Once you are covered by a dental plan, you will be able to receive dental treatments and have a portion of the cost covered by your dental plan. You or your dentist will need to file a claim every time you receive covered dental treatments.
- Dental claims should be filed within 12 months of the date of service.
- All of your benefits will be processed by Delta Dental immediately upon receipt of your claims.
- If you fail to file a claim within the time specified, you will not receive any payment for your treatment.
- Delta Dental claim forms are available online and from your payroll/personnel officer.
- If you seek treatment from a Delta Dental participating dentist, you will not need to print a claim form; the dentist will have a form and will submit it for you.
If you have any questions about your benefits or a claim payment problem, you should call Delta Dental's toll-free member service unit at 1-800-524-0149, view Delta's Web page at: www.deltadentaloh.com, or send a written inquiry to:
Delta Dental
PO Box 30416
Lansing, MI 48909-7916
Dental claims should be sent to:
Delta Dental
PO Box 9085
Farmington Hill, MI 48333-9085
Disputed Claims Procedure
If you believe Delta Dental incorrectly denied all or part of your claim, here are the steps you can take:
First, you or your dentist should contact Delta Dental's Customer and Claims Services department and ask them to check the claim to make sure it was processed correctly. You may do this by calling the toll-free number, 1-800-524-0149, and speaking with a telephone advisor. You may also mail your inquiry to the Customer and Claims Services department at the address above. When writing, please enclose a copy of your Explanation of Benefits and describe the problem. Be sure to include your name, telephone number, the date and any information you would like considered regarding your claim.
If your claim is still denied, you can submit your claim for a formal review through the Disputed Claims Procedure. Send your request in writing and mail it as Certified Mail, with a return receipt requested, to:
Dental Director
Delta Dental
PO Box 30416
Lansing, Michigan 48909-7916
Please include your name and address, the Subscriber's Social Security Number, the reason you believe the claim was wrongly denied, and any other information you would like considered regarding the claim.
Delta Dental will review your disputed claim. If your claim is still completely or partially denied, Delta Dental will notify you within 90 days after receiving your letter. Delta Dental's notice will explain why the denial was made and will also give you information about the appeal process.
Disputed Claims Appeal Procedure
If you do not agree with the results of the Disputed Claims Procedure, you may appeal to the Board of Directors of Delta Dental or its delegee. To do this, you must file a written request for review before the final appeal date listed in the Dental Director's notice denying your disputed claim. If no date is given in this notice, you have up to 150 days from the date you submitted your first letter under the Disputed Claims Procedure to appeal. Send your written request to the same address, Attention: Board of Directors (or its delegee); it must say why you are requesting a review and why you believe the Dental Director's decision was incorrect. You have the right to review the plan and documents related to it.
In your written request for this review, you may also ask for a hearing with the Board of Directors or its delegee. If the Board of Directors or its delegee decides to convene a hearing, you are entitled - at your own expense - to be represented by legal counsel, to request that a court reporter transcribe the hearing, to present evidence, to request the testimony of witnesses and to cross-examine the witnesses. A decision will be given to you as soon as possible, but not later than 120 days after receiving your written request.
If a hearing is not requested or held, the Board of Directors or its delegee will give you its decision within 60 days after receiving your written request for review. All decisions of the Board of Directors or its delegee will be in writing and will explain why the decision was made.
If you are still not satisfied, you may contact the Ohio Department of Insurance for instructions on filing a consumer complaint by calling 614-644-2673 or 1-800-686-1526. You may also write to the Consumer Service Division of the Ohio Department of Insurance, 2100 Stella Court, Columbus, Ohio 43215-1067.
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