Delta Dental of Colorado Dentist Handbook · 2012-03-03 · Delta Dental of Colorado Provider Handbook -- March 1, 2012 2 member dentists of Delta Dental, is comprised of 14 members

Delta Dental of Colorado Dentist Handbook Addendum A

Delta Dental of Colorado is pleased to furnish you and your staff with the 2012 edition of the Delta Dental Dentist Handbook which is a convenient reference tool developed to provide you with valuable information regarding Delta Dental. This handbook has been adopted by the Delta Dental of Colorado (DDCO) Board of Trustees. It defines the fundamental rules and regulations that all participating dentists have agreed to accept in accordance with their Delta Dental Participating Dentist Agreement. The handbook includes a summary of the background and formation of DDCO and the dental profession involvement, as well as the commitments of participating dentists. The Delta Dental Dentist Handbook also includes essential information regarding the submitting of dental claims, Delta Dental processing policies and other helpful tips. The continued success of Delta Dental of Colorado depends on the active support and involvement of the dentists and dental communities across Colorado. We thank you for your participation in our network. For additional information, please contact Delta Dental of Colorado:

Delta Dental of Colorado P.O. Box 173803 Denver, Colorado 80217-3803 Automated Call Center: 1-800-610-0201 Website: www.deltadentalco.com National Portal: www.deltadental.com

Corporate Mission and Beliefs ...................................................................................................................... 1

Formation of Delta Dental of Colorado (DDCO) .............................................................................................. 1

Delta Dental Organization ............................................................................................................................... 2

Objectives of Delta Dental ............................................................................................................................... 2

Basic Principles of Delta Dental ..................................................................................................................... 2

Delta Dental Membership ............................................................................................................................. 2

Dentist Status ................................................................................................................................................. 2

Fee Basis .......................................................................................................................................................... 3

How To Become A Participating Provider ....................................................................................................... 4

Delta Dental Premier® Participation ........................................................................................................... 4

Delta Dental PPOSM Participation ............................................................................................................... 5

Child Health Plan Plus (CHP+) Participation ................................................................................................ 5

Delta Dental Patient Direct® Participation ................................................................................................. 5

Delta Dental of Colorado Policy Statements ................................................................................................. 6

Delta Dental of Colorado Fee Discount Policy .............................................................................................. 7

Contract Compliance Review ......................................................................................................................... 8

Claim Submission Procedure ........................................................................................................................ 9

Electronic Claim Submission .......................................................................................................................... 9

National Electronic Attachment Inc. – FASTATTACH ................................................................................... 11

Consultant Review ........................................................................................................................................ 11

Supplemental Information .......................................................................................................................... 12

Delta Dental National Account Processing Polices .................................................................................... 12

Processing Policy Codes ................................................................................................................................ 12

Pre-‐Treatment Planning ............................................................................................................................... 12

Pre-‐determination Changes In Treatment ..................................................................................................... 13

Completion Date of Dental Treatment ....................................................................................................... 13

Coordination of Benefits ............................................................................................................................... 13

Emergency Treatment .................................................................................................................................. 14

Hospital Services ........................................................................................................................................... 14

Incentive Programs ...................................................................................................................................... 14

Plaque Control Guidelines ........................................................................................................................... 14

Periodontal Guidelines ................................................................................................................................ 14

Delta Dental Sealant Guidelines .................................................................................................................. 15

Prophylaxis Benefits ..................................................................................................................................... 15

Tooth Movement .......................................................................................................................................... 15

Orthodontic Reporting ................................................................................................................................ 15

Pre-‐Existing Orthodontic Case ..................................................................................................................... 16

Transfer Case ................................................................................................................................................ 16

Standard Information ................................................................................................................................. 16

Language Line Services ................................................................................................................................. 17

Language Line Quick Reference Guide ........................................................................................................ 17

Directory of Delta Dental Member Companies ......................................................................................... 30

The TRICARE Retiree Dental Program ......................................................................................................... 31

Delta Dental of Colorado Provider Handbook -- March 1, 2012 1

Dentist Handbook Established in 1958, Delta Dental of Colorado is the State’s largest and most experienced dental benefits carrier. As a nonprofit organization, we accomplish our mission by developing partnerships with dentists, employers and consumers. Our community partnerships result in real solutions to oral health care issues, with an emphasis on prevention.

Delta Dental of Colorado is a member of the Delta Dental Plans Association, a network of 39 independent dental i n s u r a n c e companies that conduct business in all 50 states as well as in the District of Columbia and Puerto Rico. Delta Dental member companies comprise the largest network in the country. These companies exist to service their providers and enhance their ability to provide dental benefits to customers and subscribers.

Corporate Mission and Beliefs

OUR MISSION To improve the oral health of the communities we serve.

OUR BUSINESS Delta Dental of Colorado assures subscribers, purchasers and participating dentists the finest prepaid dental care programs available in the marketplace today. We accomplish this through Delta Dental’s Participating Dentist Agreements, quality assurance programs, in-depth professional reviews, and commitment to service excellence.

OUR BELIEFS Purchasers

The purchasers of Delta Dental of Colorado dental programs will receive the highest rate of return on their premium dollar, in terms of value and dental services provided to subscribers. Beyond this, Delta Dental of Colorado strives to provide our customers with superior service in all aspects of their dental benefit programs.

Subscribers Our subscribers value dental benefits and good oral health as important components of quality of life. Our benefit programs help them achieve these objectives. We believe that a wide choice of participating dentists, reasonable treatment costs and outstanding service are paramount to our subscribers.

Dentists Since the participating dentist is vital to our Mission, we strive to provide you with timely, direct payment of their submitted claims. We also provide our participating providers a voice in the affairs of the corporation and provide appropriate support services. In exchange, we require participating dentists’ compliance with Delta Dental policies when treating Delta Dental subscribers. We provide timely processing of non-participating dentists’ claims.

Formation of Delta Dental of Colorado (DDCO) Colorado Dental Services, Inc., was founded in 1958 to meet the growing interest in dental prepayment programs. The business name was changed in 1978 to Delta Dental Plan of Colorado when the business became a member of the nationwide organization known as Delta Dental Plans Association (DDPA). In October 2005, Delta Dental Plan of Colorado changed its name to Delta Dental of Colorado. Today, the Delta Dental system, the largest carrier of prepaid dental coverage, is comprised of 39 independent Delta Dental member companies operating in all 50 states, the District of Columbia, and Puerto Rico. Delta Dental’s member companies provide coverage to 56 million people enrolled in 95,000 groups administered locally or nationally. Delta Dental of Colorado (DDCO) was established as a nonprofit health service corporation with the direction and assistance of the Colorado Dental Association. Approximately 88% of Colorado’s practicing dentists participate in at least one of Delta Dental’s networks. The Board of Trustees, elected by participating


member dentists of Delta Dental, is comprised of 14 members representing dentists and non-dentists in the fields of finance, management, labor and education. Delta Dental of Colorado was formed under the statutes governing nonprofit health service Corporations, and is regulated by the Colorado Division of Insurance.

Delta Dental Organization The overall control and policy of Delta Dental of Colorado lies with the Board of Trustees. Administrative policy is controlled by the Executive Committee, which consists of the Chairman, Vice-Chairman, Secretary, Treasurer and one other member of the Board. The Chief Executive Officer handles the routine operation of the corporation. The members of the Board of Trustees are elected for staggered three-year terms. The Board of Trustees elects officers of the Corporation. Trustees are elected via a mail ballot provided to all participating dentists. Election results are announced during a webinar for all participating dentists to attend. Dates and times will be provided via a postcard delivered in the mail. Objectives of Delta Dental Delta Dental strives to provide the best dental care possible at a reasonable cost to subscribers. In addition, Delta Dental renders all matters essential for the purpose of promoting, establishing and operating such dental care programs.

Basic Principles of Delta Dental Any Colorado licensed dentist in an active practice and in good standing with the State Board and Delta Dental of Colorado may participate in Delta Dental programs.

1. The patient and dentist shall have free choice in providing or accepting dental care. No patient shall be denied care because of race, sexual orientation, color, creed, national origin, age or religion.

2. The charge for services should be based upon the dentist’s normal fee and should not be influenced by the source of reimbursement.

3. All programs should encourage a high standard of dental treatment. 4. The administration of the clinical phases of a Delta Dental program should be entirely within

the control of the dental professionals. Professional standards and treatment should be controlled by dentists.

Delta Dental Membership All dentists, licensed and practicing in Colorado are eligible for membership in Delta Dental’s provider networks. Each dentist must execute a Participating Dentist Agreement and follow the rules and regulations, as set forth by the Board of Trustees, which are outlined in this Handbook.

Dentist Status Participating Dentist:

Membership in Delta Dental of Colorado’s networks is an expression of support. A participating dentist is a licensed Colorado dentist who has executed a Participating Dentist Agreement with Delta Dental. Amounts payable to participating dentists under commercial programs will be based on Delta Dental’s Maximum Plan Allowance (MPA) and payment will be made directly to the dentist.

Non-Participating Dentist:

Any licensed dentist who has not executed a Participating Dentist Agreement with Delta Dental is not a member of Delta Dental of Colorado’s network. Amounts payable to a non-participating dentist under commercial programs will be based on the non-participating Maximum Plan Allowance (MPA) for


the region. Payment will be made directly to the patient, unless assignment of benefits is applicable.

Fee Basis Network Fee Management Objectives

Delta Dental of Colorado strategically manages dental fee reimbursement while balancing the needs of its three constituent groups - subscribers/dental patients; dental providers; and Colorado employer groups.

Subscribers/dental patients select DDCO for its ability to provide affordable dental care to the subscriber and the subscriber's family. Dental providers select to participate in DDCO’s network for its ability to provide dental patient volume and the associated revenue for services provided. Colorado employer groups select DDCO for its ability to manage dental costs, offer competitive and effective network discounts, and maintain a high level of employee satisfaction with the dental benefit packages offered by the employer.

DDCO’s network fee management strategy seeks to recognize and optimally balance the different needs and objectives of each group. Given these factors, DDCO’s fee management principles include:

• Annual review of the dental fee paid by competing dental insurance carriers in Colorado

• Consideration of the U.S. Consumer Price Index and Colorado Department of Labor statistics in making annual fee adjustments

• Consideration of median household income changes to evaluate the subscriber/dental patients' ability to pay out-of-pocket costs for dental services

• Consideration of competing dental insurers’ rates and resulting network fee discounts required for retention and acquisition of Colorado employer groups

• Consideration of overall cost and budget allocated to Colorado employer groups

• Review of subscriber/dental patient access to, and utilization of, dental services to ensure subscriber/dental patients are seeking dental care and pursuing recommended dental treatment.

DDCO network fee schedules are reviewed once per year PPO Schedules are published by region and dental specialty on an annual basis. Premier network fees are maintained at a level which will optimize patient flow and marketing success in an increasingly cost-conscious environment. All providers by specialty and region are treated equally with no preferential or disadvantageous handling of one provider relative to his or her peer.

Maximum Plan Allowance (MPA) and two-way pricing Two-Way Pricing is a methodology used by Delta Dental of Colorado for processing and reimbursement of claims from participating and non-participating providers who treat members of Delta Dental Premier groups. With Two-Way Pricing, payment is made based on the approved amount for a procedure. The approved amount is the lesser of the dentist’s submitted fee or the Maximum Plan Allowance (MPA) fee for the procedure performed. For participating providers, any difference in fee between the dentist’s submitted fee and the MPA fee is not chargeable to the patient.

Example 1 (for illustrative purposes only) Participating dentist charges a fee that is greater than the MPA fee:

Procedure

Code Submitted

Approved

Not Chargeable to Patient

D2750 - Crown

$1000

$900

$100


Example 2 (for illustrative purposes only) Participating dentist charges a fee that is less than the MPA fee: Assume the MPA is $900.

Procedure Code

Submitted

Approved Not Chargeable to

Patient

D2750 - Crown

$800

$800

$0

MPA and Balance Billing Balance billing is not allowed because it costs more for our customers. By keeping dental care costs affordable for our members, we are working to increase the patient base enjoyed by all our network providers.

How To Become A Participating Provider Any practicing dentist licensed in the State of Colorado is eligible to apply for participation with Delta Dental of Colorado (DDCO). As a participating Delta Dental Premier provider with DDCO, you also participate as a network provider with all Delta Dental member companies across the country. A listing of the documents required to complete the application process is provided below. For dentists who wish to join the Delta Dental network, please complete all required forms and mail or fax them to Delta Dental of Colorado. After receiving the completed agreement(s) with required paperwork, Delta Dental will process the application(s) and notify the dentist in writing of the effective date of participation. If you have any questions, you may contact our Professional Services Department, Monday - Friday, 8:00 am - 4:30 pm at 303-889-8667, 800-233-0860 x667, or via email to [email protected]. You may FAX or mail the completed forms to:

Fax: Attn Provider Records - 303-741-2230 Mail: Delta Dental of Colorado ATTN: Provider Records, PO Box 5468, Denver, CO 80217-5468

Delta Dental will process your application(s) and notify you in writing of the effective date of your participation. Please allow 1-3 weeks for processing your application. The application process will be delayed if all required documents are not received.

Delta Dental Premier® Participation With Delta Dental Premier, members may choose to visit any licensed dentist. However, members wi th Premier p lans wi l l rece ive a h igher benef i t by seeing a par t ic ipat ing Premier dent is t than a non-par t ic ipat ing dent is t . To apply to participate in the Delta Dental Premier network, just complete and sign the following:

1. Participating Dentist Agreement Summary Disclosure Form

2. Delta Dental Premier Participating Dentist Agreement

3. Substitute Form W-9

4. Colorado Health Care Professional Credentials Application

Per Colorado Revised Statute §25-1-108.7 effective 01/01/2006, the Colorado legislature has mandated that all health care plans engaged in the collection of information used in the credentialing or re-credentialing of health care professionals use the Colorado Health Care Professional Credentials Application. This Application is accepted by all Colorado health care plans with whom you participate and who also require credentialing information for participation. For compliance with standards set by Delta Dental Plans Association (DDPA), all Premier and PPO dentists will be


re-credentialed every four years. An updated credentialing form will be required. Please also submit legible copies of the following:

1. Colorado Dental License 2. Dental Degree 3. D.E.A. Registration 4. Current Malpractice Insurance Declaration Page 5. Basic Life Support (CPR) Certification 6. Specialty Certification, if applicable 7. National Provider Identifier (NPI) Official Notification

Participation in the Delta Dental Premier network is required for participation in any other Delta Dental network and/or program. If participation in Delta Dental PPO or CHP+ is being requested at the same time as Premier participation, the appropriate agreement form must also be completed. Only one copy of the supportive documentation is required for submission with the agreements. Should a dentist choose to participate in additional programs at a future date, updated supportive documentation must be submitted with the new participating agreement.

Delta Dental PPOSM Participation To apply to participate in the Delta Dental PPO network, submit all of the documents required for Delta Dental Premier participation plus the Delta Dental PPO Participating Dentist Agreement. For the most up-to-date Delta Dental Premier and PPO Schedule of Allowances, please visit www.deltadentalco.com. Click on the ‘Provider’ tab, then the Documents tab for a complete listing.

Child Health Plan Plus (CHP+) Participation If you are a Delta Dental Premier dentist and agree to accept PPO fees for only the CHP+ program (and do not wish to join the PPO network), please complete the CHP+ Agreement. If you are not a Delta Dental Premier or PPO dentist, and you wish to participate in the CHP+ dentist network only, please complete and sign the following:

1. Delta Dental CHP+ Participating Dentist Agreement 2. Substitute Form W-9 3. Colorado Health Care Professional Credentials Application

Please also submit legible copies of the following: 1. Colorado Dental License 2. Dental Degree 3. D.E.A. Registration 4. Current Malpractice Insurance Declaration Page 5. Basic Life Support (CPR) Certification 6. Specialty Certification, if applicable 7. National Provider Identifier (NPI) Official Notification

For the most up-to-date Delta Dental CHP+ Schedule of Allowances, please visit www.deltadentalco.com. Click on the ‘Provider’ tab, then the Documents tab for a complete listing.

Delta Dental Patient Direct® Participation If you are a participating Delta Dental Premier dentist you may elect to add Delta Dental Patient Direct. You must complete an agreement if you choose to provide services to individuals enrolled in the Delta Dental Patient Direct discount program. All fees are collected directly from the patient. No claims are submitted to Delta Dental of Colorado, and you receive no payment from Delta Dental of Colorado. You must contact Beta Health to become a Patient Direct participating dentist. Their phone number is: 303-744-3007.


Delta Dental of Colorado Policy Statements 1. Dentist shall complete and submit an ADA-approved dental claim form, paper or electronic, for

completed treatment or pre-treatment estimate. 2. Delta Dental of Colorado may request that the dentist send all radiographs, study models, and

any other information essential to the prompt and efficient processing of the dental claim, or when requested for audit requirements. The costs of submitting to Delta Dental any radiographs, models, information, or any other similar materials requested, are neither separately payable by Delta Dental nor chargeable to the patient/subscriber by a participating member dentist. X-rays will be returned to the Provider’s office if a self-addressed stamped envelope is included with the X-ray. The exception is if payment of benefits for those diagnostic procedures is covered under provisions of dental plan contracts, subject to contract limitations.

3. Reimbursement for services to be performed, or performed, under a Delta Dental program shall not exceed Delta Dental’s Maximum Plan Allowance, or PPO Schedule of Allowances, whichever is applicable.

4. Dentist shall accept paper checks or electronic remittances as payment for benefits covered by Delta Dental programs. Dentist shall not charge, or attempt to charge at any time, an amount greater than the patient’s share of the cost of the treatment as determined by Delta Dental.

5. A dentist shall not discount to the patient any portion of, or all of, the patient’s financial obligation to the dentist for services rendered which are benefits of any Delta Dental program, except as outlined in the discount policy.

6. Delta Dental of Colorado may deny payment of a claim submitted more than twelve months after the date of service.

7. Payment for services rendered by a non-participating dentist under a commercial program will be made directly to the patient or subscriber unless assignment of benefits is applicable.

8. Dentist shall cooperate with Delta Dental in its attempts to review care provided under Delta Dental programs and in problem resolution related to claims.

9. Dentist shall schedule and render all dental treatment in accordance with recognized professional standards of care.

10. Dentist shall conduct his/her practice in accordance with the principles of ethics of the American Dental Association, the Colorado Dental Association, and the local component society within whose jurisdiction they practice.

11. Dentist shall accept total responsibility for the accuracy of information on the ADA-approved dental claim. The submission of false or inaccurate information on the claim or in support of a claim is grounds for revocation of a member’s Participating Dentist Agreement.

12. Providing an ADA-approved dental claim for treatment procedures which are not consistent with the demonstrable needs of a patient is grounds for the revocation of a member’s Participating Dentist Agreement.

13. Completion and submission of paper or electronic claims is not chargeable to the patient or Delta Dental by a participating member dentist.

14. Dentist who violates Delta Dental Board established policy shall be considered in violation of his/her Participating Dentist Agreement. DDCO has the right to terminate a Participating Dentist Agreement for cause. Such cause may include, but is not to limited to, irregular billing, falsification of reports, failure to comply with the terms of any service agreement in force, abusive or threatening language or behavior towards employees of DDCO, failure to comply with audit and certification requirements, falsification of patient or office records, or failure to timely file information and reports as the Board of Trustees deems necessary and proper. Providers shall be terminated, if appropriate, after the DDCO established termination procedure is complete, except in instances of failure to maintain a license or serious misconduct, in which case their status as Providers will be immediately terminated. Any dentist whose Participating Dentist Agreement has been canceled may request reinstatement. Reinstatement procedure will follow the same procedure by DDCO and Provider as termination.

15. Any arrangement in which the fee for any covered service is compensated in whole or in part by barter for goods or services must be supported by documentation of the fair market value, in dollars, which is, or should be, declared pursuant to the Internal Revenue Code of 1986, Section 61, as gross income from any such barter arrangement.

16. The date of service as defined by Delta Dental of Colorado’s Board of Trustees is the date treatment is completed. For multiple appointment procedures, the completion date of the procedure is the date that must be submitted on claims for payment. Completion for crowns, cast restorations and fixed


bridges is the cementation date; for removable full and partial dentures it is the insertion date; and for root canal therapy it is the final fill date.

17. By executing a Delta Dental Premier Participating Dentist Agreement with Delta Dental of Colorado (DDCO), the dentist becomes a participating member dentist in all Delta Dental Premier programs administered by DDCO, as well as any national Delta Dental Premier programs administered by other Delta Dental member companies. Execution of a Delta Dental PPO Participating Dentist Agreement results in the dentist becoming a member dentist in all Delta Dental PPO programs administered by DDCO, as well as any national Delta Dental PPO programs administered by other Delta Dental member companies. In any instance where a specific Delta Dental employer, local or national, requires a separate Participating Dentist Agreement, the DDCO participating dentist is not bound by the specific rules and regulations unless the separate Participating Dentist Agreement is executed.

18. If the deductible and/or co-payment of a claim has been waived and not reported as a discount in advance of Delta Dental’s discovery of such action by the providing dentist, or if a reasonable effort has not been made by the providing dentist to collect the patient’s portion of the fee as determined by Delta Dental, then Delta Dental will recover its entire payment, even if the charge to the patient is subsequently reinstated and collection of that portion is accomplished or reasonably attempted by that dentist.

19. Payment for incomplete, or interrupted, treatment will not exceed one-half of Delta Dental’s share for comparable completed treatment, and will be considered when correctly reported. Delta Dental will have no obligation to make payment for incomplete or interrupted treatment when misreported as completed treatment. Any amount refunded to Delta Dental from mis-reporting is not chargeable to the patient.

20. A Delta Dental participating dentist shall not use any Delta Dental service mark in the provider’s own website, signage, advertising or promotional material. The exception is the indication of the provider’s membership with DDCO in telephone directory listings and the display inside a provider’s office of the Achieve Award Certificate and plaque.

Delta Dental of Colorado Fee Discount Policy 1. Cash Discount

The policy established by Delta Dental’s Board of Trustees provides that participating member dentists “shall not charge or attempt to charge the patient at any time an amount greater than the patient’s share of the cost of treatment”. However, if a patient chooses to make payment in advance of treatment for a cash discount or other fee reduction arrangement, any such arrangement offered is subject to the following policy guidelines:

a) Any cash discount or any other fee reduction arrangement must comply with the provisions of the Colorado Statutes, specifically, but without limitation, C.R.S. 18-13-119, as it may be amended from time to time.

b) Any offer subject to this policy must be limited to payment received prior to, or no later than, the day care is delivered. Any extension of such an offer will disqualify from consideration under these guidelines.

c) The amount to which the discount is applied shall be no greater than the sum of the Delta Dental Maximum Plan Allowance for the services involved. Whether a discount is offered on the total fee or on a portion thereof (such as the subscriber’s co-payment or some other amount less than the total), the actual amount being charged, (that is, the net amount after discount), must be reported on any request for pre-treatment estimate of benefits or claim for payment submitted to Delta Dental; additionally, any such request for pre-treatment estimate or claim for payment must specify the amount of the discount, if any, offered or rendered, as the case may be. Delta Dental shall pay no more than the Delta Dental share of the actual amount charged for the services rendered to the patient.

d) Any offer subject to this policy must be made available to the dentist’s Delta Dental covered patients in the same manner it is made available to any of the dentist’s other patients: patients with other dental benefit coverage and/or patients without any dental benefit coverage. Any dentist making such an offer shall be responsible for complete, detailed records of the services


being discounted, the percentage of discount or dollar amount equivalent, the amount on which the discount was based, and payment date and care delivery date coinciding with any such offer. If requested, the dentist shall provide Delta Dental with details in writing of the office policy and individual applications of that policy to all of his/her patients covered under Delta Dental programs.

2. Professional or Other Courtesy Discount

A discount, or any other fee reduction arrangement offered as a professional, or other courtesy must meet all of the requirements of a cash discount, outlined above, with the following exceptions:

a) It must always be applied to the total fee (not merely a portion such as patient co payment).

b) It does not require payment prior to, or on the day of delivery of care.

3. Employer/Employee Discount A discount or some other fee reduction arrangement may be offered if it meets all of the requirements of a cash discount outlined above with the following exceptions:

a) The services are actually rendered to the employee by the employing dentist or member of the dentist’s staff authorized by license to perform the services.

b) A legal employer/employee relationship exists. c) It must be applied to the total fee (not merely a portion such as the patient co-payment). d) It does not require payment prior to, or on the day of delivery of care. e) The patient is covered by Delta Dental.

4. Dentist’s Family Discount

a) The services are actually rendered to the dentist’s family member by the related dentist or by a member of the dentist’s staff authorized by license to perform the services.

b) It must be applied to the total fee (not merely a portion such as the patient co-payment). c) It does not require payment prior to, or day of care, or delivery

Contract Compliance Review Under the terms of the Participating Dentist Agreement, member dentists agree to follow all rules and regulations established by the Board of Trustees of the Corporation. This includes policies regarding charging and claim submission practices, as well as terms under which the dentists accept payment directly from Delta Dental. Member dentists agree to allow a representative of the Corporation to examine any such records as Delta Dental deems necessary to determine compliance with their Delta Dental Participating Dentist Agreement and all Board policies. Guidance for Contract Compliance Listed below are some key points to help you comply with the terms of your Participating Dentist Agreement and Board policies. Please refer to this Dentist Handbook and the Update Newsletter for policy clarifications and changes. Bookkeeping

• Treatment entries recorded in the ledger must also be recorded in the patient chart • Submit services under the dentist who actually provided the treatment • All charges recorded in the ledger must be submitted on the claim form as well • Fees recorded in the ledger must be the same as fees submitted on the claim • Discounts (any and all) must be applied to the total fee, not just the patient portion • Discounts must adhere to the Delta Dental of Colorado Fee Discount Policy included in the Delta • Dental Dentist Handbook • Participating dentists collect only the patient portion at the time of treatment

Adjustments

• All amounts indicated as “not chargeable” must be recorded as a credit in the patient ledger • In the case of dual insurance, adjustments/write-off amounts should be applied after the secondary

insurance is received


Patient Records

• Patient records must reflect the standard as defined by the Colorado State Board of Dental Examiners.

• Terms and abbreviations must be clear and understood by everyone in the office • All entries must be legible • Dates and all significant, pertinent data regarding the patient evaluation and/or treatment must be

recorded Claims and Procedure Codes

• Procedure codes submitted on the claim must reflect the actual procedure completed • Claims must accurately reflect the dates, procedures and fees recorded in the patient chart and

ledger • The dentist submitted as the treating dentist on the claim form must be the dentist who actually

performed the treatment • Multi-appointment procedures (root canals, crowns, bridges, dentures) must be submitted on

completion date

Claim Submission Procedure

1. When a patient arrives in your office and advises you he/she is covered by a Delta Dental plan, you should determine the correct group and plan type. Information may be obtained for your patient/ subscriber by clicking on the Provider tab on the Delta Dental of Colorado website at www.deltadentalco.com. You may also receive a Patient Benefit Report document by calling Delta Dental’s Automated Call Center at: 1-800-610-0201. The patient also can see their own benefits on the Delta Dental of Colorado website by going to the Subscriber Tab and signing up,

2. Complete an ADA- approved dental claim, electronic or paper. Superbills are not accepted. Completed services and pre-treatment estimates (refer to guidelines in this Handbook) may be included on one ADA-approved dental claim, by dating the services that have been completed. Submit the dental claim to Delta Dental, either by mail or electronically, for processing. Inform the patient that Delta Dental will calculate the portion covered by the plan.

3. Patient eligibility will be determined and the financial obligation of Delta Dental will be calculated. 4. Effective August 1, 2002, Delta Dental of Colorado implemented the no-attachment required policy;

please do not send radiographs or periodontal charting with your claim submission. Requirements for claim review are subject to change at any time, and any diagnostic information required for accurate benefit determination will be requested. When submitting for secondary coverage, the total amount paid by the primary carrier must be included.

5. Effective April 1, 2010, Delta Dental of Colorado will no longer return any X-rays. We recommend sending x-rays only when requested. X-rays received after April 1, 2010 will be securely destroyed. If you require the X-rays be returned, you must provide a self-addressed, postage-paid envelope. You also have the option of submitting X-rays through NEA (National Electronic Attachment). For information regarding NEA, visit their website at: www.nea-fast.com.

6. Upon receipt of the pre-treatment estimate form, discuss the total cost with the patient and commence treatment. When treatment has been completed, record the date(s) of each service performed on the pre-treatment estimate form and return the original form to Delta Dental for processing.

7. Process payment for the patient’s responsibility in your usual manner. Participating members shall not bill the patient for that portion of their charges covered by Delta Dental

Electronic Claim Submission Delta Dental began accepting claims electronically on July 15, 1994, and began accepting electronic attachments in 2001. Effective May 23, 2007, all healthcare providers who utilize electronic transactions are considered covered entities and are required under HIPAA to use a National Provider Identifier (NPI), a unique identifier for each healthcare provider, on those transactions. The NPI #1 regards the provider while the NPI #2 regards the location. There is a box on the claim form for each NPI number.


Electronic claims may be submitted to Delta Dental via a clearinghouse or through the DDCO website at: www.deltadentalco.com. If you choose to transmit claims electronically through a clearinghouse, you must contact your vendor for assistance. Delta Dental of Colorado’s Payor ID Number is 84056. Using the DDCO website to Submit Claims Delta Dental’s website gives you the ability to quickly and easily perform a variety of claims-related tasks for your Delta Dental of Colorado patients. Accessing the website allows you to:

• Verify eligibility and benefits for your Delta Dental of Colorado patients, as well as their maximums, maximum used to date, deductibles, and procedure frequencies

• Submit your claims and pre-determinations directly to DDCO • Review the status of submitted claims • View all pre-determinations • View all claim history of submitted claims • View your daily Direct Deposit payments

Think Direct Deposit doesn’t matter?

Direct Deposit

• Daily payments directly into your bank account • View your check disbursements online 24/7 • No tracking of deposit slips • A safe and secure system that is confidential and protected

Enroll by going to www.deltadentalco.com and click on the Dentist link. Select the Documents tab, then select Direct Deposit Authorization Agreement. Print and complete the form, attach a voided check and fax everything to 303-741-2230, Attention: Provider Records


National Electronic Attachment Inc. – FASTATTACH National Electronic Attachment Inc. (NEA) is a leader in providing Internet-based solutions for the dental industry. Delta Dental of Colorado is one of many companies who have signed an agreement with NEA allowing the acceptance of dental attachments electronically. By utilizing NEA’s FastAttach system, the dental office is able to transmit attachments, such as radiographs, periodontal charting, intra-oral photos, and Explanation of Benefits via the Internet, to NEA’s repository where Delta Dental is able to view them in support of the claim adjudication process. FastAttach may be used with any claims clearinghouse and with any practice management software. Benefits of submitting claim attachments electronically are:

• Elimination of film duplication • Elimination of lost or damaged attachments • Reduction in administrative costs - reduced paperwork, mailing costs, and supplies • Faster claim processing

What is required at the dental office to utilize the FastAttach system?

• Pentium processor computer or equivalent • Windows 95, Windows NT 4.0 or higher • Monitor with video card capable of 24-bit color • Microsoft Internet Explorer 4.0 or higher • An existing account with an Internet Service Provider (ISP) • A means to digitize attachments (scanner or digital X-ray system) • Electronic claim submission • Minimal monthly fee which includes unlimited usage (no per attachment fee), unlimited phone

support, and software upgrades

For more information about NEA and FastAttach, visit www.nea-fast.com or contact NEA directly at 1-800-782-5150, Option 2 on the telephone menu.

Consultant Review Delta Dental has the responsibility of ensuring that the care Delta Dental pays for is:

1. Necessary 2. Appropriate 3. Covered by the contract 4. Priced within Delta Dental’s Maximum Plan Allowance for the geographic area

In addition, it has the responsibility of ensuring that the expenditure of public-funded money is restricted to essential care and that funds are expended in the most judicious manner. Delta Dental’s Review Consultants must meet the following qualifications:

• At least five years in private practice. • Licensed in Colorado and in active practice. • Have completed a successful Contract Compliance Review. • Well-respected by the profession; especially, in his/her own community. • Of high moral and ethical values, strong character, and able to communicate effectively. • Active in post-graduate study and knowledgeable in current dental therapeutics, techniques, and

materials. • Have expertise in radiographic interpretation. • Willing to consider differing opinions and to seek specialist input when indicated. • Willing to communicate with other dentists in a tactful and positive manner.

When a benefit determination is questioned, additional supporting documentation may be sent to the Customer Relations department for reconsideration. Occasionally, Delta Dental does not make payment for a particular procedure. This should not be interpreted as


disagreement with the diagnosis or treatment plan, nor should it be interpreted as questioning the necessity of the procedure. Some necessary procedures may not be covered under the terms of the subscriber contract and are DENIED; the fee is then chargeable to the patient. Payment can only be made for covered procedures. In other cases, a procedure may be considered part of another complete procedure and DISALLOWED; the fee for the procedure is not chargeable to the patient. When a service is referred to as OPTIONAL, it means that it is more complex than is covered by the subscriber’s contract. In those instances, Delta Dental may make payment up to the cost of a standard procedure; however, any additional cost is the responsibility of the patient. For example: Delta Dental may make an alternate benefit allowance for a partial denture with cast clasps toward the cost of a partial denture with precision attachments. Any difference in fee becomes the responsibility of the patient. Delta Dental cannot accept responsibility for care that is not consistent with the needs of the patient. When diagnostic radiographs do not show need, additional diagnostic information should be provided, if requested, to aid the dental consultant in making benefit determinations. Colorado State Law requires Delta Dental to report cases of “suspected or actual insurance fraud” to the State Board of Dental Examiners for review. This includes, but is not limited to, reporting procedures as completed for services not performed and misreporting dates of services to conform to deductible and/or annual maximum benefits.

Supplemental Information The procedure codes listed in the most current version of the ADA CDT Code on Dental Procedures and Nomenclature are used in the completion of an ADA approved dental claim form. The ADA CDT Codes are provided on DDCO’s website. In cases where the need for services being provided may not be readily apparent to a dental consultant who has not examined the patient, descriptive statements regarding treatment not easily discernable from procedure codes or radiographs are helpful. They may be included in the Remarks Section on the dental claim form or on a separate sheet attached to the dental claim form. Comments explaining the need for unusual fees and/or procedures are also helpful in determining patient benefits and generally accelerate claims processing.

Delta Dental National Account Processing Polices Delta Dental National Account Processing Policies describe general policies related to the processing of dental procedure codes and are applied in the absence of specific group contract provisions, limitations, and exclusions. Participating dentists agree to abide by all national processing policies for all Delta Dental member companies. The Processing Policies document, which can be found on Delta Dental’s website at www.deltadentalco.com under the Documents tab, should not be interpreted as encompassing all possible limitations and exclusions, since contractual terms can vary among groups. It is recommended that the dental office contact the appropriate Delta Dental member company to determine the specific limitations and exclusions applicable for an individual employer group since group contracts can vary.

Processing Policy Codes Whenever a dentist is providing a service that is not covered by the patient’s dental program, a service is denied or disallowed due to Delta Dental policy, or an alternate benefit allowance is made towards the cost of treatment actually performed, Delta Dental will advise the dentist of the reason the procedure is reduced or denied through the use of processing policy codes. Policy codes are indicated by number and description on the Pre-treatment Estimate Form, the Check Disbursement form, and the Explanation of Benefits.

Pre-‐Treatment Planning Pre-treatment planning is used to determine which of the necessary services are covered under contract


provisions. From that determination, the financial obligation of Delta Dental and the patient/subscriber are calculated. Once a pre-treatment plan is submitted, a pre-treatment estimate or a pre-determination will be returned to the dental office. This information will tell the dentist and the patient, in advance, which treatment is covered, and if the patient is eligible for the procedure codes submitted. Although it is possible for the dental office to make an estimate of the amount Delta Dental may pay in a particular case by referring to the information provided by Delta Dental’s website or faxed Patient Benefit Report, it is not possible for the dental office to be aware of all the factors which may affect the payment calculation unless a Pre-determination is completed. Not all groups cover the same services. Pre-determination is never granted over the phone. The accepted method for receiving a Pre-determination is to prepare and submit a standard ADA dental claim to the Delta Dental office, either electronically or by mail. After Delta Dental has processed the submitted claim, verified eligibility, and determined contractual allowances, a Pre-determination form will be returned to your office by mail. Once service has been completed, simply fill in the date of service on the Pre-Determination and return it to Delta Dental for processing. No need to file a new claim. It is recommended that a Pre-determination be obtained for the following procedures:

• Special restorations • Fixed prostheses (bridges) • Oral surgery (partial and full bony impactions) except emergency procedures • Periodontal treatment • Orthodontic treatment

Pre-determination is required by certain subscriber contracts for the following procedures:

• Plaque control programs (when allowed by a specific dental plan) • Temporomandibular joint disorder related services (some dental plans also require a second

opinion be obtained prior to treatment) • Implant services

Pre-‐determination Changes In Treatment For minor changes in the treatment plan, draw a line through any services on the Pre-determination that will not be performed. Add the new service not previously reported to the bottom of the Pre-determination form. If major changes to the Pre-determination form are necessary, void your initial treatment plan and send a new ADA-approved dental claim form to Delta Dental for a new Pre-determination.

When additional services are required and are unrelated to procedures on the original Pre-determination form, please send a new ADA-approved dental claim form for payment or a new Pre-determination of these procedures.

Completion Date of Dental Treatment For multiple appointment procedures, the completion date of the procedures must be submitted on claims for payment. By contract, Delta Dental can pay benefits only for completed treatment. Completion date for cast crowns and fixed bridges is the cementation date, for dentures and partials it is the insertion date, and for root canal treatment it is the final fill date.

Coordination of Benefits Delta Dental contracts contain provisions for patients covered simultaneously under two or more programs. These provisions are designed to give maximum coverage, but not to exceed 100% payment for covered services.


For a patient eligible for coverage under two or more dental care programs, a claim must be filed with each carrier. If the patient has dual coverage under two Delta Dental member companies, a claim must be filed under each employee. All secondary claims must include a copy of the primary Explanation of Benefits. When filing an ADA dental claim to be coordinated between two dental plans, complete the patient sections, particularly those items regarding dual coverage. It is critical to supply the name, social security number or alternate ID, birth date, and group number of the other employee. Failure to provide all necessary information may result in claim denial. To determine the order of benefit payment, the plan covering the patient as the employee has the primary responsibility for payment, before the plan covering the patient as a dependent. If the patient is a dependent child, the plan covering the patient as primary is the plan of the parent whose birthday falls first in the calendar year. The plan of the patient whose birthday falls second in the calendar year has secondary responsibility. This rule applies only if the parents are married.

Emergency Treatment Emergency treatment may be rendered to an eligible patient without a Pre-treatment Estimate from Delta Dental. Emergency treatment is defined as the elimination of acute infection, bleeding and/or severe pain. Completed endodontia is not considered emergency treatment.

Hospital Services Delta Dental provides for covered services rendered in a hospital or outpatient surgical center, as requested by the attending dentist. However, all hospital or surgical center costs and any additional costs for providing covered procedures in a hospital setting are the responsibility of the patient.

Incentive Programs Certain contracts provide for the decrease in patient co-insurance percentages each year the patient is eligible and necessary treatment is completed. As the co-insurance percentage of the patient decreases, benefits for covered services increase in 10% increments beginning at 70% or 80%. Prosthodontic and Orthodontic benefits do not qualify for co-insurance decreases. Depending on the contractual limitations, if the patient does not visit a dentist in a calendar year the following will happen:

• The incentive level will drop to the beginning level. • The incentive level will remain at the highest level last achieved.

Plaque Control Guidelines Some Delta Dental contracts provide plaque control programs as a benefit once per patient per his/her lifetime. In these situations, payment will be made if the service Pre-treatment Estimate is completed prior to services being started. To be a benefit, a control program must meet the following guidelines.

• Systematic and repetitive instruction of patients in the techniques and skills necessary to remove plaque from their own teeth.

• Proper use of toothbrush, floss, disclosing tablets or other aids to achieve control of plaque. • Suitable instruction to the patient on the importance of plaque removal.

Periodontal Guidelines When reporting periodontal treatment, list procedures with the ADA CDT code number as individual line items on the ADA dental claim and include applicable quadrant designations. A Pre-treatment Estimate of benefits for periodontal treatment should be obtained in a two-stage manner.


The initial stage should be successfully completed and evaluated before the second stage (surgical) is initiated. A Pre-determination for a surgical phase, in most cases, should not be requested until completion phase. If you feel surgery is indicated prior to completion of the phase, attach a note of explanation. Use the ADA dental claim form to list each planned procedure for benefit determination prior to each stage. A Pre-determination form will be returned, indicating the benefits available. Simply indicate the completion date of each service on the Pre-determination, sign and return it to Delta Dental for payment. If you have submitted your Pre-Determination electronically through the DDCO website, you will be able to submit your Pre-determination form as a claim form.

Delta Dental Sealant Guidelines Not all Delta Dental employer groups include sealant coverage in their dental plan contract. When covered, sealants are subject to the following guidelines adopted by Delta Dental:

• Sealants must be placed after eruption of the tooth and as soon as it is possible to isolate. • Routine coverage will be made for sealants applied to occlusal surfaces of permanent molars

without caries or restorations on the occlusal surface, for children through age 14. • No additional coverage will be made for replacement or repair within 36 months of initial

application.

Prophylaxis Benefits The majority of Delta Dental programs provide coverage for two prophylaxes (codes D1110, D1120) in twelve months or two in a calendar year, depending on the contract. The cost of additional prophylaxes is the patient’s responsibility. Some, but not all, programs provide coverage for additional prophylaxes when special need exists. In these cases written documentation of the special need signed by the attending dentist must be submitted for consideration. For some patients with periodontal problems, follow-up preventive periodontal procedures (code D4910) may be necessary. Only when a patient has a history of periodontal disease with documentation of prior definitive periodontal treatment (such as scaling and root planing, or osseous surgery) may Periodontal Maintenance (“perio prophys”) be a covered benefit by the contract provisions.

Tooth Movement Orthodontic care is covered under Delta Dental programs if the employer has elected it. However, most basic (non-orthodontic) plan designs include coverage for preventive services, one of which is space maintenance. A passive appliance designed to maintain space is covered under preventive services of a basic dental plan. An active appliance, which may be intended to maintain space as one function, but also accomplishes tooth movement, is a covered benefit if the dental plan contract includes Orthodontic benefits.

Orthodontic Reporting Orthodontic care, as covered by many of Delta Dental’s groups, provides for the necessary procedures associated with the movement of teeth into proper alignment, position, and occlusion. Use of the following outline should minimize procedural problems.

1. Prepare initial records, diagnosis, and treatment plan. 2 . Complete an ADA-approved dental claim form in order for Delta Dental to determine its obligation

under your patient’s contract. The completed claim form will allow Delta Dental to set up the necessary records so future payments can be made automatically.

3 . Be certain to include the following on the ADA-approved dental claim form: o The total fee o Initial fee (including banding date if treatment has commenced) o Monthly fee o Total number of treatment months o Previous amount paid by prior carrier (for a patient in active treatment when they


become eligible for Delta Dental benefits) If treatment has not started and you are requesting a Pre-treatment Estimate, Delta Dental will process the ADA-approved dental claim form, verify eligibility, and determine contractual allowances. A Pre-determination form showing the orthodontic benefits allowed under the group contract will be returned to your office. Eligibility is verified for the month the Pre-determination is received.

Pre-‐Existing Orthodontic Case If a patient is currently in active treatment when they become eligible for Delta Dental benefits, use the following procedure:

1. Send a completed ADA-approved dental claim including original treatment codes, total case fee, banding date, and total number of treatment months.

2. Delta Dental will calculate the balance to be paid based on the eligibility of the patient and maximum benefit remaining.

Transfer Case If a patient transfers to your office during treatment, the following procedure will apply:

1. Send a completed ADA-approved dental claim including original treatment codes, total case fee and total number of treatment months to complete the case.

2. Delta Dental will calculate the balance to be paid based on eligibility of the patient and maximum benefit remaining.

Standard Information Fee Basis

• Delta Dental Premier Maximum Plan Allowance (MPA) • Delta Dental PPO Schedule of Allowances

Services Covered*

• Diagnostic • Preventive • Basic Restorative (fillings) • Oral Surgery • Endodontics • Periodontics • Major Restorative • Prosthodontics

* Subject to standard contract limitations Services Not Covered

• Plaque control programs • Correction of congenital, development or acquired malformations, except intraoral dental services for

the treatment of a condition that is related to, or developed as a result of, cleft lip and/or palate. • Associated sedation procedures • Cosmetic dentistry • Procedures necessary to alter or correct occlusion or vertical dimension, attrition, abrasion, or

restoration of tooth structure lost through wear.

Additional Services* • Orthodontic Services • Treatment for disturbances of the temporomandibular joint • Implant Services

*Refer to individual subscriber contract information


Eligibility* Eligibility for a patient may be changed at any time due to amendments by the purchaser or selections made by the member. Please verify patient eligibility through use of Delta Dental’s Automated Call Center or the DDCO website should you have any questions.

*NOTE: Since many dental programs have voluntary spouse/dependent coverage, Delta Dental cannot guarantee eligibility unless a Pre-treatment Estimate has been completed prior to beginning any services.

Language Line Services Delta Dental of Colorado is pleased to offer a value-added service to DDCO participating providers through our association with Language Line Services. An interpreter service, Language Line offers services in over 150 different languages representing over 98% of all customer requests. Line Services can assist in establishing effective communications with your limited English-speaking patients, at no charge to you. You can access the Language Line Services Quick Reference Guide and Language Line Services Tutorial through Delta Dental’s website under the Documents tab.

Language Line Quick Reference Guide Delta Dental of Colorado – Provider Services Keep this Quick Reference Guide (QRG) nearby for easy reference to effectively utilize Language Line Over-the-phone Interpretation Service.

When receiving a call:

1. Use Conference Hold to place the non-English speaker on hold. 2. Dial 866-876-7189 3. Press 1 for Spanish and PRESS 2 for all other languages. Speak the name of the language.

NOTE: If you need assistance, press 0 or stay on the line to be connected to a representative. 4. Enter on your phone key pad, or tell the representative: • Client ID Number 7 3 6 4 1 7 • Organization Name Delta Dental of CO – Provider Services • Personal/Access/User Code: Please enter your 9-Digit Tax ID Number • An Interpreter will be connected to the call.

5. Brief the interpreter. Summarize what you wish to accomplish and give any special instructions.

6. Add the non-English speaker to the line. 7. Say, “end of call” to the Interpreter when the call is completed.

When placing a call to a non-English speaker, begin at Step 2. If you need assistance placing a call to a non-English speaker, please inform the interpreter at the beginning of the call. Use the following important tips to help you optimize your experience.

• Unknown language: If you do not know which language to request, our representative can help. Line quality problems: Explain the problem and ask the representative to stay on the line to check for sound quality. If you have problems before reaching a representative, press “0” to be transferred.

• Working with an interpreter: Give the interpreter specific questions to relay. Group your thoughts or questions to help conversation flow quickly.

• Length of Call: Expect interpreted comments to run a bit longer than English phrases. Interpreters convey meaning-for-meaning, not word-for-word. Concepts familiar to English speakers often require explanation or elaboration in other languages and cultures.

• Interpreter identification: Our interpreters identify themselves by first name and number only. For reasons of confidentiality, they do not divulge either their full names or phone number.

• Demonstration line: To hear a recorded demonstration of over-the-phone interpretation call our demonstration line at 1 800 996-8808 or visit our website at www.LanguageLine.com.

• Document translation: We also provide written translation services, for more information you can contact our Document Translation Department at 1 888 763-3364 or e-mail us at Translation@


LanguageLine.com. Customer Service Department: 1-800-752-6096, Option 1. © 2003 Language Line Services • 2/13/03 1 Lower Ragsdale Drive • Monterey, CA 93940 • www.LanguageLine.com


Directory of Delta Dental Member Companies All Dentists participating with Delta Dental of Colorado in the administration of DDCO dental programs are also considered participating under similar programs of Delta Dental member companies.

Alabama Florida Send Claims to: Send Claims to: Delta Dental Insurance Company Delta Dental Insurance Company PO Box 1809 PO Box 1809 Alpharetta, GA 30023-1809 Alpharetta, GA 30023-1809 (800) 521-2651 www.deltadentalins.com (800) 521-2651 www.deltadentains.com

Alaska Georgia Send Claims to: Send Claims to: ODS Health Plans Delta Dental Insurance Company PO Box 40384 PO Box 1809 Portland, OR 97240-0384 Alpharetta, GA 30023-1809 (800) 452-1058 www.odscompanies.com (800) 521-2651 www.deltadentalins.com

Arizona Hawaii Send Claims to: Send Claims to: Delta Dental of Arizona Hawaii Dental Service PO Box 43000 700 Bishop Street Suite 700 Phoenix, AZ 85080-3000 Honolulu, HI 96813-4196 (800) 352-6132 www.deltadentalaz.com (800) 232-2533 ext. 248 www.deltadentalhi.org

Arkansas Idaho Send Claims to: Send Claims to: Delta Dental of Arkansas Delta Dental of Idaho PO Box 15965 PO Box 2870 Little Rock, AR 72231-5965 Boise, ID 83701 (800) 462-5410 (800) 356-7586 www.deltadentalid.com

California Illinois Send Claims to: Send Claims to: Delta Dental of California Delta Dental of Illinois PO Box 997330 PO Box 5402 Sacramento, CA 95899-7330 Lisle, IL 60532 (800) 765-6003 www.detladentalca.com (800) 323-1743 www.deltadentalil.com

Colorado Indiana Send Claims to: Send Claims to: Delta Dental of Colorado Delta Dental of Indiana PO Box 173803 PO Box 9085 Denver, CO 80217-3803 Farmington Hills, MI 48333-9085 (800) 610-0201 (800) 524-0149 www.deltadentalin.com (800) 233-0860 www.deltadentalco.com

Connecticut Iowa Send Claims to: Send Claims to: Delta Dental of New Jersey Delta Dental of Iowa PO Box 222 PO Box 919 Parsippany, NJ 07054-0222 Ankeny, IA 50021-0919 (800) 452-9310 www.deltadentalct.com (800) 544-0718 www.deltadentalia.com Delaware Kansas


Send Claims to: Send Claims to: Delta Dental of Pennsylvania Delta Dental of Kansas One Delta Dental Drive PO Box 789769 Mechanicsburg, PA 17055-6999 Wichita, KS 67278-9769 (800) 932-0783 www.deltadentalins.com (800) 234-3375 www.deltadentalks.com

Kentucky Montana Send Claims to: Send Claims to: Delta Dental of Kentucky Delta Dental Insurance Company PO Box 242810 PO Box 1809 Louisville, KY 40224-2810 Alpharetta, GA 30023-1809 (800) 955-2030 www.deltadentalky.com (800) 521-2651 www.deltadentalins.com

Louisiana Nebraska Send Claims to: Send Claims to: Delta Dental Insurance Company Delta Dental of Minnesota PO Box 1809 PO Box 245 Alpharetta, GA 30023-1809 Minneapolis, MN 55440-0245 (800) 521-2651 www.deltadentalins.com (866) 827-3319 www.deltadentalne.org

Maine Nevada Send Claims to: Send Claims to: Northeast Delta Dental Delta Dental Insurance Company One Delta Drive PO Box 1809 PO Box 2002 Alpharetta, GA 30023-1809 Concord, NH 03302-2002 (800) 521-2651 www.deltadentalins.com (800) 537-1715 www.nedelta.com

Maryland New Hampshire Send Claims to: Send Claims to: Delta Dental of Pennsylvania Northeast Delta Dental One Delta Dental Drive One Delta Drive Mechanicsburg, PA 17055-6999 PO Box 2002 (800) 932-0783 www.deltadentalins.com Concord, NH 03301-2002

(800) 537-1715 www.nedelta.com

Massachusetts New Jersey Send Claims to: Send Claims to: Delta Dental of Massachusetts Delta Dental of New Jersey PO Box 9695 PO Box 222 Boston, MA 02114 Parsippany, NJ 07054-0222 (800) 872-0500 www.deltadentalma.com (800) 452-9310 www.deltadentalnj.com

Michigan New Mexico Send Claims to: Send Claims to: Delta Dental of Michigan Delta Dental of New Mexico PO Box 9085 2500 Louisiana Blvd NE Suite 600 Farmington Hills, MI 48333-9085 Albuquerque, NM 87110 (800) 524-0149 www.deltadentalmi.com (877) 395-9420 www.deltadentalnm.com

Minnesota New York Send Claims to: Send Claims to: Delta Dental of Minnesota Delta Dental of Pennsylvania PO Box 330 One Delta Dental Drive Minneapolis, MN 55440-0330 Mechanicsburg, PA 17055-6999 (800) 553-9536 www.deltadentalmn.org (800) 932-0783 www.deltadentalins.com Mississippi North Carolina


Send Claims to: Send Claims to: Delta Dental Insurance Company Delta Dental of North Carolina PO Box 1809 PO Box 1609 Alpharetta, GA 30023-1809 Minneapolis, MN 55440-1609 (800) 521-2651 www.deltadentalins.com (800) 662-8856 www.deltadentalnc.org

Missouri North Dakota Send Claims to: Send Claims to: Delta Dental of Missouri Delta Dental of Minnesota PO Box 8690 PO Box 330 St Louis, MO 63126-0690 Minneapolis, MN 55440-0330 (800) 392-1167 www.deltadentalmo.com (800) 553-9536 www.deltadentalmn.org

Ohio Tennessee Send Claims to: Send Claims to: Delta Dental of Michigan Delta Dental of Tennessee PO Box 9085 240 Ventura Circle Farmington Hills, MI 48333-9085 Nashville, TN 37228 (800) 524-0149 www.deltadentaloh.com (800) 223-3104 www.deltadentaltn.com

Oklahoma Texas Send Claims to: Send Claims to: Delta Dental of Oklahoma Delta Dental Insurance Company PO Box 54709 1701 Shoal Creek #240 Oklahoma City, OK 73154-1709 Highland Village, TX 75007 (800) 990-7337 www.deltadentalok.org (800) 521-2651 www.deltadentalins.com

Oregon Utah Send Claims to: Send Claims to: ODS Health Plans Delta Dental Insurance Company PO Box 40384 PO Box 1809 Portland, OR 97240-0384 Alpharetta, GA 30023-1809 (800) 452-1058 www.odscompanies.com (800) 521-2651 www.deltadentalins.com

Pennsylvania Vermont Send Claims to: Send Claims to: Delta Dental of Pennsylvania Northeast Delta Dental One Delta Dental Drive One Delta Drive Mechanicsburg, PA 17055-6999 PO Box 2002 (800) 932-0783 www.deltadentalins.com Concord, NH 03301-2002

(800) 537-1715 www.nedelta.com

Puerto Rico Virginia Send Claims to: Send Claims to: Delta Dental of Puerto Rico Delta Dental of Virginia PO Box 9020992 4818 Starkey Road San Juan, PR 00902-0992 www.deltadentalpr.com Roanoke, VA 24018

(800) 237-6060 www.deltadentalva.com

Rhode Island Washington Send Claims to: Send Claims to: Delta Dental of Rhode Island Washington Dental Service PO Box 1517 PO Box 75983 Providence, RI 02901-1517 Seattle, WA 98125-0983 (800) 843-3582 www.deltadentalri.com (800) 554-1907 www.detladentalwa.com South Carolina West Virginia Send Claims to: Send Claims to:


Delta Dental of Missouri Delta Dental of Pennsylvania PO Box 8690 One Delta Dental Drive St Louis, MO 63126-0690 Mechanicsburg, PA 17055-6999 (800) 335-8266 www.deltadentalmo.com (800) 932-0783 www.deltadentalins.com

South Dakota Wisconsin Send Claims to: Send Claims to: Delta Dental of South Dakota Delta Dental of Wisconsin PO Box 1157 PO Box 828 Pierre, SD 57501 Stevens Point, WI 54481-0828 (800) 627-3961 www.deltadentalsd.com (800) 236-3712 www.deltadentalwi.com

Wyoming District of Columbia Send Claims to: Send Claims to: Delta Dental of Wyoming Delta Dental of Pennsylvania PO Box 29 One Delta Dental Drive Cheyenne, WY 82003-0029 Mechanicsburg, PA 17055-6999 (800) 735-3379 www.dentaldentalwy.org

Delta Dental of Colorado Handbook 2012 31

The TRICARE Retiree Dental Program The TRICARE Retiree Dental Program (TRDP) was authorized by Congress in 1997 to provide a basic dental program for Uniformed Services retirees and their family members. The U.S. Department of Defense awarded the first five-year contract to administer the TRDP to the Federal Services division of Delta Dental of California (DDCA). In 2000, further legislation allowed the program to include comprehensive coverage. The Department of Defense awarded Delta Dental the current TRDP contract, effective October 1, 2008. The contract award allows Delta Dental to continue to administer the program through September 30, 2013 and has expanded TRDP coverage worldwide to include enrollees living overseas. The TRDP is a voluntary dental benefits program with 100 percent of the premiums paid by enrollees. Enrollees in the TRDP may be in either the basic program (# 4600), which offers coverage for basic and preventive services, or in the enhanced program (# 4601) or Enhanced-Overseas Program (group #4602), which both offers a full scope of benefits including orthodontics and dental accident. New enrollments in the TRDP are limited to the enhanced program. Service Area Covered services under the TRDP are offered throughout the 50 United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, the Commonwealth of the Northern Mariana Islands, and Canada. Coverage through the Enhanced-Overseas Program is available worldwide for retirees living outside these areas. New Contract Information The TRDP is supported by both the Delta Dental PPO and Delta Dental Legion national networks. While enrollees have the option to see any licensed dentist, they are encouraged to seek care from a dentist in one of these networks, where available.* *Delta Dental does not maintain a dentist network in Canada, American Samoa, the Northern Mariana

Islands, or outside any of the other areas mentioned above.

TRDP Covered Services at a Glance

Benefits available during the first 12 months of enrollment:

*Delta Dental Pays Group #4600 Groups

#4601 & #4602

Diagnostic Services 100% 100%

Preventive Services 80-100% 80-100%

Basic Restorative Services 80% 80%

Endodontics 60% 60%

Periodontics 60% 60%

Oral Surgery 60% 60%

Dental Accident Coverage NAB 100%

Additional services available after 12 months of continuous enrollment:

Cast Crowns, Onlays & Bridges NAB 50%

Dental Implants NAB 50%

Partial/Full Dentures NAB 50%

Orthodontics 1 NAB 50%

Deductibles & Maximums

Annual Deductible per Patient 2 $50 3

$50 3

Delta Dental of Colorado Handbook 2012 32

Annual Maximum per Patient 4 $1000 $1200

Orthodontic Maximum per Patient NAB $1500

Dental Accident Maximum per Patient NAB $1000 Benefit Year: October 1- September 30

NAB = Not a Benefit 1 Children and adults are eligible for Orthodontics. 2 Does not apply to diagnostic and preventive services covered at 100%, orthodontics, or dental accident coverage. 3 Family deductible limit of $150. 4 Does not apply to diagnostic and preventive services covered at 100%.

TRDP Claims Information Basic and Enhanced Program Claims Claims for TRDP enrollees in the Basic and Enhanced Programs should be sent to:

Delta Dental of California Federal Services PO Box 537007 Sacramento, CA 95853-7007

It is important that all TRDP claims be submitted using the retiree’s (sponsor) social security number. Claims may be submitted electronically or by mail. Although special claim forms are not required, a TRDP claim form is available for downloading and printing on the DDCA web site. Claims will be processed based on Delta Dental national network processing policies. Frequency limitations, waiting periods, and exclusions for specific benefits are applied based on contractual requirements, as set by the federal government. Direct payment will be made to all Delta Dental network dentists. When a non-Delta Dental dentist renders services, payment by Delta Dental is made to the patient unless otherwise indicated on the claim. Payments for electronic TRDP claims are sent directly to the dentist, regardless of his or her participation status.

Enhanced-Overseas Program Claims There is no available dentist network overseas, nor is there any resultant savings or discount for TRDP dental treatment obtained overseas. For services provided by an overseas dentist, Enhanced-Overseas TRDP enrollees will be required to pay in full at the time of service and should obtain a detailed receipt. To be reimbursed, enrollees must submit their claims directly to Delta Dental of California and include the dentist’s full name, address (including city and country) phone number and/or e-mail address, services performed and a list of the teeth treated. Delta Dental of California will convert the fees to U.S. dollars and make payment directly to the enrollee in U.S. dollars based on the date of service. Benefits under the Enhanced-Overseas TRDP are not assignable to dentists overseas under any circumstances. An Enhanced-Overseas TRDP claim from is available on the DDCA web site for enrollees to download and print. Claims for TRDP enrollees in the Enhanced-Overseas Program should be completed, signed and submitted by the enrollee along with the detailed original receipt obtained from the dentist, to Delta Dental at the following address:

Delta Dental of California Federal Services PO Box 537006 Sacramento, CA 95853-7006 United States of America

TRDP Contact Information Dental offices may contact us at: Delta Dental of California Toll-free: 1-(888) 838-8737 Federal Services Web site: www.trdp.org P.O. Box 537007 Sacramento, CA 95853-7007