Understanding Your Benefits
This guide is designed to help you get the most from your dental plan. It highlights the key things you need to know as a member. This information is intended to answer general questions you may have about your covered services and is not specific to each employer groups coverage. For information specific to your employers group coverage, please consult with your HR manager.


How to Contact Us
Finding Your Plan Information on the Web
How to Use Your Benefits

Grace Periods and Claims Pending
Retroactive Denials and Recoupment of Overpayments
Eligible Dependents
Visiting the Dentist
Understanding the Delta Dental Networks
Pre-determination of Benefits
Filing Claims
Prior Authorization, Medial Necessity and Enrollee Responsibilities
Complaint and Appeals Procedures
Coordination of Benefits
Common Dental Terminology

 

How to Contact Us

Call Delta Dental of Oklahoma (DDOK) if you have any questions about your dental plan. You can reach us by calling 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). Customer Service representatives are available Monday through Friday, 7 a.m. to 6 p.m. to help with:
 

  • General questions
  • Claims questions
  • Information about network dentists and specialists
  • Complaints and problem resolution

 

Delta Dental also offers Benefax, a 24-hour automated phone system which can be used to:
 

  • Check the status of a claim
  • Order a new ID card
  • Locate a provider
  • Get updates on available benefits
     

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Finding Your Plan Information on the Web

We encourage all Delta Dental of Oklahoma subscribers to register for Spotlight, our online oral health services site. Spotlight provides secure access to real-time information regarding your dental benefits plan, including claim status, explanation of benefits (EOB), answers to frequently asked questions and more. Only one (1) Spotlight account for the primary subscriber is needed to access the entire family’s dental benefits information. Click here to register today!

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How to Use Your Benefits

You are covered for dental services when enrolled in one of Delta Dental’s plans. Our plans are designed to make covered services more affordable. In most cases, this plan will pay a portion of the cost of your covered services (up to any plan maximum). You may be responsible for deductibles, coinsurance and in some cases, dentists' charges that exceed what Delta Dental covers. Please see your schedule of benefits for more details about what is covered under your plan.

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Grace Periods and Claims Pending

DDOK provides a grace period for premium payment(s) of three (3) consecutive months if an enrollee is receiving Advance Premium Tax Credits (APTC) and has previously paid at least one (1) full month’s premium during the benefit year. During the grace period, DDOK will pay all claims eligible for services rendered. If the enrollee does not make premium payment(s) by the end of the grace period the enrollee may be retro-terminated. If the enrollee is retro-terminated, a retroactive denial of a previously paid claims(s) may occur.

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Retroactive Denials and Recoupment of Overpayments

DDOK may retroactively deny previously paid claims in cases for which an enrollee was retroactively terminated. Retroactive terminations may occur when an enrollee does not make timely premium payment or when the Centers for Medicare and Medicaid Services (CMS) approves an enrollee’s request for retro-termination via Health Insurance Casework System (HICS). If your coverage has been retroactively terminated or you need assistance in obtaining a refund for overpayment of premium for another reason, please contact our Customer Service department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free).

In the event benefits are issued for a claim and your eligibility is subsequently changed resulting in you not being eligible for the date(s) of service benefited, benefits may be recouped by Delta Dental. If the benefit payment was issued to the Delta Dental participating dentist, Delta Dental will request the monies from the dentist and you will be required to pay the dentist directly. If the benefit payment was issued directly to you, Delta Dental will request the monies directly from you.

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Eligible Dependents

Your spouse and unmarried, dependent children (please see your schedule of benefits for details on the dependent age limits) are eligible to be covered under your plan. If you need to add dependents to your coverage, please see your benefit administrator. For full details regarding eligibility, please refer to your summary plan description (SPD) or contact your human resources department.

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Visiting the Dentist

You may choose to go to any licensed dentist when you need dental care. Whatever dentist you choose, you will receive some level of coverage for covered services. However, there are advantages when you receive treatment from a dentist participating in one of the Delta Dental networks. If you receive treatment from a non-participating dentist, you will be responsible for paying the nonparticipating dentist both the payment received from DDOK, and any portion of the non-participating dentist’s fee not discharged by such payment. For questions about your benefits, log on to Spotlight or call our Customer Service Department at 800-522-0188 or 405-607-2100.

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Understanding the Delta Dental Networks

  • Delta Dental Premier Plans 
    If you are enrolled in a Delta Dental Premier plan, to receive the highest level of benefits you should choose a dentist who participates in the Delta Dental Premier Network. These dentists participate in our largest network and also reduce your out-of-pocket costs by agreeing to accept our Delta Dental Premier plan allowance as full payment for covered services. You will be responsible for any deductible and coinsurance due at the time of service. We pay the dentist directly, so you do not have to pay the whole bill up front and wait for reimbursement.
     
  • Delta Dental PPO Plans 
    If your plan is a PPO plan, you can enjoy the ultimate balance of cost and flexibility. Just choose a dentist who participates in the Delta Dental PPO network, and you will receive the greatest level of savings on your out-of-pocket costs. PPO dentists have agreed to accept a greater discount (The Delta Dental PPO plan allowance) as payment in full for covered procedures. This means that you only pay your deductible and any coinsurance for covered services. We pay PPO dentists directly, so you do not have to pay the whole bill up front and wait for reimbursement. 
     
  • Delta Dental PPO/Premier Dual Plans 
    With these plans you are provided with a unique opportunity we call the "Plus Premier" feature. This feature allows you to select a dentist from either the Delta Dental PPO or the Delta Premier network with no balance-billing. These participating dentists have agreed to accept our plan allowance as payment in full for your covered services. This means that you pay your deductible and any co-insurance for covered services. We pay the dentist directly, so you do not have to pay the whole bill up front and wait for reimbursement.


Note: If services are provided by a non-participating dentist, you may be required to file your own claim and you will be balance billed up to the dentist’s submitted amount. Delta Dental has no exceptions to out-of-network liability.

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Pre-determination of Benefits

To assist you in managing your total costs, Delta Dental also offers what’s called "pre-determination of benefits." Dentists may submit their treatment plan to Delta Dental for review and estimation of coverage before procedures are started. Delta Dental advises the patient and the dentist of what services are covered and what the payment would be. The actual payment for these pre-determined services depends on eligibility, any plan limitations, coordination of benefits and the remaining maximum at the time services are performed.

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Filing Claims

Most dentists file claims electronically or have claim forms on hand. If they don’t, you may obtain one by visiting the Forms & Resources portion of our Web site. In some cases your human resources office may have a supply, or you can call Customer Service at 800-522-0188 or 405-607-2100. 

If you use a Delta Dental participating dentist, your claim will be submitted for you. If you visit a non-participating dentist, you may need to submit your own claim. Complete your portion of the claim form and present the form to the dentist for completion. If you visit a non-participating dentist you may need to mail your completed claim form to the address below. 

Mail to:
Delta Dental of Oklahoma
Attn: Claims Department
P.O. Box 548809
Oklahoma City, OK 73154-8809

All claims must be submitted within twelve (12) months of the date services are completed. If the claim is for orthodontic services, the claim should be filed at the time of the banding.

Once DDOK has received a completed claim and the patient’s financial responsibility is greater than $0, an Explanation of Benefits (EOB) will be sent, as required by law, to the Policyholder by DDOK within a reasonable time, but no later than 30 days after receipt of a claim. DDOK may extend this time period one (1) time up to 15 days, prior to the expiration of the 30 day period. If DDOK requires additional information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the Policyholder will be given 45 days from receipt of the notice within which to provide the necessary information.

EOBs for all finalized claims are also available on Spotlight, DDOK’s online member portal. Spotlight is available 24 hours a day, seven (7) days per week.  

The EOB provides you with the following information:
 

  1. Patient Name
  2. Service(s) submitted
  3. Date(s) of service
  4. Treating dentist’s information
  5. Charged amount(s)
  6. Allowed amount(s)
  7. Deductible amount(s) applied, if any
  8. Coordination of benefits information, if any
  9. Processing policies applied, if any
  10. Delta Dental’s payment amount
  11. Patient’s financial responsibility (to be paid to the dentist)
  12. Appeals procedure


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Prior Authorization, Medical Necessity and Enrollee Responsibilities

DDOK does not require prior authorizations for any dental services. However, a predetermination of benefits is recommended for any services that exceed $250. By submitting a predetermination of benefits, both you and your dentist know the amount Delta Dental will benefit as well as your financial responsibility prior to any services being provided.

Under the federally compliant plans, medical necessity is required in order for various services to be covered benefits. Orthodontic benefits are available only with orthognathic surgery cases or certain designated syndromes or genetic disorders such as cleft palate. Orthodontic benefits are only allowed for medically necessary orthodontic services to help correct severe handicapping malocclusions caused by cranio-facial orthopedic deformities involving the teeth. Other procedures must be medically necessary based on Delta Dental’s guidelines and will be reviewed by our dental consultants on a case by case basis.

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Complaint and Appeals Procedures

You have the right to file a complaint or a claim. Please consult the SPD section at the end of your handbook for details.

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Coordination of Benefits

If you are covered under another dental plan, Delta Dental will coordinate your covered services as described in your SPD. Among other things, coordination of benefits eliminates duplicate payments for the same dental or orthodontic services. Please see the SPD handbook for details on the rules regarding which insurance plan would be considered primary and which would be considered secondary for payment purposes.

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Common Dental Terminology

Commonly used dental terms.

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