Transparency in Coverage

Delta Dental of Nebraska – Individual and Family Plan Claims and Other Important Processing Guidelines

1. Nonparticipating provider liability and balance billing –
   1. What is nonparticipating provider liability and balance billing? Claim payments are based on the Plan’s Payment Obligation, which for nonparticipating providers is the treating dentist's submitted charge or the Table of Allowances established solely by Delta Dental, whichever is less. The Table of Allowances is a schedule of fixed dollar maximums established by Delta Dental for services rendered by a licensed dentist who is a nonparticipating provider. You may be balance billed for any amount that is over allowed amount on the Table of Allowances. Balance billing occurs when a nonparticipating provider bills a subscriber or responsible party for charges other than copayments, coinsurance, or any amounts that may remain on a deductible. The covered person is responsible for all treatment charges made by the nonparticipating provider. When services are obtained from a nonparticipating provider, any benefits payable under the contract are paid directly to the covered person. Under most Delta Dental Individual and Family Plans, YOU ARE FREE TO GO TO THE DENTIST OF YOUR CHOICE. You may have additional out-of-pocket costs if your dentist is not a participating provider with the plan. There may also be a difference in the payment amount if your dentist is not a participating provider with Delta Dental. This payment difference could result in some financial liability to you. The amount is dependent on the nonparticipating dentist's charges in relation to the Table of Allowances determined by Delta Dental. Payments are made by the plan only when the covered dental procedures have been completed. The plan may require additional information from you or your provider before a claim can be considered complete and ready for processing.
2. Subscriber claim submission – When utilizing a participating provider, the provider will submit the claim form on your behalf
   1. How do I submit a claim form for a nonparticipating provider?
      1. Obtain the claim form by calling customer service or clicking here.
      2. Have the dentist perform dental services
      3. Have the dentist, or a member or his/her staff, complete and sign the claim form on your behalf
      4. For benefit plans purchased from Healthcare.gov: Submit the claim form, so that it is received no later than 12 months from the date the services were completed to : Delta Dental of Nebraska, PO Box 9120, Farmington Hills, MI 48333 For all other benefit plans: Send the claim form to the claim submission address on the back of your ID card, so it is received no later than 12 months from the date the services were completed
      5. If you have any questions on this process, For benefit plans purchased from Healthcare.gov: Please call 1-855-663-5677, Monday through Friday between 7am to 7pm Central time to speak with a Customer Service Representative For all other benefit plans: Please call the customer service number on the back of your ID card
3. Grace periods and claims pending policies during the grace period*The grace period explained below, only applies to members of Certified Pediatric Dental Plans purchased through Healthcare.gov or MNsure.org and are receiving Advanced Premium Tax Credits (APTC). For grace periods for other plans, please review your plan booklet and contract.
   1. What is a Grace Period? A 90 day period, after the date the premium payment is due, during which the member can pay their premiums, without penalty or suspension of benefits. If the premium payment has not been made by the end of the grace period, the policy will be terminated for non-payment back to the last day of the month after which the last payment was due. For example, if your premium was due on June 1st, and if the complete premium is not paid by August 31st, the policy will be terminated back to June 30th.
   2. What will happen to my claims during the grace period?Any claims received for a date of service after the first 30 days of the grace period, will be pended until payment is received. If payment is not received by the end of the grace period, the policy will be terminated and the associated claims will be denied due to an inactive policy. If payment is received prior to the end of the grace period, any claims that are pending payment, will be processed according to the provisions and coverage of the plan.
4. Retroactive Denials
   1. What is a retroactive denial? A retroactive denial is the reversal of a previously paid claim, for which the responsible party then becomes responsible for payment to the provider. A retroactive denial will occur after services have been rendered by your dental professional, if the status of your eligibility changes or the plan does not cover the services rendered by the provider.
   2. How can I try to prevent a retroactive denial?There is never a guarantee of benefits until the services are rendered, the claim is submitted, and reviewed against your current eligibly and benefit plan coverage. However, there are numerous ways to assist with the claim processing and in accordance with the coverage in your plan contract, including, but not limited to the following:
      • Pay premium payments on time
      • Call customer service prior to receiving services to verify coverage for the anticipated services
      • Have your provider submit a pretreatment estimate to determine coverage and payment that will be made for anticipated services
      • Respond in a timely manner to all correspondence received from the exchange or Delta Dental of Nebraska
5. Subscriber Recoupment of Premium Overpayments
   1. What is a Premium Overpayment?A premium overpayment is the result of a situation where Delta Dental of Nebraska may have over-billed the subscriber for premiums due on the account.
   2. If I believe that I am due a refund of premium payment due to a premium overpayment what should I do?Many times, Delta Dental will notice the overpayment on your account and automatically issue you a premium overpayment refund without any action needed on your part. If you believe you are due a refund due to a premium overpayment for your dental policy, please call the customer service number on the back of your ID card. The Delta Dental Customer Service Representative will review your current premium account status and determine if a premium overpayment refund is due. If a refund is due, the customer service representative will process the refund according to our refund process and processing times.
   3. How will I receive my refund if one is owed to me?In general, a premium refund will be refunded to you in the way the premium was paid. If the premium was paid via a check, then your refund will be sent as a check to the address on record. If the premium was paid via an ACH payment or credit card, and is processed within the timeframes allowed by the issuing bank, the refund will be returned to the ACH or credit card account. If the timeframe has passed, then the refund will be issued via a check to the address on record.
6. Dental necessity and pretreatment estimates timeframes and subscriber responsibilities
   1. What is a pretreatment estimate?The pretreatment estimate is a valuable tool for you and your dentist. It is a claim-like form that the dentist submits, which includes the treatment codes that the dentist anticipates performing as part of your treatment plan. While it is a good idea to get a pretreatment estimate prior to receiving dental care that involves major, periodontic or prosthetic services, it is not required. Submission of a pretreatment estimate allows you and your dentist to determine what benefits you have for the treatment plan submitted. The pretreatment estimate outlines what you will have to pay to the dentist, such as co-payments, coinsurances and deductibles. It allows the dentist and you to make any necessary financial arrangements before your treatment begins. This process does not prior authorize the treatment, nor does it determine its dental or medical necessity.The estimated payment is based on your current eligibility and contract benefits in effect at the time of the estimate. It is an estimate ONLY. Submission of additional claims or services, a change in eligibility, or a change in your coverage or other coverage you have may alter the final payment.*In the case of coverage for pediatric orthodontic treatment for certified pediatric dental plans, the pretreatment estimate and any other documentation submitted will be used to determine dental necessity and determine the applicability of coverage under your benefits plan.
   2. How does dental necessity affect Delta Dental’s claim processing?Delta Dental of Nebraska does not determine whether a service submitted for payment or benefit under the Plan is a dental procedure that is dentally necessary to treat a specific condition or restore dentition for an individual. Delta Dental evaluates dental procedures submitted to determine if the procedure is a covered benefit under your dental plan. Your dental Plan includes a preset schedule of dental services that are eligible for benefit by the Plan. Your dentist may recommend or prescribe other dental care services that are not covered, are cosmetic in nature, or exceed the benefit frequencies of this Plan. While these services may be necessary for your dental condition, they may not be covered by Delta Dental. There may be alternative dental care service available to you that is covered under your plan. These alternative services are called optional treatments. If an allowance for an optional treatment is available, you may apply this allowance to the initial dental care service prescribed by your dentist. You are responsible for any costs that exceed the allowance, in addition to any coinsurance or deductible you may have. Services that are not covered by the Plan or exceed the frequency of Plan benefits do not imply that the service is or is not dentally necessary to treat your specific dental condition. You are responsible for dental services that are not covered or benefited by the Plan. The decision as to what dental care is best for you is solely between you and your dentist.
   3. Does a pretreatment estimate expire? A pretreatment estimate does not expire, however if an extended amount of time has passed, if there have been benefit or enrollment changes, or if there have been changes to your treatment plan, we recommend that you or your provider resubmit the pretreatment estimate so that you can make decisions based on up-to-date information.
7. Information on Explanation of Benefits (EOBs)
   1. What is an Explanation of Benefits (EOB)?An EOB is a statement Delta Dental will send the subscriber to explain what dental treatments and/or services it paid for on a subscriber’s behalf. Including, the payment made by Delta Dental, the subscriber’s financial responsibility, and explanation of services that were denied or pended by Delta Dental in accordance with the plan provisions.
   2. When I will receive an Explanation of Benefits (EOB)?An Explanation of Benefits will be sent to the subscriber when there is a portion of the claim owed by the member or all or some of the claim was denied by Delta Dental. An Explanation of Benefits will not be sent to the subscriber when the entire claim was allowed and paid for by Delta Dental.3) How do I read a Delta Dental EOB?For an explanation on how to read the Delta Dental EOB, please click on this link: Understanding an EOB
      
      If you have additional questions on the EOB, we encourage you to contact the customer service number on the back of your ID card.
      
8. Coordination of Benefits
   1. What is Coordination of Benefits? Coordination of Benefits takes place when a patient is entitled to benefits from more than one dental plan. The plans will coordinate the benefits to eliminate over payments or duplication of benefits. When both plans have COB provisions, the plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent would be secondary. In addition, state laws and regulations often mandate coordination of benefits. Plan sponsors should be certain that the plan they select specifies its method for coordinating benefits with other plans.
   2. What happens if I am entitled to benefits from more than one dental plan? Delta Dental of Nebraska’s Individual and Family Plans do not have a coordination of benefits provision. Therefore, your Delta Dental Individual and Family Plan will always pay first. Your other dental plan(s) can coordinate their payment based on the primary payment made by Delta Dental.