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How to Request a Predetermination of Benefits

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Asking your dental provider to obtain a pre-determination of benefits before a dental procedure is performed can save you from being surprised with a bill for a service you thought was covered.

Dental coverage is a great benefit that is proven to improve oral health by making dental care more affordable. However, it is not designed to cover every dollar for every dental service.

The amount covered by the dental carrier depends on many factors such as group plan design, deductibles, and maximums. Using a network or non-network dentist plays a role in determining coverage level and reimbursement as well. You’ll likely enjoy more out-of-pocket savings if you visit a network dentist.

With all those factors, it is easy to see how you could be surprised with a bill for a service you thought was covered in full or covered at a larger percentage.

 A great way to avoid that surprise is to ask your dental provider to obtain a pre-determination of benefits before a dental procedure is performed. By doing so, you can get good idea of just how much that procedure will cost and what your dental plan covers before the treatment begins.

When Do You Need a Predetermination of Benefits?
It is not required, but we recommend that you ask your dentist to predetermine services over $200. If your dentist recommends a certain procedure that will cost over $200, ask him or her to send a predetermination to Delta Dental of Illinois. We will issue a predetermination that indicates the amount covered for the procedure in advance. Assuming no changes are made to eligibility and no additional benefits for other claims are paid prior to receiving treatment, you and your dentist will have a better idea how much will be covered under the benefit program and how much you will be required to pay for the service.

How Long Will it Take to Receive Approval?
 If you need a predetermination of benefits, encourage your dentist to submit your request electronically. Doing so expedites the turnaround time, receiving a determination in as little as one to five days, and works to avoid lost or misplaced documentation.

What Else Can I Do?
The State of Illinois group plans are self-funded. This means that claims are paid by the State as funds become available. Currently, reimbursement time for network dentists is different than that for non-network dentists.

You can maximize your benefits by using an in-network dentist. You can also encourage your dentist to submit your claims electronically. This allows for the expediting of payments when funds are made available.

Ask your dentist for a predetermination and encourage them to file those requests and any claims electronically.

 Having a clear understanding of your dental benefit coverage, including an estimate of what will be covered and what you may owe, will alleviate the risk of receiving an unexpected bill.

If you have questions about your coverage, you can review your specific information through the Member Connection (you must register first), or contact Delta Dental of Illinois’ Customer Service at 1-800-323-1743 (press 5) or via email at csi@deltadentalil.com.