Affordable Care Act (ACA) Dental Plans
Information for individuals who are enrolled in an ACA (Affordable Care Act) certified dental plan through the Health Insurance Marketplace:
Out-of-network Liability and Balance Billing
You must choose a Delta Dental PPO dentist to receive coverage for dental care. PPO dentists accept reduced fees (Delta Dental's PPO allowed fee) as payment in full. Deductible and Co-payment may apply. If Delta Dental's allowed PPO fee is lower than that dentst's usual charge, the dentist cannot "balance bill" you the difference between his or her usual fee and Delta Dental's allowed fee.
If you visit a dentist that is not a part of the Delta Dental PPO network, you may be liable for all charges incurred for dental services received, except for care for an emergency.
Click here to find a Delta Dental PPO dentist.
Enrollee claims submission
If you visit a Delta Dental PPO dentist, then they will submit a claim for you. If the dentist failed to submit a claim on your behalf, you may download a claim form, complete and mail to:
P.O. Box 103
Stevens Point, WI 54421
PAYOR ID: WDENC
Claims must be submitted within one year after dental treatment. For more information or assistance with submitting a dental claim, please call our customer service department at 833-247-4746, Monday through Friday, 8 a.m. - 5 p.m. (Central Time).
Please note: If you visit a dentist that is not a part of the Delta Dental PPO network, you may be liable for all charges incurred for dental services received, except for care for an emergency.
If you receive treatment for an emergency condition from a non-network dentist, you should file a claim only if that dentist has not filed one for you. You should file a claim only after the procedure is completely finished. Do not file for payment before a procedure is completed.
If you receive treatment for an emergency condition from a non-network dentist, we will pay you directly, unless you assign the payment to your dentist.
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual dental care plans, if you do not pay your premium on time, you will receive a 30-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly.
If you are enrolled in an individual dental care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a three-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the three-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
Grace periods and claims pending policies during the grace period
Premiums are to be paid by you to us on each premium due date. While each premium is due by the due date, there is a grace period for each premium payment. If the premium payment is not received by the end of the grace period, coverage will terminate as follows:
- If you do not receive advance payments of premium tax credits for coverage in the Illinois Health Insurance Marketplace and fail to pay the required premium within a 31 day grace period, coverage will terminate retroactively back to the last date premiums were paid. You will be responsible to pay for any claims submitted during the grace period.
- If you receive advance payments of the premium tax credit and have paid at least one full month's premium, you are entitled to a grace period of three consecutive months. During the grace period, we will pay all appropriate claims for services rendered to the covered individual during the first month of the grace period and we may pend claims for services rendered to the covered individual in the second and third months of the grace period.
Claims pending during the Grace Period
When a claim is pending, it means that the claim has been submitted but not yet paid because additional information is needed.
How will you know when your claim is processed?
Network dentists are paid directly: Unless your payment responsibility is zero, you will receive an Explanation of Benefits Statement that describes the services your dentist submitted and the benefits that your dental program covers. The treating dentist will receive an Explanation of Payment along with the payment.
If you receive treatment for an Emergency Condition from a non-network dentist, we will pay you directly, unless you assign the payment to your dentist. Along with our payment, you will receive an Explanation of Payment Statement that describes the services your dentist submitted and the benefits that your dental program covers. If you have assigned payment to your non-network dentist, your dentist will be paid directly
A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.
Delta Dental of Illinois does not retroactively deny claims.
Enrollee recoupment of overpayments
Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to the over-billing by the issuer.
Delta Dental of Illinois does not refund overpayment of premium by the enrollee. If overpayment is received, Delta Dental of Illinois provides credit on the enrollee's account.
Pre-Treatment Estimate timeframes and enrollee responsibilities
A predetermination of benefits, or pre-treatment estimate, for dental procedures is not required. However, a predetermination is recommended for treatment plans exceeding $200. The pre-treatment estimate lets you know in advance whether the requested services are covered under your policy.
Delta Dental of Illinois will typically respond to a request for a pre-treatment estimate for dental services within 72 hours of us receiving the request for urgent cases or 30 days for non-urgent cases.
There are no ramifications for not obtaining a pre-treatment estimate.
Information on Explanation of Benefits (EOBs)
When you are covered by a dental plan, you often receive an explanation of benefits (EOB) from your dental carrier after a trip to the dentist's office. The EOB is not a bill, but rather an explanation of the procedures that were performed at the appointment and what is covered by your particular dental plan.
The EOB includes the portion your plan paid and any amount you may owe (such as the deductible, coinsurance or non-covered services). It should also include an update on how much of your annual maximum has been used and the amount you have paid toward your deductible. Delta Dental of Illinois will send you an EOB after a claim is paid.
You can access your EOB any time through our Member Central.
How will you be notified of Delta Dental of Illinois' Payment determination?
If you make a claim for benefits under your policy, and the claim is denied in whole or in part, you will receive written notification within 30 days after we receive a completed claim form, unless special circumstances require an extension of time for processing. The claim decision will be sent on a form entitled, "Explanation of Benefits Statement".
You will receive an Explanation of Benefits Statement, if you have to pay any portion of the claim, or if payment is issued directly to you for the treatment of an emergency condition. If your payment responsibility is zero, we will issue payment directly to the dentist, and you will not receive an Explanation of Benefits Statement because your claim has been paid in full. However, you may still check claim status on our website or by using the automated phone system.
Coordination of benefits (COB)
Coordination of benefits (COB) is when you and/or your dependents are covered by more than one benefit plan (dual coverage), and the two benefit plans are coordinated so that no more than 100 percent of the total covered expense of any treatment is paid.
Delta Dental of Illinois does not allow Coordination of Benefits on ACA plans purchased through the Health Insurance Marketplace.