Prior authorization is the process through which an issuer approves a request to access a covered benefit before the member accesses the benefit. Delta Dental does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a pre-treatment estimate.
A claim is pending when it has been submitted to Delta Dental and is still being processed by the claims department.
If the member fails to pay the full amount of the premium by the date it is due, a grace period will apply. The grace period allows the member additional time to pay the premium without losing coverage. The grace period refers to either a three-month grace period for members receiving advance payments of premium tax credit, or a general grace period for members not receiving advance payments of premium tax credit.
- The general grace period is a 31-day grace period. This means that if a premium, other than the initial premium, is not paid by the date it is due, it may be paid during the following 31 days. Your policy will remain in force during this grace period. The grace period will not apply if, at least 30 days before the due date, Delta Dental has delivered or mailed to your last known address a written notice of our intent not to renew your policy.
- The three-month grace period applies to members receiving advance payments of the premium tax credit who have previously paid at least one full month's premium during the benefit year. Your policy will remain in force during this grace period. If premium payment is not received within the three-month grace period, your coverage will terminate on the last day of the first month of the grace period.
During the three-month grace period, Delta Dental will pay all appropriate claims for services rendered to the member during the first month of the grace period and may pend claims for services rendered to the member in the second and third months of the grace period.
A retroactive denial is the reversal of a previously paid claim, as a result of which the member then becomes responsible for payment. A claim can be denied retroactively, for example, if Delta Dental pays a claim during the grace period and it is discovered that the member has terminated the policy prior to covered services being rendered.
The best ways to prevent retroactive denials are to:
- pay your premium on time online or by phone
- ensure you have provided us with the correct information
- ensure you are covered when services are performed.
To update your individual account information, you can visit the Member Portal.
If an overpayment occurs, it will automatically be given as a credit toward the next month's premium unless the member contacts customer service to request a refund. The refund will be issued in the way the premium was paid, or a refund by check can be requested.
The Essential Health Benefits (EHB) requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary. In the case of orthodontia, this means that only orthodontic treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered an EHB. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.
Coordination of benefits
Coordination of benefits is a procedure for paying health care expenses when people are covered by more than one dental plan. The goal of coordinating benefits is to make sure the cost of the dental procedure is covered within the scope of the plans, without exceeding the amount of the actual bill.
If you or your dependent are covered by two or more dental plans, the coverage will be coordinated in accordance with the coordination of benefit rules set forth in your policies.
Explanation of Benefits
After you visit your dentist, you will receive an Explanation of Benefits. The Explanation of Benefits will display the fee your dentist submitted, the amount Delta Dental will cover and the amount you owe for the service. If you owe any amount, you will need to pay your dentist the remaining balance. Learn more about how to understand your Explanation of Benefits.