SummaHealthDeltaDentalHighPlan

WelcometoDeltaDentalofOhio!

Beginningonyoureffectivedate,youwillbecoveredunderDeltaDentalHighPlanPPOSM(Point-of-Service)andwillhaveaccesstotwoofthenation’slargestnetworksofparticipatingdentists:DeltaDentalPPOSMandDeltaDentalPremier®network.DeltaDentalishonoredthatyouhavechosenus,andwelookforwardtoservingyou.Formoredetails,pleasereviewtheenclosedSummaryofBenefits.

HowcanIsave?

DeltaDentalPPOandDeltaDentalPremierDentists§ Submitsclaimsforyou

§ Onlychargesyouforyourcopaymentanddeductible,ifany;nobalancebilling

§ Out-of-pocketcostsarelikelytobelower

NonparticipatingDentists§ Mayrequireyoutosubmityourownclaims§ Maychargeyouthefullcostofaprocedure§ Mayaskforpaymentinfullupfront

Howwillthedentistreceivepayment?

DeltaDentalPPOandDeltaDentalPremierDentistsPaymentwillbesentdirectlytoyourdentist.

NonparticipatingDentistsYouwillberesponsibleformakingfullpaymenttoyourdentistandthenDeltaDentalwillsendyouthecheckforcoveredservice.

WhatisthedifferencebetweenaDeltaDentalPPOandaDeltaDentalPremierdentist?

Thoughyourbenefitlevelfordentalserviceswillremainthesameregardlessoftheparticipatingstatusofthedentist,yourout-of-pocketcostswilllikelybethelowestifyouuseaDeltaDentalPPOprovider.ThisisbecauseDeltaDentalPPOprovidershaveagreedtoacceptalowerfee(inotherwords,they'veagreedtoalargerclaimdiscount)thanDeltaDentalPremierdentistswouldaccept.Becauseyourcopayments(ifany)arebasedonapercentageofthisfee,thedollaramountofthecopaymentwillbelowerifthedentistacceptsalowerfee.Pleaseseeourattachedpricingsamplesforadetailedexample.

HowcanIfindaparticipatingdentistorfindoutifmydentistparticipates?

Youcanfindparticipatingdentistsbyvisitingourwebsiteatwww.deltadentaloh.comorbycallingDeltaDental’sCustomerServicedepartmentat(800)524-0149.

WhatifmydentistdoesnotparticipateandIwouldlikeDeltaDentaltorecruithim/her?

Ifyourdentistisnotaparticipatingdentistyoucanrequestthatwerecruitthembyvisitingourwebsiteatwww.deltadentaloh.comandcompletingthe“ReferYourDentist”formorbycallingoremailingourCustomerServicedepartment.YoucanalsotalktoyourdentistaboutjoiningaDeltaDentalnetwork.

ShouldItellmydentistmycoveragechanged?

Yes!PleasetellyourdentistthatDeltaDentalofOhioisprovidingyouwithcoverageunderaDeltaDentalPPOplan.Seeenclosedbenefithighlightsforyourdentalplanbenefits.

WherecanIfindinformationaboutmyeligibilityandclaims?

OnceyouareenrolledwithDeltaDental,youcanreviewyoureligibilitystatus,claimsinformation,andbenefitsbyvisitingourConsumerToolkit®atwww.deltadentaloh.com.ThistoolkitwillalsoenableyoutoprintyourownIDcardsandcanprovideyouwithoralhealthtips.

WhatifIaminthemiddleoftreatment?

Weencourageyoutocompletemultiple-stepproceduresinprogress(likecrowns,bridges,ordentures)priortoyoureffectivedatewithDeltaDental.However,DeltaDentalwillcoverservicesthatarecompletedafteryoureffectivedatewhereapplicable.

Tofindaproviderusethecodebelow.

www.deltadentaloh.com

Howwillorthodonticclaimsbeprocessed?

Iforthodontictreatmentiscurrentlyinprogressforyouoroneofyourdependents,pleaseaskyourdentisttosubmitanewtreatmentplantoDeltaDental.Theremainingliabilityoftheclaimwillberecalculatedbasedonthenumberofmonthsleftinthetreatmentplan.DeltaDentalwillalsoreceivetheorthodonticlifetimemaximumhistoryfromyourpreviouscarrier.Yourorthodonticmaximumbenefitavailableunderyournewplanwillbereducedbythebenefitamountusedunderyourpreviousplan.

Whereshouldclaimsbesubmittedforservicesrenderedpriortomyeffectivedate?

Claimsfordentalservicesrenderedpriortoyoureffectivedatemustbesubmittedtoyourpreviousdentalcarriertoreceivereimbursement.

WhatifIhaveotherquestions?

Ifyouhaveotherquestionsaboutyourdentalbenefits,pleasecontactDeltaDental’sCustomerServicedepartmentat(800)524-0149.

PricingExampleDeltaDentalHighPlanPPO(PointofService)

DeltaDentalPPODentist1

DeltaDentalPremierDentist2

Out-Of-NetworkDentist3

ADULTCLEANING

Submittedfee: $80.00 $80.00 $80.00MaximumApprovedFee: $54.00 $77.00 $63.00Coveragelevel: 100% 100% 100%AmountDeltaDentalPays: $54.00 $77.00 $63.00AMOUNTYOUPAY: $0.00 $0.00 $17.00

CROWN

Submittedfee: $950.00 $950.00 $950.00MaximumApprovedFee: $675.00 $898.00 $744.00Coveragelevel: 60% 60% 60%AmountDeltaDentalPays: $405.00 $538.80 $446.40AMOUNTYOUPAY: $270.00 $359.20 $503.60

1. ADeltaDentalPPODentistisonewhohasagreedtoaccepttheDeltaDentalPPOFeeScheduleamountaspaymentinfull.TheDeltaDentalPPOFeeScheduleamountisgenerallylowerthantheMaximumApprovedFeeusedforadentistwhoparticipatesinDeltaDentalPremier.

2. TheMaximumApprovedFeeisthemaximumamountDeltaDentalhasapprovedforaspecificprocedureperformedbyaDeltaDentalPremierdentist.DeltaDentalPremierdentistsagreetoacceptthisamountaspaymentinfull.

3. TheNonparticipatingDentistFeeisthemaximumamountDeltaDentalhasapprovedforaspecificprocedureperformedbyadentistwhodoesnotparticipateineitherDeltaDentalPPOorDeltaDentalPremier.

Fordentalservicesrenderedafteryoureffectivedate,yourdentistshouldsendallclaimsto:

DeltaDentalP.O.Box9085

FarmingtonHills,MI48333-9085