Fees and Treatment
Q. What is Delta Dental's coverage for resin fillings (also called composite, plastic or white fillings)?
A. Virtually all of Delta Dental's plans cover resin fillings on the teeth where their cosmetic advantages are most important: the six front teeth (incisors and cuspids), and on the facial (cheek side) surfaces of bicuspids. DDSD will cover resin fillings up to the first molar and the buccal surface of the first molar.
When an enrollee whose plan limits resin fillings to front teeth receives a resin filling on a back tooth, Delta Dental makes an allowance toward its cost. The allowance is based on Delta Dental's Maximum Plan Allowance for the equivalent amalgam ("silver") filling. There are other kinds of "white" fillings, such as resin inlays. These are specialized techniques and are excluded from most plans. When they are provided, Delta Dental makes an allowance toward their cost based on the fee for either an amalgam or resin filling, depending on the plan.
Q. Why doesn't Delta Dental of South Dakota allow for posterior composite fillings?
A. Composites are considered to be cosmetic. Amalgams are less expensive and clinically equivalent to composite resins. Delta Dental reimburses dentists for the least costly clinically equivalent fillings in back (posterior) molars.
Q. What fee should I put on the claim form - the Delta Dental allowance or my usual fee?
A. It's your decision. You may submit either fee on your claims.
Q. Is there an advantage to submitting my usual fee on claims?
A. Yes, because Delta Dental will calculate future allowances based on fees submitted on claims by participating dentists.
Q. I don't want to give patients the impression that I am trying to overcharge them. Can I submit claims with the Delta Dental allowance?
A. Yes. However, note that many dental offices submit their usual fees and then adjust off any difference when they get the Delta Dental check. Those offices have not reported any negative reactions from patients.
Q. What does Delta Dental tell my patients if I submit claims with my usual fees, and my fees are higher than Delta Dental's allowances?
A. When Delta's Dental's allowance is less than the fee you submit on the claim, the message on the patient's Explanation of Benefits will state that the approved fee is based on the maximum plan allowance. We use the term "maximum plan allowance" to reduce the chance that your patient will think that something was wrong with your fee.
Q. Will Delta Dental consider a higher allowance for exceptional cases?
A. Yes. Under Delta Dental's definition of the term "Reasonable," you may submit a claim for special consideration. Our dental consultants will review the claim, your brief explanation of the extraordinary circumstances, the radiographs, laboratory reports, etc., and determine if the fee on the claim can be allowed.
Q. Can I bill the patient the difference between my fee and Delta Dental's allowance?
A. When you participate with Delta Dental, if your fee for a service exceeds Delta Dental's maximum plan allowance, participating dentists agree to write-off any difference and not charge this amount to the patient.
Q. If I don't participate with Delta Dental, do my patients still have benefits?
A. Under most plans, your patient will still receive benefits, but he or she may have more out of pocket expenses and the Delta Dental payment will go to the patient.
Q. Am I required to submit a predetermination of benefits before beginning treatment on a patient?
A. In most cases, predeterminations are not required but are strongly encouraged. Predeterminations allow your patient the opportunity to make proper financial arrangements for their portion of the treatment cost before the actual work is begun. Predeterminations also reduce patients' confusion about coverage levels and enhance goodwill among the dentist, the patient, and Delta Dental.
Q. Do I have to take a write-off on a procedure that isn't covered by the patient's dental plan?
A. Services not paid for reasons of deductible, frequency or annual maximums, but covered under the patient's plan, are held to Delta's maximum plan allowance. However, when a procedure is excluded under the patient's benefit plan, you are not required to take a write off.
Q. How do I get a breakdown of my patient's dental coverage?
A. A dental benefits summary is available on-line. Use this link to the portal to view your patient's Benefits/Eligibility.
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