If the patient’s plan is:
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And you participate in the Delta Dental Premier network only:
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And you participate in the Delta Dental Premier and Delta Dental PPO networks:
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And you participate in the Delta Dental Premier and DeltaCare networks:
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Delta Dental Premier |
Payment is made directly to you. For coinsurance plans, the Delta Dental payment is based on the member’s benefit (100%,80%,50%, etc.) for the procedure performed. You are required to collect any coinsurance/deductible from your patient. If the member is covered by a group-specific “Table of Allowance” plan, the member is responsible for the difference between the Table fee and your Delta Dental Premier contract fee. You cannot balance-bill the patient for any difference between your contract fee and your submitted charge for a procedure. |
Payment is based on your Delta Dental Premier agreement. |
Payment is based on your Delta Dental Premier agreement. |
Delta Dental PPO |
Payment is made directly to you as a participating dentist but reimbursement is based on PPO out-of-network coverage. Your patient may be billed the balance up to your submitted charge. There may be a $100 out-of-network deductible, regardless of coinsurance level, before out-of-network reimbursement is made. |
Payment is made directly to you based on your Delta Dental PPO contract fee or based on a group-specific “Table of Allowance." The patient is responsible for the difference between the Delta Dental payment and your Delta Dental PPO contract fee. You cannot balance-bill the patient for any difference between the PPO contract fee and your submitted charge for a procedure. |
If you do not participate in the PPO and you are a primary care office, payment is based on your Delta Dental Premier agreement.
Note: Specialists enrolled in the Delta Dental PPO are also enrolled in the DeltaCare specialty network. |
Delta Dental PPO Plus Premier |
Dentists who only only belong to the Delta Dental Premier network are considered participating out-of-network providers for this plan. Payment is made directly to you and is based on your Delta Dental Premier contract fee. Claims are processed based on out-of-network benefits. Usually in- and out-of-network benefits are paid at the same coinsurance level, but in some instances the out-of-network coinsurance levels are reduced. |
Payment is made directly to you and is based on the Delta Dental PPO contract fees. You cannot balance-bill the patient for any difference between your PPO contract fee and your submitted charge for a procedure. |
Payment is based on your Delta Dental Premier agreement. |
Delta Dental PPO Value Plan |
Payment is made to you for diagnostic and preventative services at 80% of your Delta Dental Premier contract fees. The patient may be billed the balance up to your submitted charge. The patient is responsible for your full submitted charge for all other services.* |
Payment is made to you for diagnostic and preventative services at 100% of your Delta Dental PPO contract fee. Basic and major restorative services are payable by the patient at 100% of the Delta Dental PPO Contract Fee Schedule for your region and specialty.* |
Payment is made to you for diagnostic and preventative services at 80% of your Delta Dental Premier contract fees. The patient may be billed the balance up to your submitted charge. The patient is responsible for your full submitted charge for all other services.* |
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*Total benefits are not subject to a maximum for each member for each calendar year, however time limitations still apply. |
Tufts/Delta Dental Pediatric Option Plan |
No benefits are available outside the Delta Dental PPO network. The patient is responsible to pay your submitted charge. |
Coverage is limited to diagnostic and preventative services for children up to 12 years old and reimbursement is made to you based on the Delta Dental PPO contract fees. |
No benefits are available outside the Delta Dental PPO network. The patient is responsible to pay your submitted charge. |
DeltaCare |
A limited out-of-network benefit is provided. Payment is made to the patient. You may bill the patient up to your submitted charge. |
A limited out-of-network benefit is provided. Payment is made to the patient. You may bill the patient up to your submitted charge. |
For Primary Care Providers payment is issued monthly in the form of capitation payments based on the number of DeltaCare patients assigned to your practice. You may collect the copayment amounts referenced in the Member Copayment Schedule from the patient as well as your office fee for any non-covered service. You are also paid supplemental fees for some specialty care provided by you and to help offset laboratory charges for some major restorative procedures. |