Understanding Our Networks
Delta Dental Premier | Delta Dental PPO | DeltaCare | Delta Dental EPO
Delta Dental Premier
is our traditional fee-for-service program in which dentists submit usual fees, and are reimbursed based on a maximum approved fee. Close to 96% of the state's licensed dentists participate in Delta Dental Premier.
Reimbursement for Delta Dental Premier patients is based on a regional fee schedule which is reviewed annually. Delta Dental pays participating dentists directly for each covered service rendered based on the lesser of the submitted fee or the fee published in Delta Dental’s Premier fee schedule.
Fees are increased every January 1st
Delta Dental PPO
is our preferred provider organization program in which dentists accept reduced fees, resulting in enrollee savings and lower group rates.
Reimbursement for Delta Dental PPO patients is based on a regional fee schedule which is reviewed annually. Delta Dental pays participating dentists directly for each covered service rendered based on the lesser of the submitted fee or the fee published in Delta Dental’s PPO fee schedule. Patients eligible for benefits can receive care from any dentist they choose, but they can lower their out-of-pocket costs by choosing a Delta Dental PPO participating dentist.
Fees are increased every January 1st
Signed Consent for Non-Covered Services for Medicare Advantage Members
It is important that your office have a written policy for members regarding the provision of non-covered services to Medicare Advantage members. CMS regulations governing the Medicare Advantage program require that a member (1) be informed of treatments not covered by DDMA and (2) expressly consent to the provision of recommended services. If you are uncertain whether DDMA might cover a recommended service, your office must
request a determination from DDMA prior to the provision of the services. If you do not request a determination from DDMA prior to providing a service, whether or not you are uncertain if DDMA might cover a recommended service and it is determined that the service is NOT a covered service, neither DDMA nor the member will be liable for payment of said service.
Where DDMA's policy clearly does not cover a service or DDMA has determined that the service is not covered for the member, to be compliant with CMS regulations for Medicare Advantage members you are required to ensure that:
Express written consent is obtained from the member prior to the provision of a non-covered service using a CMS-compliant consent form, which clearly discloses all non-covered services.
Both the member and provider must sign the consent form acknowledging the information has been reviewed and agreed upon.
Copies of the signed consent form must be kept in the Member's treatment record as part of their file.
If the Member will be subject to collection action upon failure to make the required payment, the terms of the agreement, and any collection activity, must be kept in the Member's treatment record as well. The member fee is not to exceed the maximum rate of your usual and customary fees as payment in full for the agreed procedure(s) or treatment(s).
is our dental health management program in which dentists receive a fixed monthly fee for each patient. Members choose a Primary Care Dentist (PCD) from our network to manage their dental care.
Primary care dentists are reimbursed through a combination of fixed monthly capitation payments, lab fee supplements, specialty payments, and member co-payments that are collected directly from the patient. Participating DeltaCare PCDs receive a fixed monthly fee for each DeltaCare patient regardless of whether the patient receives treatment in a given month. Specialty services are reimbursed based on the appropriate regional Delta Dental PPO fee schedule for the treating dentist’s specialty. We limit the number of dentists in each geographic area so that we can guarantee adequate patient flow.
Delta Delta EPO
is our Exclusive Provider Organization Program which was created in response to Health Care Reform. The Delta Dental EPO Network is also the network for the Delta Dental Patient Direct Discount Plan.
Reimbursement for Delta Dental EPO patients is based on a fee schedule. Delta Dental pays participating dentists directly for each covered service rendered based on the lesser of the submitted fee or the fee published in Delta Dental’s EPO fee schedule.