer to from time to time. This section highlights a few of these
key underwriting areas for participation, member eligibility, and
retroactivity.
Participation Requirements refer to the number of employees
who enroll in the plan compared to the number of employees who
are eligible to enroll, excluding those employees with other
coverage (e.g. spouse’s plan, other employer group).
The group’s eligibility requirements and enrollment may be reviewed and audited at least once each year—
typically prior to the renewal date—to ensure compliance with these requirements.
Please note: If an employee has dental coverage elsewhere (e.g. through a spouse), that employee may be
eliminated from the calculation of the total eligible population.
Who Can Enroll?
Active Employees: All active employees who are eligible for your group’s benefits program and for whom
the company contributes all, some, or none of the premium charge are eligible for membership in your
group’s dental benefits plan. Active employees—including owners, partners, and corporate officers—must
regularly work 30 or more hours per week and be on the company’s payroll. Only employees (and their
family members, if your company has family coverage) are eligible for coverage.
Dependents: Your plan’s family coverage includes the following dependent categories:
• The employee’s legal spouse
• Children by birth, step-children, or legally adopted children to age 26
• Children over 26 who are mentally or physically incapable of earning their own living
(proof of which must be on the file with Delta Dental of Tennessee).
• Divorced spouses in accordance with applicable federal and state law. In the case of remarriage,
the ex-spouse can no longer be covered under the family plan.
When Coverage Begins
Please review the Certificate of Coverage for your group’s eligibility period (this is in accordance with the
3
If any employees or eligible dependents do not enroll when they are first eligible, they must wait to apply
until the next open enrollment period scheduled for your company or when a qualifying event occurs.
Qualifying Events
The monthly premium rates have been developed assuming all members have committed to a 12-month
enrollment period. For a new enrollee to join the program or make a status change, the member must meet
an industry-accepted qualifying event.
Qualifying Events include:
• New Hire
• Marriage or Divorce
• Birth, Adoption, Change of Custody
• Workers’ Compensation
• Family Medical or Disability Leave
• Spouse’s Loss of Coverage
• Full Time/Part Time Status Change
• Death of a Member
Rejoining the Plan
An enrolled member who voluntarily cancels membership in the group may not re-enroll in that group until
the first open enrollment following 12 months without coverage. The re-enrollment must occur on the
group’s anniversary or open enrollment unless a qualifying event occurs.
When Coverage Ends
Coverage ends on the last day of the month in which the group notifies us that coverage is cancelled by
completing the applicable form or online transaction.
Please review your contract for detailed participation, enrollment and re-enrollment requirements.
Member Retroactivity
Retroactivity occurs when we are notified of an addition, change or termination after the requested effective
date has occurred.
Additions: Member additions are made on the first day of the month or as your contract allows.
Terminations: Member terminations take effect on the first day of the month following the last date of
coverage or as your contract allows. The maximum credit that can be given is 90 days, provided there are
no claim(s) paid on the member during this period. If a claim(s) has been paid, the termination will take
effect on the last day of the month in which the claim(s) was paid.
Example: On July 8th, you request a retroactive termination effective July 1st. However, the member went to
the dentist on July 6th and a claim was submitted and paid. As a result, the member’s coverage will be
cancelled effective August 1st.
Verifying Eligibility Information
With our streamlined administration, the same eligibility records are used for both claims processing and
monthly billings. This means there is no discrepancy between the two functions and that corrections and
4
updates need only be made once. In addition, a complete Subscriber List (there is a list for each of your
sub-groups) is available online through e-Billing. You can also request this listing by fax.
The Subscriber List displays all employees who are eligible to receive dental benefits and the type of
coverage. Review these lists carefully to ensure that the information is correct.
Filling out the Enrollment/Change Form
Enrollment forms need to be completed for new hires. Please see page 12 for a sample of an enrollment
form.
When adding a dependent, terminating a dependent, changing an address or terminating the subscriber,
please complete a change form. Please see page 13 for a sample of a change form.
ID Cards
Delta Dental automatically issues identification cards (ID cards) for all employees covered under your plan.
ID cards are mailed to each enrolled employee’s home address and should be received within 7 to 14 days
after their enrollment is completed.
The front of each ID card contains your Company’s name, your Delta Dental group number, and the
Subscriber’s name. The back of the card indicates how to contact Delta Dental and outlines claim filing
instructions. Please see page 21 for a sample of an ID Card. Your employees should always present their
ID card when they visit a dentist outside of the state of Tennessee.
Employees may replace a lost ID card by printing a paper copy from the Consumer Toolkit at
www.DeltaDentalTN.com/consumertoolkit. Or, they may contact Customer Service at (800) 223-3104 to
request that a new card be mailed to them.
Coordination of Benefits
To enhance benefits and prevent duplication of coverage, Delta Dental coordinates benefits for members
covered under a second insurance policy (e.g. through a spouse’s plan). This process is known as
Coordination of Benefits (COB).
A document with additional information about Coordination of Benefits is included on page 11 of this
manual. Please check your contract to see if your company allows COB.
Delta Dental’s rigorous performance of dental benefits coordination during claims processing is designed to
help your company and its employees control dental care costs. Delta Dental handles COB in accordance
with industry standards. We use the “Birthday Rule” when dependent children are covered by both parents’
dental plans. The Birthday Rule means covered dependent children are generally covered first (primary) by
the plan of the parent whose birthday occurs earlier in the year.
COBRA
How is COBRA processed?
Delta Dental does not administer COBRA. The group must
pay all premiums. Delta Dental does not accept personal
checks from the COBRA participant.
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Billing
Your coverage with Delta Dental of Tennessee is a prepaid benefits plan with premiums due on the first of the
month. You can choose to receive your monthly invoice (no billing detail) by mail or email. To view a complete
statement including billing details like subscriber listings, you can sign up for e-fax or log in to e-Billing. A
sample invoice is included on pages 16-17 of this manual.
For assistance with your billing statement, e-Billing, or Online Bill-pay please contact Billing at
(615) 255-3175 x.6585.
e-Billing
Signing up for e-Billing gets you faster, more secure access to your monthly invoice and billing detail. If you do
not currently have e-Billing access, but are interested in enrolling, complete the included e-Billing form on page
18 and send it to your Account Manager. Complete PART I of the form to receive an emailed invoice only.
Complete PART I and PART II to receive an emailed invoice and be able to log in to view complete billing
information.
The monthly billing process starts around the 17th of each month. Once the statement is created and available
for online access, an email will be sent to the user who has enrolled in e-Billing. The email will include a PDF of
the invoice and a link to log in to e-Billing to view complete billing information.
At the e-Billing login page, the user will enter the chosen User ID and the Password provided by Finance.
The login information is typically created at the initial group implementation or when the e-Billing access is
requested. If you are unsure of the User ID or Password, contact your Account Manager.
6
Login – After you have successfully logged in, the Account Selection page will be displayed. Here you will
click on the link with your group name, where SAMPLE GROUP 2012 is indicated below.
SAMPLE GROUP 2012
Access Options – The following screen will allow you three separate access options. To view your billing
statement, you will click the option titled E-Billing.
Sample Group 2012 ExtraNet
Welcome Sample Group 2012, Group Number TN057100001
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Document Format Options – Billing statements are typically available in both .xls spreadsheet and PDF
document formats. However, the PDF version is the most frequently used format.
On the final screen, as shown below, you have the option to choose the format that you prefer. Simply click on
the appropriate document link to open the document.
Welcome Sample Group 2012, Group Number TN057100001
20120517-1523-0000000-0000000-Extract.XLS
20120517-1523-0000000-0000000-E-Billing.pdf
Online Bill-pay
Online Bill-pay is a new feature that allows you to pay your monthly invoice quickly and securely through our
bank’s online portal. There is a $3.00 processing fee per transaction, but there is no sign-up process and all
you need to make a payment is your group number and a Visa, MasterCard, or checking account.
To make an online payment, go to www.DeltaDentalTN.com/OnlineBillPay. Go to page 19 of this manual for
step-by-step instructions.
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Claims
One of the most significant benefits to Delta Dental of Tennessee members is that they do not have to
file claims when using participating dentists. Participating dentists file claims directly with Delta Dental.
When seeing a non-participating dentist, members may need to submit a claim form to Delta Dental.
Claim Filing
You can find a claim form on our website at www.DeltaDentalTN.com under the Employer Resources Section.
For services performed by a participating dentist
As a member of Delta Dental, your employees enjoy distinct
advantages when they visit a participating dentist. The dentist
agrees to accept our payment as payment in full—minus any
applicable deductibles or coinsurance—and your employees
are protected against being billed for any remaining balance. A
participating dentist will also file your employees’ claims directly
with us and handle all of the paperwork.
How it works:
1. The member presents his or her ID card at the
dentist’s office.
2. The dentist contacts Delta Dental to verify eligibility
and benefits.
3. Once treatment is rendered, the dentist files a claim
directly with Delta Dental.
For services rendered by non-participating dentists
Non-participating dentists may require the member to file their own claims. To file a claim, members will need
to do the following:
1. Download a Claim Form from the Consumer Toolkit.
2. Follow the completion instructions on page 2 of the downloaded document.
3. Review the form to make sure that all required information is provided and that dentist and
member/patient signatures are included.
4. Mail the completed Claim Form and any other applicable attachments to:
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228
All claims must be submitted within 15 months of the date of service.
Payment for claims submitted by participating providers will be paid directly to the dentist.
Claim payment for claims submitted by a non-participating dentist will be issued to the subscriber. (The only
exception is when state law mandates assignment of benefits or if the group contract specifies assignment of
benefits).
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When payment is issued to the member, it is the member’s responsibility to pay the dentist. If the dentist is
non-participating, the member is responsible for the difference between the dentist’s full charge and the Delta
Dental payment, plus any applicable coinsurance, deductibles, etc.
Members receive an Explanation of Benefits form for services rendered by both participating and nonparticipating dentists.
Explanation of Benefits
The Explanation of Benefits (EOB) is used to inform the subscriber when a claim is processed. The EOB also
indicates the total charges for the services rendered by the dentist, as well as any amount payable by the
employee for deductibles, coinsurance, and charges for non-covered services.
A Claim Payment Statement is also sent to the participating dentist who performed the treatment. The Claim
Payment Statement includes the same information as the patient’s EOB.
A document with additional information about the Explanation of Benefits is included on pages 22-25 of this
manual.
Pre-treatment Estimates
For certain services (e.g. crowns, bridges, Periodontics,
orthodontics), participating dentists are encouraged to submit a
pre-treatment estimate (aka predetermination) to Delta Dental.
This provides members with an estimate of the total cost of
services and the members’ out-of-pocket expenses before
services are performed. It is important that your employees are
aware of this. To help ensure that the process does not
unnecessarily delay the delivery of services, Delta Dental quickly
responds to pre-treatment estimates submitted by dentists. In
addition, Delta Dental encourages members to ask their dentist to file a pre-treatment estimate when the cost
of the treatment is expected to exceed $250.
Once the estimate is reviewed, a Predetermination Notice (Pre-Treatment Estimate) form is sent to both the
member and the dentist describing the procedures that are covered or not covered. It also estimates how much
Delta Dental will pay the dentist and any cost sharing the member will incur. The Pre-Treatment Estimate is
not a guarantee of payment. Payment determination is made at the time that the actual claim for services is
processed. It is based upon eligibility and subject to the applicable coinsurance, deductible and calendar year
maximum.
If the patient proceeds with the estimated treatment, the date of service should be added to the
Predetermination Notice form and submitted as the claim for payment.
Appealing a Claim
If a payment for services was denied, the EOB will give the reason. If the subscriber disagrees with the denial,
he or she may appeal the denial by submitting request in writing asking that the claim be reviewed. Such
requests should include the reason why the subscriber believes the claim was wrongly denied. The request
must be received by DDTN within 180 days of the subscriber’s receipt of the EOB. Upon receipt, DDTN will
10
review the appeal and may ask for more documents if needed. Unless unusual circumstances arise, a decision
will be sent to the subscriber within 30 days after DDTN receives the request for review.
If the subscriber does not agree with the first level review decision, he or she may refer the request for review
to the Professional Relations Advisory Committee of Delta Dental. This second level review request must be in
writing and received by Delta Dental within a reasonable time after the subscriber receives the first level review
decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after
Delta Dental receives the request for second level review.
If the subscriber does not agree with the second level review decision, he or she may file civil action in court.
Health and Wellness
Why Dental Benefits?
A healthy smile is important—not only to oral health, but for overall health, too. Did you know a dentist can
detect more than 120 symptoms of non-dental diseases—including cancer, diabetes, heart disease, kidney
disease, and osteoporosis—during a routine oral exam? A dentist may be the first line of defense in diagnosing
health problems that could be more costly in the long run.
Having dental coverage helps members get the care they need to stay healthy. It also can help keep overall
health care costs down. After all, good health starts with a healthy smile!
We offer several health and wellness publications that will help your employees understand the need for dental
benefits. You can find the downloadable documents on our website in the Wellness section.
Contact Information
We have dedicated account service representatives
available to assist you with all of your dental benefit needs,
including billing inquiries. The name and contact information
for your representative is included on your Welcome Letter.
Employees who need assistance may contact our Customer
Service department at (800) 223-3104, Monday through
Friday from 7:00 AM to 5:00 PM (CST).
Our website, www.DeltaDentalTN.com, also provides
access to our Dentist Search, Consumer Toolkit, Benefit
Manager Toolkit, Wellness information, and more.
11
ENROLLMENT FORM
SOCIAL SECURITY NUMBER
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
_
_
Telephone 615-255-3175
GROUP
NUMBER
SUBLOCATION
NUMBER
FIRST NAME
GROUP
NAME
M
LAST NAME
STREET ADDRESS
CITY
STATE
ZIP
M
BIRTH
DATE
EFFECTIVE
DATE
F
SEX
If enrolling spouse and/or dependents, please list them below
FIRST NAME & M.I. (LAST NAME IF DIFFERENT)
SEX
M
F
BIRTH DATE
SPOUSE:
CHILD:
CHILD:
CHILD:
CHILD:
I agree to make the required contribution. I certify that the information contained in this form is true and correct to the
best of my ability.
Signature:
Date:
DECLINE COVERAGE
I have been given the opportunity to apply for group dental insurance coverage through my employer and choose at this
time to not take coverage. I understand that by signing this area I am declining this coverage because:
I have other dental coverage
I do not want at this time
Other: _____________________
Date:
Declination Signature:
DDTN SS 1 EF (Rev 9/08)
12
CHANGE FORM
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
Telephone 800-223-3104
SOCIAL SECURITY NUMBER
SUBLOCATION
NUMBER
GROUP
NUMBER
FIRST NAME
GROUP
NAME
M
LAST NAME
If terminating or adding a dependent(s) ONLY, use ‘Drop (D)/Add (A)’ box below
SEX
D
A
FIRST NAME & M.I.
(LAST NAME IF DIFFERENT)
BIRTH
DATE
M F
REASON
EFFECTIVE
DATE
SPOUSE:
CHILD:
CHILD:
CHILD:
CHILD:
CHANGE NAME
CHANGE ADDRESS
To:
From:
To:
CHANGE SUBLOCATIONS:
From:
To:
Effective Date:
TO TERMINATE EMPLOYEE COVERAGE, PLACE EFFECTIVE DATE HERE:___________ _______
(Rehired Employees and COBRA enrollees should fill out a new enrollment form)
Signature:
Date:
DDTN SS 2 CF (Rev 6/09)
13
DENTAL CLAIM
STATEMENT
TYPE OF TRANSACTION
1.
STATEMENT OF ACTUAL SERVICES
PREDETERMINATION REQUEST
DELTA DENTAL
240 VENTURE CIRCLE
NASHVILLE, TN 37228
MAIL CLAIMS TO
SUBSCRIBER INFORMATION
11. SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP
OTHER COVERAGE
2.
OTHER DENTAL OR MEDICAL COVERAGE?
IF NO, SKIP TO #11
NO
4.
3.
AMOUNT OF PRIMARY PAYMENT
$
YES
SUBSCRIBER NAME (LAST, FIRST, MIDDLE INITIAL), ADDRESS, CITY, STATE, ZIP
12. DATE OF BIRTH
13. GENDER
14. SUBSCRIBER ID (SSN OR ID#)
M
F
15. PLAN/GROUP NUMBER
16. EMPLOYER NAME
PATIENT INFORMATION
5.
DATE OF BIRTH
6.
GENDER
7.
M
8.
SUBSCRIBER/POLICYHOLDER ID (SSN OR ID#)
17. PATIENT NAME (LAST, FIRST, MIDDLE INITIAL)
F
PLAN/GROUP NUMBER
9.
RELATIONSHIP TO PATIENT
SELF
18. RELATIONSHIP TO SUBSCRIBER
SPOUSE
CHILD
OTHER
SELF
10. OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME
SPOUSE
19. DATE OF BIRTH
CHILD
20. GENDER
OTHER
M
F
21. IF PATIENT IS A DEPENDENT OVER AGE 19, PLEASE INDICATE STATUS
FULL TIME STUDENT
TOTALLY & PERM DISABLED
IRS DEPENDENT
SPONSORED DEPENDENT
DENTAL SERVICES
22. DATE OF SERVICE
23. AREA OF ORAL
MM/DD/CCYY
24. TOOTH NO. OR
CAVITY
25. TOOTH
LETTER
26. CURRENT CDT
SURFACE
27. DESCRIPTION
28. FEE
PROCEDURE CODE
1
2
3
4
5
6
7
8
9
10
MISSING TEETH
30. PLACE
x ON MISSING
TOOTH NUMBERS
PERMANENT
PRIMARY
29. TOTAL FEE CHARGED
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
O
N
M
L
K
REMARKS
31.
AUTHORIZATIONS
ADDITIONAL CLAIM INFORMATION
32. AS PERMITTED UNDER LAW, I CONSENT TO THE USE AND DISCLOSURE OF MY PROTECTED HEALTH
34. PLACE OF TREATMENT
INFORMATION FOR PURPOSES OF PAYMENT OF THIS CLAIM.
DENTAL OFFICE
HOSPITAL
ECF
OTHER
35. NUMBER OF ENCLOSURES
RADIOGRAPHS _______
PATIENT/GUARDIAN SIGNATURE
DIGITAL IMAGES
_______
MODELS
_______
DATE
36. IS TREATMENT RELATED TO ORTHODONTICS?
NO
33. IF PERMITTED, I HEREBY ASSIGN AND AUTHORIZE PAYMENT OF THE DENTAL BENEFITS OTHERWISE
PAYABLE TO ME TO THE TREATING DENTIST.
YES DATE APPLIANCE PLACED _______________
MONTHS OF TREATMENT REMAINING _______
37. TREATMENT RESULTING FROM:
OCCUPATIONAL ILLNESS/INJURY
AUTO ACCIDENT
OTHER ACCIDENT
38. REPLACEMENT OF PROSTHESIS?
SUBSCRIBER SIGNATURE
DATE
YES
DATE PRIOR PLACEMENT _______________
BILLING DENTIST/DENTAL ENTITY (#40 - #43: USE FOR GROUP PRACTICE/MULTIPLE LOCATIONS)
39. NAME, ADDRESS, CITY, STATE, ZIP
NO
TREATING DENTIST AND LOCATION
44. I HEREBY CERTIFY THAT I HAVE PERFORMED THE PROCEDURES AS INDICATED BY DATE AND/OR WISH TO
PREDETERMINE THE PROCEDURES WHICH ARE NOT DATED. THE PROCEDURES WERE/ARE NECESSARY IN MY
PROFESSIONAL JUDGEMENT.
X
SIGNED (TREATING DENTIST)
45. NPI
DATE
46. LICENSE NUMBER
47. TIN
48. ADDRESS, CITY, STATE, ZIP (IF DIFFERENT THAN #39)
40. NPI
41. LICENSE NUMBER
43. PHONE NUMBER
(
)
42. TIN
49. PHONE NUMBER
(
50. ADDITIONAL DENTIST ID
51. SPECIALTY CODE
)
© 2008 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF TENNESSEE WITH PERMISSION –12/2009
INSTRUCTIONS FOR COMPLETING THE SCANNABLE CLAIM
Optical scanning of paper claims can decrease total processing time by two to three days over those claims that must be manually keyed.
FOR CLAIMS TO BE OPTICALLY SCANNED:
•
Clearly type, hand write, or use a computer printer to enter information.
•
Use all upper-case (capital) letters, if possible.
•
Write, type, or print in black or blue pen/ink—do not use red or green ink or any color of highlighter.
•
Keep information within the correct field.
•
Make sure the typewriter or printer ribbon is dark and the print can be easily read.
•
Cover mistakes with line tape and print or type over—do not use liquid correction fluid.
•
Use paperclips to hold attachments whenever possible. Place stapled items only at the lower edge of the form.
FIELDS 2 THROUGH 21—PATIENT/SUBSCRIBER INFORMATION:
•
If the patient has dental coverage through another carrier(s), complete the other coverage section, fields #2 through #10 (if not, leave them blank). Fill
in the amount of primary payment (#3) ONLY when the claim is billing for secondary benefits. Do not enter $0 unless the primary carrier’s determination
of payment was $0. DO NOT ATTACH the primary carrier’s voucher.
•
Enter the patient’s and subscriber’s names in this order: last, first, middle initial. Do not use titles, such as Mrs. or Dr.
FIELDS 22 THROUGH 31—DENTAL SERVICES AND REMARKS:
•
Hand or machine print
•
When machine printing, double-space lines and enter information in between the correct column guidelines. Dates may be entered without
separators (/).
•
Use current ADA CDT procedure codes.
•
Use the REMARKS section (#31) for information necessary to process the claim, such as non-standard COB, miscellaneous codes, codes for
which Delta Dental requires a report, or supporting documentation that will assist in accurately processing the claim. Keep documentation within the
designated field. Unnecessary documentation delays processing.
FIELDS 39 THROUGH 51—BILLING DENTIST AND TREATING DENTIST:
•
The dentist’s name or business name entered in field #39 must match the name on file with Delta Dental.
•
Enter the license number and Tax Identification number (TIN) of the treating dentist in fields #46 and #47. Enter his/her National Provider Identifier
(NPI) in field #45.
•
Fields #40 through #43 are optional for group practices or practices with more than one location who have more than one NPI, license number
and/or TIN.
NOTICE TO ALL PARTIES COMPLETING THIS FORM:
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
MAIL CLAIMS TO:
FAX CLAIMS TO:
TELEPHONE FOR ELIGIBILITY AND BENEFIT INFO
WEB SITE
Delta Dental
240 Venture Circle
Nashville, TN 37228
(615) 244-8108
(800) 223-3104
(615) 255-3175
www.deltadentaltn.com
15
© 2008 DELTA DENTAL OF MICHIGAN • REPRINTED BY DELTA DENTAL OF TENNESSEE WITH PERMISSION –12/2009
BILLING STATEMENT
Invoice Cover Sheet
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
(615) 255-3175 or (888) 281-9396
Invoice No. : 05SPVLU
Group No. : 0000111
SARAH SMITH
Tn Company ABC
PO Box 1234
Nashville, TN
37228-0100
Run Date :
Billing Date :
Closing Date :
Due Date :
04-17-2014
04-17-2014
04-17-2014
05-01-2014
-
05-31-2014
05-01-2014
Billing Period :
Group Number 0000111
Contract ID
Sub Group 2001
Net Update Adjustment
Current Month Billing
$0.00
$4,507.49
Sub Group Amount Due
Group Number 0000111
Contract ID
Group Number 0000111
Contract ID
Group Number 0000111
Contract ID
Sub Group 3001
Net Update Adjustment
Current Month Billing
$4,507.49
$0.00
$53.30
Sub Group Amount Due
$53.30
Sub Group 5001
$0.00
Net Update Adjustment
$337.74
Current Month Billing
$79.95
Current Month Cobra Billing
Sub Group Amount Due
$417.69
Sub Group 7001
Net Update Adjustment
Current Month Billing
$169.13
$542.75
Sub Group Amount Due
$711.88
Detach and return with payment
Group Number: 0000111
Subgroup: 2001
Amount Due: $5,690.36
Due Date: 05-01-2014
Invoice Number: 05SPVLU
Make checks payable to: Delta Dental of Tennessee and mail to the following address:
Delta Dental of Tennessee
P.O. Box 305172
Dept. 35
Nashville, TN 37230-5172
Monday, May 05, 2014
1858
16
Page 1 of 2
BILLING STATEMENT
Invoice Cover Sheet
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
(615) 255-3175 or (888) 281-9396
TOTAL AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$5,690.36
* If the subscriber count falls below the minimum of 140 subscribers as stated in your
contract, you will be billed to meet the minimum requirement.
Detach and return with payment
Group Number: 0000111
Subgroup: 2001
Amount Due: $5,690.36
Due Date: 05-01-2014
Invoice Number: 05SPVLU
Make checks payable to: Delta Dental of Tennessee and mail to the following address:
Delta Dental of Tennessee
P.O. Box 305172
Dept. 35
Nashville, TN 37230-5172
Monday, May 05, 2014
1858
17
Page 2 of 2
E-Billing Registration Form
Group Name: ____________________________________________
Group Number: ________________
Effective Date: _____________________
Complete PART I below to receive an invoice only or to add, update, or delete current users. To receive an invoice AND
access complete billing detail, complete PARTS I and II.
PART I: Invoice Only (no login needed)
USER 1 INFORMATION
New User
Update User
Name: __________________________________________________
Delete User
Phone Number: ________________
Email: _________________________________
USER 2 INFORMATION
New User
Update User
Name: __________________________________________________
Delete User
Phone Number: ________________
Email: _________________________________
PART II: Invoice with Billing Detail/Subscriber Listings (login required)
USER 1
Requested User ID (min. 6 characters; can match BMT): ____________________________________________
Password:
For security purposes, the Billing Department will email a password to you.
Subgroup Access:
All Subgroups
Listed Subgroups: ___________________________________________________
Billing File Formats (choose one):
PDF & Excel
E-Fax
Fax #: _______________________
USER 2
Requested User ID (min. 6 characters; can match BMT): ____________________________________________
Password:
For security purposes, the Billing Department will email a password to you.
Subgroup Access:
All Subgroups
Listed Subgroups: ___________________________________________________
Billing File Formats (choose one):
PDF & Excel
E-Fax
Fax #: _______________________
For questions or other billing changes, please contact the Billing Department at (615) 255-3175 x.6585.
Please scan and email, fax, or mail this form to your Account Manager.
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228
18
Fax: (615) 244-8108
Online Bill-pay Instructions
Go to www.DeltaDentalTN.com/OnlineBillPay and click on ‘Pay My Bill’
Make Payment
Screen 1
Click ‘Next’ to approve the $3.00 fee.
Screen 2
Enter your Group Number (without leading zeros).
Screen 3
Choose ‘Make Payment’ in the upper left corner (see ‘View Payment’ instructions below). Click the check box
next to the invoice you would like to pay. You can only pay the total invoice amount, not a partial amount.
Screen 4
Set up your payment method by clicking ‘Add Account.’ You can select ‘Credit Card’ or ‘Checking’ from the
drop down list, and then add the information. The payment information will be saved for future use, so you
won’t have to add it again.
Screen 5
With the correct payment method selected, click ‘Continue.’ You can also select ‘Add Account’ to add another
payment method.
Screen 6
For a credit card, enter the CVV2 code, expiration date, and set the payment date (which can be up to 5
business days out). For a checking account, the payment date will default to the same day, although the
payment won’t clear until the next business day.
Screen 7
Review the payment details and accept the terms and conditions by clicking on the check box. You can click
‘Cancel’ to end the transaction, or click ‘Pay Now’ to complete the payment.
Screen 8
You will see your payment confirmation and receive a confirmation number.
View Payment
Screen 1
Choose ‘View Payment’ in the upper left corner. Choose your search criteria from the dropdown menu (‘Group
Number/Payment Amount’ is best), and then search for a payment by the amount or the payment date. When
a list of payments is generated, you can view the payment by clicking on the Confirmation Number.
Screen 2
You will see the complete payment information for that invoice, including the confirmation number. You can
also download this information into Excel format.
19
What is...
Coordination of Benefits
Coordination of Benefits (COB) is a way of paying health care expenses when people are covered by more than one
plan. The goal of COB is to make sure the cost of a dental procedure is covered within the scope of the plans, without
exceeding the amount of the actual bill. If you are covered by two or more dental plans—usually because both you
and your spouse receive coverage through work—your coverage will be coordinated.
Standard COB – How it Works
In Tennessee, if you have coverage through your employer, it will pay as primary. If you are also covered by your
spouse’s plan, it will pay as secondary. If you do not have your own coverage, but are covered under your spouse’s
plan, it will pay as primary.*
For example: Robert and Sara Johnson each have dental coverage through their employer.
Robert is also covered under Sara’s plan and vice versa. Last time Robert went to the dentist,
he had a cleaning. His dental plan will pay as primary, and Sara’s plan will pay as secondary.
Procedure
Estimated Bill
Robert’s Plan
Pays 80%
Cleaning
$100
$80
Sara’s Plan
Pays Remainder
$20
The Birthday Rule
For children covered by both parents’ (or guardians’) dental plans, the primary carrier is
determined by the “birthday rule.” The plan that covers the parent or guardian whose birthday
comes first in the calendar year will be considered the primary carrier. The birthday rule may be
superseded by a divorce judgment or court ruling.
For example: Robert and Sara have a daughter, Amy, who is covered under both Robert
and Sara’s dental plans. Sara’s birthday is in February. Robert’s birthday is in July.
Because Sara’s birthday comes first, Amy is covered under Sara’s plan as primary
and Robert’s plan as secondary.
Questions?
Review your coverage in our online Consumer Toolkit at
www.DeltaDentalTN.com/consumertoolkit.
Dental made simple.
Or, call Customer Service at (800) 223-3104.
*While this is the standard way COB is handled, it can vary by plan.
Review your Certificate of Coverage to confirm how your plan works.
271 1/14
20
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228 -1604
Your ID Card
Your new ID cards are below! You do not have to show your ID card to your dentist to receive treatment, however you may wish to carry
it for reference. Our toll-free phone number, website, and mailing address are listed on the back.
Your Subscriber ID may be either your Social Security Number (SSN) or an alternate ID number. If it is your SSN, it will not be listed on
your ID card to help protect your privacy.
Your Benefits, 24/7
Benefits on the Go
Our secure, online Consumer Toolkit®
allows you to:
•
Check benefit eligibility
•
Print ID cards
•
Find current benefit information
•
Review claims
•
And more!
The Delta Dental Mobile App lets you securely access your
benefit information anytime, anywhere and includes:
•
Dentist search
•
Mobile ID card
•
Toothrush timer
Download the app for free for Apple® or Android
by searching for ‘Delta Dental.’
Go to www.DeltaDentalTN.com and log in under
“Toolkits & Resources.” Click on “New User” to
register the first time.
Find a Dentist
Customer Service
Choosing a dentist from the Delta Dental PPOSM or Delta
Dental Premier® networks will help you save money and get
the most from your benefits. You also have the option to
visit any licensed dentist.
Call (800) 223-3104 to reach representatives Monday
– Friday, 7:00am to 5:00pm CST. You can also call
anytime and use DASI, our automated system, to access
information about your eligibility, benefits, claim status, and
listings for nearby dentists.
Go to www.DeltaDentalTN.com and click on
“Find a Dentist” or call (800) 223-3104.
NAME
NAME
CLIENT
CLIENT
CLIENT NO.
CLIENT NO.
SUBSCRIBER ID
SUBSCRIBER ID
21
Understanding your Explanation of Benefits
The Explanation of Benefits (EOB) form is your key to understanding dental claim payments.
We produce this form when your claims are processed to give you a record of how your
dental benefits were used. We send the EOB directly to you, and it will provide you with
the information you need, including:
•
•
•
•
•
•
Dental services performed (procedure description)
Dentist fees
Delta Dental’s payment
Your payment
Coordination of benefits information, if applicable
Annual maximums used in the current benefit year
We have included two samples in this brochure to help you understand your EOB:
•
•
Example A shows a complete and fairly simple claim payment.
Example B shows areas of the EOB that would apply to a coordination of benefits.
To access any information you may need about your dental coverage, visit Consumer
Toolkit® at www.DeltaDentalTN.com/consumertoolkit. Consumer Toolkit provides enrollees
and their dependents all the information they need to learn about their plan, review claims
and claim payments, access a searchable dentist directory, and more.
If you have questions, please contact Customer Service at (800) 223-3104. Representatives are
available Monday through Friday from 7:00 a.m. to 5:00 p.m. CST.
22
Example A—EOB (Simple Claim)
Explanation of Benefits
(THIS IS NOT A BILL)
www.DeltaDentalTn.com
1 Patient Name: JANET DOE
2
3
Date of Birth:
Relationship:
Subscriber:
Patient Acct:
4 Business/Dentist: FRIZ FLOSSMOOR, D.D.S.
02-29-1973
SPOUSE
JEFFERY DOE
5
6
7
8
License No.:
Check No.:
Issue Date:
Receipt Date:
Claim No.:
000-000000
XXXXXXXXXXXX
08-25-2013
08-25-2013
00000-0000
9 Pay To: C = Custodial Parent
S = Subscriber
P = Provider
Area/Tooth
Code/Surface
Date of
Service
Procedure
Description
Submitted
Amount
Maximum
Approved Fee
Par Dentist
Savings
Allowed
Amount
CLIENT/ID: 10
S UB CL I E N T : 11
Deductible / P atient
Co-Pay / O ffice V isits
Co-Pay %
Payment
Patient
Payment
Pay
To
PLAN: 12
P R O DUCT: 13
14
15
03
21
30
05
LR
08/25/13
08/25/13
08/25/13
08/25/13
08/25/13
16
EXTRACTION
EXTRACTION
EXTRACTION
EXTRACTION
SURGERY
26
Total
18
19
20
21
22
168.00
168.00
168.00
168.00
255.00
17
110.00
110.00
110.00
110.00
211.00
58.00
58.00
58.00
58.00
44.00
110.00
110.00
110.00
110.00
211.00
.00
.00
.00
.00
.00
100%
100%
100%
100%
100%
927.00-
651.00
276.00
651.00
.00
23
24
110.00
110.00
110.00
110.00
171.00
.00
.00
.00
.00
40.00
611.00
40.00
25
P
P
P
P
P
GENERAL MAXIMUM USED TO DATE
FOR INQUIRIES: 1-800-223-3104
.DELTA DENTAL OF TENNESSEE
240 VENTURE CIRCLE
NASHVILLE, TN 37228-1604
27
.
Payment for these services is determined in accordance with the specific terms of your dental plan and/or Delta Dental’s agreements
with its participating dentists. For inquiries regarding participating dentists, please call the number listed above. Delta Dental’s
payment decisions do not qualify as dental or medical advice. You must make all decisions about the desirability or necessity of
dental procedures and services with your dentist.
If your claim was denied in whole or in part so that you must pay some amount of the claim, upon a written request and free of
charge, we will provide you with a copy of any internal rule, guideline or protocol or, if applicable, an explanation of the scientific or
clinical judgment relied upon in deciding your claim. If you still believe your claim should have been paid in full, you may ask to have
the claim reviewed. Your written request for a formal first level review must be sent within 180 days of your receipt of this EOB to
the address listed. You may submit any additional materials you believe support your claim. A decision will be made no later than 30
days from the date we receive your request. If we again deny the claim, you may request a second level review. The manner in which
to seek a second level review will be included with the letter informing you of our first level review decision. The second level review
decision will be made no later than 30 days from the date we receive your request. If your claim is denied in whole or in part after
both stages, you have the right to seek to have your claim paid by filing a civil action in court within one year from the final denial.
Your privacy is important to us. To access our HIPAA Notice of Privacy Practices, please visit our website.
ANTI-FRAUD TOLL FREE NUMBER
1-800-524-0147 (select option 7)
Insurance fraud signi ficantly increases the cost of health
care. If you are aware of any false information submitted
to Delta Dental, you can help us lower these costs by
contacting us at the number given above. You do not
need to identify yourself.
P at i e n t
23
Co p y
Page 1 of 1
EOB_Subscriber
Example A—EOB (Simple Claim)
1. Patient Name: The first and last name of the person
who received the dental treatment.
2. Relationship: Identifies the relationship of the patient to
the subscriber.
3. Subscriber: The person who has obtained the health
insurance. In the case of employer-sponsored health
insurance, this is the employee.
4. Business/Dentist: The treating business or
dentist name.
5. Check No.: The check number issued by Delta Dental.
20. Allowed Amount: The portion of the dentist’s submitted
fee allowed by Delta Dental for the procedure
performed. Your copayment percentage is based on this
figure.
21. Deductible/Patient Co-Pay/Office Visits: The dollar
amount that was subtracted from the allowed amount
before calculating your payment and Delta Dental’s
payment. Within the column itself a deductible amount
will be preceded with a D, a patient copay with either a
PC or a C, and an office visit with an O or OV.
22. Co-Pay %: The percentage, as stated in your group’s
contract, used to calculate Delta Dental’s payment.
6. Issue Date: The date the EOB was issued. This is also
the date the claim was paid.
23. Payment: The amount paid by your dental plan.
7. Receipt Date: The date the claim was received by
Delta Dental.
24. Patient Payment: The amount you are responsible for
paying.
8. Claim No.: The number assigned to the claim that
corresponds to the EOB. This number and your
subscriber ID number are needed to locate claims and
should be used when making inquiries.
25. Pay To: Identifies whether Delta Dental sent payment to
a custodial parent (C), you (S), or your dentist (P). See
item #9.
26. Total: Column totals.
9. Pay to: This key is for the “Pay To” column in item #25.
It lets you know where payment was sent.
27. ERISA Statement: Delta Dental’s claims appeal
procedures as required by the federal law known as the
Employee Retirement Income Security Act of 1974.
10. Client/ID: The number assigned to the main group
under which you have dental coverage. (This is usually
your employer.)
11. Subclient: The number assigned to the particular
category, branch or location under which you have
dental coverage.
12. Plan: The name of the plan under which you have
dental coverage (e.g. Delta Dental of Tennessee)
13. Product: The benefit plan selected by your group.
14. Area/Tooth Code/Surface: The number or letter of the
tooth or area of the mouth that was treated. For area of
the mouth, 01 = Upper Arch; 02 = Lower Arch;
10 = Upper Right; 20 = Upper Left; 30 = Lower Left;
40 = Lower Right. (For orthodontic EOBs, see
information on following page.)
15. Date of Service: The date treatment was rendered.
16. Procedure Description: A brief description of
the procedure.
17. Submitted Amount: Amount submitted by the dentist.
18. Maximum Approved Fee: The portion of the dentist’s
submitted fee approved by Delta Dental for the
procedure performed. Your out-of-pocket expense is
based on this figure.
19. Par Dentist Savings: The difference between what the
dentist submitted and what Delta Dental will allow. This
is the benefit of seeing a network dentist.
24
Date of Birth:
Relationship:
Subscriber:
Patient Acct:
License No.:
Check No.:
Issue Date:
Receipt Date:
Claim No.:
Example B—EOB (Coordination of Benefits/Processing Policies)
Pay To: C = Custodial Parent
S = Subscriber
P = Provider
Area/Tooth
Code/Surface
Date of
Service
Procedure
Description
Submitted
Amount
Maximum
Approved Fee
Par Dentist
Savings
CLIENT/ID:
S UB CL I E N T :
Allowed
Amount
Deductible / P atient
Co-Pay / O ffice V isits
Co-Pay %
Payment
Patient
Payment
Pay
To
PLAN:
P R O DUCT:
NETWORK:
1. Other Carrier: The name of the primary
dental carrier. (That is, the carrier that
will pay first when you have coverage
ORIGINALLY SUBMITTED:
under more than one dental plan.)
08/25/13
CLEANING
50.00
.00
.00
2. Other Carrier Payment Amount: The
REPLACED BY:
08/25/13
CLEANING
50.00
50.00
50.00
amount paid by the primary carrier for
POLICY CODE: BB0010
the services listed.
3. Originally Submitted: The procedure
THE FOLLOWING POLICIES ARE APPLIED TO EXPLAIN BENEFITS PAYABLE AND ARE NOT INTENDED TO ALTER THE TREATMENT
code the dentist originally submitted on
PLAN DETERMINED BY THE DENTIST AND PATIENT.
the claim form.
BB0010. THE PROCEDURE CODE WAS CHANGED BASED ON THE INFORMATION SUBM 4. Replaced By: The procedure code by
which Delta Dental based its payment
according to the group’s benefit plan
allowances.
5. Policy Code: This code number refers
to a Delta Dental processing policy. The
policy code applies to the services listed
directly above it.
Total
6. Explanation of Policy Codes: The
explanation of each policy code used.
GENERAL MAXIMUM USED TO DATE
1 OTHER CARRIER:
3
4
5
6
OTHER DENTAL PLAN
2 OTHER CARRIER PAYMENT AMOUNT:
.
FOR INQUIRIES: 1-800-223-3104
.DELTA DENTAL OF TENNESSEE
240 VENTURE CIRCLE
NASHVILLE, TN 37228-1604
Please note: When an adjustment is
necessary for a previous claim payment, the
EOB will show the original line information
as well as the adjusted line information. The
policy code(s) relating to the adjustment will
be explained on your EOB.
Payment for these services is determined in accordance with the specific terms of your dental plan and/or Delta Dental’s agreements
with its participating dentists. For inquiries regarding participating dentists, please call the number listed above. Delta Dental’s
payment decisions do not qualify as dental or medical advice. You must make all decisions about the desirability or necessity of
dental procedures and services with your dentist.
If your claim was denied in whole or in part so that you must pay some amount of the claim, upon a written request and free of
charge, we will provide you with a copy of any internal rule, guideline or protocol or, if applicable, an explanation of the scientific or
clinical judgment relied upon in deciding your claim. If you still believe your claim should have been paid in full, you may ask to have
the claim reviewed. Your written request for a formal first level review must be sent within 180 days of your receipt of this EOB to
the address listed. You may submit any additional materials you believe support your claim. A decision will be made no later than 30
days from the date we receive your request. If we again deny the claim, you may request a second level review. The manner in which
to seek a second level review will be included with the letter informing you of our first level review decision. The second level review
decision will be made no later than 30 days from the date we receive your request. If your claim is denied in whole or in part after
both stages, you have the right to seek to have your claim paid by filing a civil action in court within one year from the final denial.
Your privacy is important to us. To access our HIPAA Notice of Privacy Practices, please visit our website.
Orthodontic EOBs
15.
ANTI-FRAUD TOLL FREE NUMBER
1-800-524-0147 (select option 7)
Insurance
fraud signi
increasestreatment:
the cost of health
Area/Tooth Code/Surface: For orthodontic EOBs, this column is used to identify
the stage
of ficantly
orthodontic
care. If you are aware of any false information submitted
T = Total; total fee for orthodontic treatment plan
to Delta Dental, you can help us lower these costs by
I = Initial; initial fee for banding or placement of orthodontic appliances contacting us at the number given above. You do not
to identify
yourself.
Numeric Value(s) (01-99) = The month of the treatment plan processed (forneed
example:
“01”
would be the first month
of treatment after banding, “02” would be the second month of treatment after banding, etc.)
L = Last; completion or last payment by Delta Dental
for the orthodontic treatment plan
P at i e n t Co p y
Page 1 of 1
O = Only; only or one-time payment for orthodontic treatment
EOB_Subscriber
Please note:
• On this EOB, Delta Dental’s total liability and your total liability for orthodontic treatment are shown. (Please see the
information on the line with “T” in the tooth column.) Because this is merely a statement of liability for as long as the
patient remains eligible and in treatment, these figures are not included in the column totals.
•
Delta Dental will automatically make the monthly payments specified on the original orthodontic claim. If treatment
is discontinued for any reason, notify Delta Dental immediately.
•
When an adjustment is necessary for a previous claim payment, the EOB will show the original line information as
well as the adjusted line information. The policy code(s) relating to the adjustment will be explained on your EOB.
25