Delta Dental uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures.
For a participating dentist, the maximum amount is the amount the dentist has agreed to accept for a particular service
MPA is the maximum amount that Delta Dental will reimburse out-of-network providers. For services provided by an out-of-network provider, the amount above the MPA may be the member’s responsibility. Charging this extra amount is called balance billing.
All participating dentists and most non-participating dentists will bill Delta Dental directly. If members need to send a claim they can download and mail a claim form or submit an itemized receipt with information about the date of service, the service provided and the amount of service.
Claims need to be filed within 12 months of the date of service.
P.O. Box 40384
Portland, OR 97240-0384
For Direct Option plans
Willamette Dental Group
Attention: Administrative Application Specialist
6950 NE Campus Way
Hillsboro, OR, 97124
For additional help, members can call our team of customer service experts toll-free at 888-217-2365.
A grace period to pay premiums is an extension of the due date. If premiums are paid during the grace period there is no interruption of coverage. Individual members who receive the advance premium tax credit (APTC) and have paid their first month of premium are eligible for a three-month grace period. Claims received during the first month will be processed on schedule. Claims received during the remaining grace period will be considered pending (not paid or denied) until Delta Dental receives the premium.
Grace periods and claims pending procedures for members not receiving APTC are different. Members should consult their handbooks for more information.
A retroactive denial is the reversal of a claim that Delta Dental has already paid. If Delta Dental retroactively denies a claim that has already been paid, the member will be responsible for payment. Some reasons why a member might have a retroactive denial include having a claim that was paid during a grace period or having a claim paid for a service for which they were not eligible. Members can avoid retroactive denials by paying their premiums on time and in full and making sure they are covered when services are performed.
If premiums are not paid for the first month of coverage or within the applicable grace period, member coverage will be retroactively terminated effective as of the last month that the premium was paid. Claims will be denied for any months in which members do not have active coverage.
Delta Dental reconciles accounts on a monthly basis. Any overpayment discrepancies are refunded to the member or credited to the next month’s bill. Members receive a statement reflecting the method of adjustment. Oregon members who want to request a reimbursement or who have questions about the process are encouraged to contact Customer Service at 888-217-2365.
Medical necessity and prior authorization timeframes and member responsibilities
Delta Dental does not require prior authorization on dental services. Members may request a predetermination of benefits to get an estimate of what the dental plan would pay.
Delta Dental will report its action on a claim by providing the member a document called an Explanation of Benefits (EOB). Members are encouraged to access their EOBs electronically by signing up through the Member Dashboard. Delta Dental may pay claims, deny them, or accumulate them toward satisfying the deductible, if any. If all or part of a claim is denied, the reason will be stated in the EOB. For help reading and understanding an EOB, Oregon members are encouraged to call Customer Service at 888-217-2365 or see the “How to read an EOB” document for more information. If a member does not receive an EOB or an email letting them know that an EOB is available within a few weeks of the date of service, this may indicate that Delta Dental has not received the claim. To be eligible for reimbursement, claims must be received within the claim submission period.
If a claim is denied, Delta Dental will send an EOB explaining the denial within 30 days of receiving the claim.
If additional time is needed to process the claim for reasons beyond Delta Dental’s control, a notice of delay will be sent to the member explaining those reasons within 30 days after Delta Dental receives the claim. Delta Dental will then complete its processing and send an EOB to the member no more than 45 days after receiving the claim.
If additional information is needed to complete processing of the claim, the notice of delay will describe the information needed. The party responsible for providing the additional information will have 45 days to submit it.
Once the additional information is received, processing of the claim will be completed within 15 days. Submission of information necessary to process a claim is subject to the plan’s claim submission period.
Coordination of Benefits (COB) occurs when a member has healthcare coverage under more than one plan.
If a member is covered by more than one dental health plan, Delta Dental coordinates benefits with other insurers to help the member receive the full benefit of those plans. By coordinating benefits, Delta Dental may be able to reduce the member’s out-of-pocket expenses for covered services.
Upon initial enrollment, Delta Dental requests information from each member regarding any other health insurance coverage they may have to verify any changes that may have happened during the year. Additionally, with each claim submitted we review whether there have been any changes in other health insurance. In order to prevent a claim from being delayed or denied, members should let Delta Dental know if they or anyone in their family have any other current medical or dental coverage that has existed in the last 12 months. This includes Medicare and Medicaid. Members let us know by completing a Coordination of Benefits form and returning it to Delta Dental. Members can also call Customer Service at 888-217-2365.