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Federal Employees Dental Program

Plan FAQ

Eligibility and Enrollment

Why should I enroll in the Delta Dental Federal Employees Program?

With the Delta Dental Federal Employees Program you have a choice between two great plans. Both offer free cleanings, free exams and free x-rays with no deductible when you go to a network dentist. Both plans cover the same exact procedures, but as you might expect, the High Plan covers a larger percentage of those procedures, as well as offers higher maximums and lower deductibles. There are no waiting periods in either plan other than for orthodontics for kids under age 19, so you’ll get great coverage on your first effective date of coverage. When you see a dentist in our large, nationwide network, which you can easily find through our Dentist Search, you will guarantee yourself maximum program savings and will ensure that you’re getting high quality care. Dental insurance is all we do — we pioneered the dental insurance industry about 60 years ago and currently have more than 60 million enrollees.

Am I eligible for the Federal Employees Dental Program?

Visit BENEFEDS.com Offsite link to find out eligibility requirements and enroll.

When can I enroll for coverage with Delta Dental?

Federal employees and annuitants eligible for benefits can select Delta Dental during the Open Enrollment Season. Newly hired and newly eligible employees can enroll within 60 days after becoming eligible.

How do I enroll?

Go to BENEFEDS.com Offsite link and log in with your username and password, or click the “Sign up Now” link if you have not yet created one. Once you have signed into your BENEFEDS account choose dental coverage and then click on Delta Dental. If you don’t have internet access, call toll-free 877-888-3337. For TTY call 877-889-5680.

When does my coverage start?

If you enrolled during Open Season your coverage will begin on January 1. If you are a new hire, you can enroll within 60 days after you become eligible. Your enrollment will be effective date the first day of the pay period following the one in which BENEFEDS.com Offsite link receives and confirms your enrollment.

Do I need an enrollment card?

If you are an enrollee in Delta Dental’s Federal Employee Dental Program, you do not need an enrollment card, though it assists the dental office in verifying your benefits. The dental office can use your social security number to verify your eligibility and benefits. If you would like an enrollment card you can print one from our Consumer Toolkit®

How do I add a family member to my coverage?

Outside of open enrollment season, you can add a family member to your current plan if you experience a Qualifying Life Event (QLE). For specific details, please refer to the Plan Brochure or visit BENEFEDS.com Offsite link or call 877-888-3337.

Can I enroll my adult children?

Eligible family members include your spouse and unmarried dependent children under age 22. Under certain circumstances you may continue coverage for a disabled child 22 years of age or older who is incapable of self-support. For more information on family member eligibility visit the website at www.opm.gov Offsite link or contact your employing agency or retirement system.

Please keep in mind Federal Employee Dental Program rules and Federal Employee Health Benefit plan rules for family member eligibility are NOT the same.

I am already enrolled in a Delta Dental plan. If I switch over to Delta Dental’s Federal Employees Dental Program, do I have to tell my dentist?

Let your dentist know that you are now enrolled in Delta Dental’s Federal Employees Dental Program. Since there are many different Delta Dental plans with different plan designs and claims addresses, you’ll want to make sure that they have the correct information. As a reminder, maximum savings are obtained when you use a network dentist. In addition, it is very important that you verify if your current dentist is part of the Federal Employee Dental Program network. View the Dentist Search to see if your dentist is in the network. If not, your can request that your current dentist join the network or select a new dentist that is in-network.

I am pretty healthy; do I need dental insurance?

That’s a personal decision, but the data out there shows that when you have dental insurance you’re twice as likely to visit the dentist. Ultimately you save money when you visit your dentist regularly because you can prevent dental problems or treat them before they get serious and costly. The features that many of our enrollees most appreciate about our plans are the free in-network routine cleanings, exams and x-rays. Since you’re healthy, the Standard Plan is probably your best fit. You get back most of your money when you go for just routine services. Aside from providing peace of mind and financial protection should expensive dental work arise, the true benefit of having dental insurance is that it helps you get in a routine of taking good care of your teeth and gums to improve your overall health.

As an existing customer with Delta Dental, do I still have to meet the 12-month waiting period for orthodontics?

Yes, but you and your family members would be eligible for all other covered services on your first day of coverage.

Why do I see “Delta Dental of California” in my Federal Employees Dental and Vision Insurance Program open season materials?

Delta Dental of California was selected to administer the Federal Employees Dental Program. Delta Dental of California is a specific company within The Delta Dental Plans Association that provides dental coverage to over 60 million people in the U.S.

Whom do I contact if I have any additional questions about dental coverage from Delta Dental?

Delta Dental is committed to making sure you have all the information you need to make the right decision for you and your family. If you’d like to know more about Delta Dental’s Federal Employee Dental Program, email or call us at 855-410-3255. Customer service representatives are available Monday through Friday, 8 a.m. to 8 p.m., Eastern Time.

My dentist isn’t in your network, so does it make sense for me to enroll with Delta Dental?

As an enrollee in Delta Dental’s Federal Employees Dental Program, you can actually see any licensed dentist you want to. We can still pay on your covered services, but your out-of-pocket costs and deductible would increase and your annual maximum would be lowered. That said, have you checked our dentist network recently? We have over 200,000 network locations, so if your dentist isn’t in the network, there are bound to be several in your area to choose from who are waiting to save you money and take great care of you. When you use a network dentist for your covered services, you don’t pay a penny for your preventive services so you never have a deductible and you pay only your copayment. There are also no extra “allowed” fees when you see a network dentist, so it’s a win-win all around. Find a network dentist near you by using our Dentist Search. View the 2018 Plan Brochure PDF 1.4 MB to see what qualifies as preventive, Class A services.

I’ve found lower rates elsewhere, why should I go with you?

The Delta Dental Federal Employee Program provides very good coverage at an affordable price. If you enroll in the Standard Plan, for example, and use an in-network dentist for just your routine services, you end up getting more out of the program than you put in. Delta Dental strives to provide extremely good service to enrollees. Dental insurance is all we do and all we have ever done since we pioneered the industry 60 years ago. We currently have more than 60 million enrollees and more are signing up each day for a good reason. We hope that you join them, and us!

In order for me to be eligible to enroll into Delta Dental’s Federal Employees Dental Program, am I required to have coverage for 5 years of service prior to retirement?

There is no requirement to have coverage for 5 years of service prior to retirement in order to establish or continue dental coverage into retirement, as there is with the FEHB Program. You can enroll in FEDVIP during any open season before or after you retire.

Claims Processing & EOB Statements

What is an EOB Statement?

EOB is an acronym for Explanation of Benefits. You might think an EOB is a medical bill, but it actually gives you details regarding how your dental claim was processed. The EOB will also tell you what portion of a claim was paid to your dentist and for what portion of the payment, if any, you are responsible.

Important note: Delta Dental does not have a record of what you paid your dentist at the time of service. Please make sure to compare what you already paid the dentist, to what your EOB states is your full responsibility. If you paid more than what’s indicated on your EOB, then the office should refund you the difference. If you paid less than what’s indicated on your EOB, then the dental office will be sending you a bill for the balance due.

How do I sign up for paperless claims and can I still print them?

Sign into the Consumer Toolkit, click on the subscription button located at the top of the page, then select “Go Paperless.” You can download and also print from your computer. Your Dental Explanation of Benefits (EOB) Statement history will remain online for a minimum of two years plus the current year.

How do I file for reimbursement of a claim?

The best way to avoid having to file for claim reimbursement is by receiving services from an in-network dentist. Your dentist will directly submit your claims to Delta Dental. If you see an out-of-network dentist, ask for an itemized statement then simply download a claim form PDF 261 KB and take it with you to your appointment, then submit completed claims to: Delta Dental of California, Federal Government Programs, P.O. Box 537009, Sacramento, CA 95853-7009

How long does it take to process a claim?

The time it takes to process a claim depends on the type of service performed. Most claims flow through our system quickly and efficiently, with 99% being processed within 10 business days. If additional information is needed for a claim, it may take longer.

Plan Information & Benefits Coverage

What is covered by Delta Dental’s Federal Employees Dental Program?

The services covered by Delta Dental’s Federal Employees Dental Program are outlined in the Plan Information section.

How should I decide which Plan option is right for me?

To get a better idea of what Plan might suit you best, we recommend watching the video Offsite link as well as consulting the Get a Plan page. There are two plans available — Standard and High, tailored specifically for federal employees. Both plans offer the same dental benefits but have different annual maximums and out-of-pocket costs.

Are the Federal Employees Dental Program benefits just like other Delta Dental plans I’ve had?

Delta Dental offers many different dental plans. Your previous plan may have different coverage benefits than this plan. Make sure to look at the services covered in this plan, outlined in the Plan Information section. In addition, it is very important that you visit the Dentist Search and verify your doctor is in-network.

Are the rates based on my home address or the address of my dentist?

Rates are based on your home address.

How do I know what is covered?

Visit our Plan Information page to view the plan brochure as well as limitations and exclusions.

How do I find the subscriber ID number to register on the Consumer Toolkit®?

The subscriber ID number is the primary enrollee’s social security number. This number should always be used when registering for the Consumer Toolkit, even if someone other than the subscriber (for example, the enrolled spouse) is registering.

If I live internationally, can I view my benefits online?

International participants are able to register and access the Consumer Toolkit. With access to the Consumer Toolkit, users can print an enrollment card, check the status of a dental claim, and review any claims processed to date.

How does the plan handle overseas travel and dentist visits?

The enrollee will need to pay the overseas dentist upfront at the time of treatment. There are in-network dentists in the United States and Puerto Rico. There are no participating dentists elsewhere. The enrollee is responsible to submit the claim PDF 261 KB along with dental office treatment documentation and proof of payment. Delta Dental will then reimburse the enrollee in U.S. dollars based on the non-network allowance for covered benefits.

How do I know if my doctor is in-network?

To confirm that your dentist is in-network for your Delta Dental plan in FEDVIP, use the Dentist Search to locate an in-network dentist near you. Note that there are different dentist networks for other Delta Dental plans, so if your dentist is not listed in the dentist directory, he or she is not in network for this program.

What if I want to see an out-of-network dentist?

You may obtain care from any licensed dentist. If the dentist you use is not part of our network, benefits will be considered out-of-network. Because these providers are out of our network, we pay for services based on an out-of-network plan allowance. You are responsible for the copay percentage based on the out-of-network plan allowance, plus the difference between the allowable fee and total approved charges. If the out-of-network deductible for that service has not been met fees will be higher. If you’re currently seeing a network dentist, you’re already saving! If not, or you’re unsure, check the Dentist Search to find a dentist near you.

Network Versus
Non-Network Dentist Enrollee Savings
Dentist’s total charge for service = $350
Network Dentist Non-Network Dentist
Enrollee Pays:
$50(cost is absorbed by the network dentist)
Enrollee Pays This Cost Too:$0Non-network dentists do not absorb any cost Enrollee pays the difference between dentists.
Delta Dental Pays:
$210Delta Dental Pays 70% of the highest fee allowed (70% x $300 allowed fee)
Delta Dental Pays:
$180Delta Dental Pays 60% of the highest fee allowed (60% x $300 allowed fee)
Enrollee Copay:
$90Enrollee Pays 30% of the highest fee allowed (30% x $300 allowed fee)
Enrollee Copay:
$120Enrollee Pays 40% of the highest fee allowed (40% x $300 allowed fee)
Enrollee Out-of-Pocket Total:
$90
Enrollee Out-of-Pocket Total:
$170Enrollee pays fee not absorbed by dentist. plus higher percentage of agreed upon Delta Dental allowed fee. If deductible has not yet been met enrollee fees will be higher.

Why should I see an in-network dentist?

As an enrollee in Delta Dental’s Federal Employees Dental Program, you can actually see any licensed dentist you want to. We can still pay on your covered services, but your out-of-pocket costs and deductible would increase and your annual maximum would be lowered. That said, have you checked our dentist network recently? We have 234,000 network locations, so if your dentist isn’t in the network, there are bound to be several in your area to choose from who are waiting to save you money and take great care of you. When you use a network dentist for your covered services, you don’t pay a penny for your routine services, you never have a deductible and you pay only your copayment. There are also no extra “allowed” fees when you see a network dentist, so it’s a win-win all around.

Network Versus
Non-Network Dentist Enrollee Savings
Dentist’s total charge for service = $350
Network Dentist Non-Network Dentist
Enrollee Pays:
$0(cost is absorbed by the network dentist)
Enrollee Pays This Cost Too:$50Non-network dentists do not absorb any cost Enrollee pays the difference between dentists.
Delta Dental Pays:
$210Delta Dental Pays 70% of the highest fee allowed (70% x $300 allowed fee)
Delta Dental Pays:
$180Delta Dental Pays 60% of the highest fee allowed (60% x $300 allowed fee)
Enrollee Copay:
$90Enrollee Pays 30% of the highest fee allowed (30% x $300 allowed fee)
Enrollee Copay:
$120Enrollee Pays 40% of the highest fee allowed (40% x $300 allowed fee)
Enrollee Out-of-Pocket Total:
$90
Enrollee Out-of-Pocket Total:
$170Enrollee pays fee not absorbed by dentist. plus higher percentage of agreed upon Delta Dental allowed fee. If deductible has not yet been met enrollee fees will be higher.

I have a missing tooth, can I get it replaced? What if I need to replace a denture, bridge, implant or other prosthodontic device?

The installation of complete or partial removable dentures, fixed partial dentures (bridges), implants, and other prosthodontic services will be covered when replacing or repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior to your Delta Dental Effective Date of Coverage. Initial prosthodontic services to replace natural teeth that are missing prior to your Delta Dental Effective Date of Coverage are not covered.

If I switch from a plan I am currently on to Delta Dental’s Federal Employees Dental Program, do I have to change my dentist?

Although you can obtain care from any licensed dentist in the United States or overseas, using a network dentist always maximizes your out-of-pocket savings. Not only are your preventive services free when you use a network dentist, but you also never have a deductible and you are only responsible for your copayment on covered services. To locate a network provider near you, simply use our Dentist Search.

Do you cover Orthodontics for both adults and children? How are the benefits calculated?

Benefits for orthodontic treatment will be payable at 50% up to a lifetime maximum which varies, depending on the plan option under which you have coverage. Orthodontic benefits are subject to a 12-month waiting period which begins on the effective date of coverage.

Orthodontia services are not covered for adults and are limited to dependent children under age 19. Dependent children receiving orthodontic services must be covered under the same plan option for the entire 12-month waiting period. Adult orthodontic benefits are not covered.

Does Delta Dental offer a wellness program?

SmileWay®, our wellness site offers interactive oral health and wellness tools to keep your smile healthy and bright.

Why are your annual maximums lower than some other carriers?

Although a large annual maximum may seem like a great benefit, it typically goes unused. In one of our other programs, we’ve found that only 3% of the nearly 1.5 million enrollees ever reach their annual maximum benefit of $1,300. That means the majority of enrollees — 97% — never come close to spending more than $1,300 a year on dental care. The cost of certain complex treatment and/or implant services could come close to or even exceed $20,000, but these cases are rare and not indicative of your average enrollee’s situation. And even then, an enrollee could be paying more than $10,000 out-of-pocket (50% cost share for major dental care) for these rarely administered services. Our High and Standard plans are both designed to provide quality dental benefits while achieving the optimal balance between the enrolleeā€™s premium and yearly maximum, especially when using a dentist from our large network. The added value of this plan design is our close working relationship with our network dentists, which helps limit the potential of over-treatment merely to exhaust a large annual maximum. Reducing out-of-pocket costs wherever possible helps enrollees avoid overspending and is in the best interest of their overall oral health.

What happens with my annual maximum if I see an out-of-network dentist for a portion of my dental care and then see an in-network dentist for another portion of my dental care?

For High Plan Enrollees: Under the High Plan, you are allowed an annual maximum amount of $4,000 for in-network benefits. The first $3,000 can be used for either in-network or out-of-network benefits. The last $1,000 is only available for in-network benefits. Any amount of your annual maximum remaining at the end of one benefit year (January 1 through December 31), whether for out-of-network or in-network care, does not roll over into the next benefit year.

For Standard Plan Enrollees: Under the Standard Plan, you are allowed an annual maximum of $1,500 for in-network benefits. The first $600 can be used for either in-network or out-of-network benefits. The last $900 is only available for in-network benefits. Any amount of your annual maximum remaining at the end of one benefit year (January 1 through December 31), whether for out-of-network or in-network care, does not roll over into the next benefit year.

How many cleanings can I get per year?

Two cleanings are covered in a calendar year. For example, if coverage was provided for a cleaning performed on March 2, 2017, and August 24, 2017, then coverage for this procedure will be available again on or after January 1, 2018. Use the online Consumer Toolkit® to help you track your cleanings to date and when you’re eligible for your next one.

What is a flexible spending account?

A Flexible Spending Account (FSA) is a tax-favored program offered by employers that allows their employees to pay for eligible out-of-pocket health care and dependent care expenses with pre-tax dollars. By using pre-tax dollars to pay for eligible health care and dependent care expenses, an FSA gives you an immediate discount on these expenses that equals the taxes you would otherwise pay on that money.

In other words, with an FSA, you can both reduce your taxes and get more for your money by saving from 20% to more than 40% you would normally pay for out-of-pocket health care and dependent care expenses with after-tax (as opposed to taxed) dollars.

What is FSAFEDS? Does Delta Dental participate?

FSAFEDS is the Federal Flexible Spending Account Program. Delta Dental now participates in FSAFEDS and offers paperless reimbursement of your dental claims. A Flexible Spending Account (FSA) is a tax-favored program offered by employers that allows their employees to pay for eligible out-of-pocket health care and dependent care expenses with pre-tax dollars. OPM offers three types of accounts: health care, limited expense health care and dependent care. FSAFEDS is the Federal Flexible Spending Account Program. Visit www.FSAFEDS.com Offsite link for more information.

FSAFEDS offers three types of FSAs:

  • The Health Care Flexible Spending Account (HCFSA), which can be used to pay for qualified medical costs and health care expenses that are not paid by your Federal Employees Health Benefits (FEHB) plan or any other insurance. PLEASE NOTE: A HCFSA cannot be used to pay for any type of insurance premiums, including long-term care insurance premiums.
  • The Limited Expense Health Care Flexible Spending Account (LEX HCFSA) is only available to employees who enroll in a Federal Employees Health Benefits (FEHB) Program under a High Deductible Health Plan (HDHP) with a Health Savings Account (HSA). Eligible expenses are limited to dental and vision care services/products that meet the IRS definition of medical care. By using a LEX HCFSA, you can preserve the funds in your Health Savings Account to use/save for other purposes.
  • The Dependent Care (Day Care) Flexible Spending Account (DCFSA), used to pay for eligible dependent care expenses such as child care for children under age 13 or day care for anyone who you claim as a dependent on your Federal tax return who is physically or mentally incapable of self-care so that you (and your spouse, if you are married) can work, look for work, or your spouse can attend school full-time.

Visit the FSAFEDS Program FAQs or www.FSAFEDS.com Offsite link for more information.

Coordinating Benefits with Other Coverage

Is there a benefit to having two dental plans? I already have coverage through my spouse’s employer (or my FEHB plan).

Having dual coverage can be advantageous and very smart, and it often leaves you with little, or no, out-of-pocket expense. You can be in two different dental programs, so long as they’re not both FEDVIP plans. For example, you have a crown; if both plans cover it at 50%, there’s a good chance that you might not have a bill at all. You would submit to your own carrier first then your spouse’s carrier second (and vice versa if your spouse has the work done). If your other dental coverage is within your Federal Employee Health Benefits (FEHB) plan, it is important to keep in mind that per government rules, you’ll always need to submit your claim with that carrier first and then with Delta Dental secondarily. It is your responsibility to let the dentist know if you have dual coverage so the claim can be submitted and processed correctly. You may also have dual coverage with Delta Dental programs. Some of our enrollees are part of the TRICARE Retiree Dental Program and the Federal Employees Dental Program. Coordinating these benefits is very simple. The claims go to the same building and get processed very quickly and easily.

When benefits are coordinated between Delta Dental and a non-Federal Employee Health Benefits (FEHB) carrier, the maximum allowable charge may vary depending upon the contractual relationship and contracted fee between Delta Dental and non-FEHB carrier. The participant may be responsible for the difference between the combined non-FEHB and Delta Dental benefit payment and the providers’ allowable charge.

If I am enrolled in a FEHB Plan and enrolled in Delta Dental’s Federal Employees Dental Program, how will my claims be coordinated and processed?

Approximately 70% of federal employees and annuitants have dental benefits through one of the Federal Employee Health Benefits (FEHB) Plans.

  • Advise your dentist if you are covered by/enrolled in a FEHB plan. The FEHB plan is primary with Delta Dental as the secondary payor.
  • Provide your dentist your FEHB Plan Name and Plan Code (in most instances this information can be found on your FEHB enrollment card).

With all the proper information submitted on a claim regarding primary coverage and payment, coordination of benefits should not take any longer than processing claims without other coverage, which is approximately 10 business days.

FSAFEDS Program

What is a Flexible Spending Account?

A Flexible Spending Account (FSA) is a tax-favored program offered by employers that allows their employees to pay for eligible out-of-pocket health care and dependent care expenses not covered by your health care plan with pre-tax dollars. The money you contribute to an FSA is not subject to payroll taxes, so you end up paying less in taxes and take home more of your paycheck each year.

How do I know if I’m eligible to enroll in FSAFEDS?

If you are an active employee of an Executive Branch agency, or an agency, commission, or other federal entity that has adopted the Federal Flexible Spending Account Program (FSAFEDS), you are most likely eligible to enroll for at least one of our FSAs. Some federal agencies do not participate in FSAFEDS, but may offer their own FSA program to employees. These agencies include:

  • Administrative Office of the U.S. Courts (The Federal Judiciary)
  • District of Columbia Government
  • Farm Credit Administration
  • Farm Credit System Insurance Corporation
  • Federal Deposit Insurance Corporation
  • Federal Reserve System
  • Office of the Controller of the Currency
  • Office of Thrift Supervision
  • The Supreme Court of the United States

For more answers to Frequently Asked Questions, visit https://www.fsafeds.com/support/faq. Offsite link

Online Inquiry Form

If you are already enrolled with Delta Dental you may use our Online Inquiry Form for further help.

General Dental Insurance FAQs

Plan Basics

  • Most insurance companies offer a variety of benefit plans with different features. You may have co-workers or friends who also have dental insurance, but their coverage may differ from yours.
  • Your dentist may not “participate” in the network for your dental plan. If your dentist does, he or she will submit your claim. If not, you may be responsible for paying your dentist and submitting your claim to Delta Dental or another insurance carrier.
  • If you are entitled to benefits from more than one group dental plan, the amounts paid by the combined plans will not exceed 100 percent of your dental expenses. Benefits for dependents vary from plan to plan. Pay particular attention to special clauses and to language about dependents.
  • Dental benefits are calculated within a “benefit period,” which is typically for one year but not always a calendar year. Check your benefits information so that you know when you might be approaching your deductible payments or plan maximums.

Key Concepts

What are “Maximums”?

Most dental plans have an annual dollar maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period. The patient is personally responsible for paying costs above the annual maximum. Consult your Plan Brochure for specific information about your plan.

2018 Plan Brochure PDF 1.4 MB

What are “Deductibles”?

Both the Standard and High dental plan have a specific dollar deductibles. It works like your car insurance. During a benefit period, you personally will have to satisfy a portion of your dental bill before your benefit plan will contribute to your cost of dental treatment. Your plan information will describe how your deductible works.

What is “Coinsurance?”

Many insurance plans have a coinsurance provision. That means the benefit plan pays a predetermined percentage of the cost of your treatment, and you are responsible for paying the balance. What you pay is called the coinsurance, and it is part of your out-of-pocket cost. It is paid even after a deductible is reached.

What are “Reimbursement Levels”?

Delta Dental’ Federal Employees Dental Program offers four classes of coverage. Each class provides specific types of treatment and typically covers those treatments at a certain percentage.

Here is the way the three levels typically work:

  • Class A procedures are diagnostic and preventive and typically are covered at the highest percentage. This gives patients a financial incentive to seek early or preventive care, because such care can prevent more extensive dental disease or even dental disease itself.
  • Class B includes basic procedures — such as fillings, extractions and periodontal treatment — that are sometimes reimbursed at a slightly lower percentage.
  • Class C is for major services and is usually reimbursed at a lower percentage.
  • Class D is for orthodontia. There is a 12 month waiting period before orthodontic services are covered under the plans.

What are “Negotiated Networks”?

Network dentists agree to accept payment in full for covered services. Payment is usually lower than their normal charge. When you use an in-network dentist, you are responsible for only the difference between your plan’s benefits payment amount and the negotiated fee for the services rendered.

Can I estimate my dental costs for treatment?

If your dental care will be extensive, you may ask your dentist to complete and submit a request for a cost estimate, sometimes called a pre-treatment estimate. This will allow you to know in advance what procedures are covered, the amount the benefit plan will pay toward treatment and your financial responsibility. A pre-treatment estimate is not a guarantee of payment. When the services are complete and a claim is received for payment, Delta Dental will calculate payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements.

What are “Limitations and Exclusions”?

Dental plans are designed to help with part of your dental expenses and may not always cover every dental need. The typical plan includes limitations and exclusions, meaning the plan does not cover every aspect of dental care. This can relate to the type or number of procedures, the number of visits or age limits. These limitations and exclusions are carefully detailed in the plan booklet and warrant your attention. This booklet can help you develop realistic expectations of how your dental plan can work for you.

Allowances for some procedures covered under your benefits may be subject to limitation or denial based upon clinical criteria applied by Delta Dental’s licensed dentist consultant staff. We maintain written guidelines for the use of clinical criteria in making benefit determinations. You may obtain a copy of such guidelines for:

  • Basic benefits
  • Crowns, inlays, onlays and cast restoration benefits
  • Prosthodontic benefits

by sending us a request in writing for the specific benefit category or dental procedure range.

The materials provided to you are guidelines used to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.