Delta Dental of Oklahoma

FREQUENTLY ASKED QUESTIONS:

Q. What does Delta Dental pay for different services?

Delta Dental’s payment will vary depending on:

The dentist you select.
The program you are enrolled in.

To better understand your Delta Dental coverage, review the plan materials you receive when you enroll. You may also call Delta Dental of Oklahoma’s customer service department with specific benefit questions.

Q. Do I need pre-approval for major work?

A. Delta Dental programs do not require pre-approval for treatment. However, whether or not your program requires it, it is a good idea to know that the treatment proposed is covered under your dental plan and exactly what your share of the cost will be before you receive treatment. Delta Dental can provide your dentist with a free estimate, called a "predetermination of benefits", based on your records and your dentist’s proposed treatment plan.

Q. What happens when I am covered by two dental plans? Does this mean I now get four cleanings a year instead of two?

A. Having two dental programs (called "dual coverage") does not "double" your coverage. However, it may mean that you will pay lower out-of-pocket costs. One program will be considered primary (the one that usually covers you as an employee), and the other will be secondary (the one that typically covers you as a dependent). When a person has coverage through two carriers, benefits are coordinated by the two carriers so the person gets the maximum benefit from both plans, but not to exceed 100% of the total charge.

Q. How do I know if my dentist is a Delta Dental dentist?

A. You can ask your dentist if he or she is a Delta Dental participating dentist, or you can check the Dentist Directory on our web site at www.DeltaDentalOK.org.

Q. What are the advantages of visiting a Delta Dental participating dentist?

A. When you visit a Delta Dental participating dentist:

You do not pay the entire bill and wait for reimbursement from Delta Dental. Instead, Delta Dental pays its portion of the cost directly to your dentist. We send you a notice explaining your portion of the bill (an Explanation of Benefits). You pay the dentist only the amount shown in the patient pay column of your E.O.B. This does not include co-patments.
Delta Dental makes sure you are not charged extra for services that should be included in the cost of treatment. For example, when you receive a crown, you cannot be charged additional fees for tooth preparation, local anesthesia, an impression, or a temporary crown.
The dentist handles all claim forms and other paperwork for you.

Q. My dentist is not a Delta Dental dentist. Can I still visit him or her?

A. Delta Dental programs allow you to select any licensed dentist. While we recommend you select a Delta Dental participating dentist because you may enjoy lower out-of-pocket costs and the convenience of having your claim forms handled free-of-charge by the dental office, you are free to choose any dentist.

Q. How do I change dentists?

A. Delta Dental programs allow you to see any dentist you wish, and there is no need to notify us when you change dentists. You and your family members are also free to see different dentists, if you prefer.

DENTAL BENEFITS: GLOSSARY OF TERMS

Birthday rule: When a dependent child's parents both have dental coverage, this rule states that the "primary" program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary vs. secondary coverage, but it may be superseded by a court order such as a divorce agreement.

Contract year: The 12-month period over which a group's deductibles, maximums and other provisions apply. Also known as the benefit year.

COB: The abbreviation for Coordination of Benefits. When you are covered by more than one benefit plan, the two benefits are coordinated so that no more than 100 percent of the total covered expenses are paid. See "non-duplication of benefits" and "birthday rule."

Copayment: Your share of the cost of a given service. It may be a percentage of the dentist's approved fee or a fixed dollar amount.

Deductible: The amount you pay for treatment before certain benefits are paid. In most programs, deductibles must be met each year.

Dual choice: An option that allows you to select from two or more types of dental programs. Also called "dual option."

Dual coverage: When you have coverage under more than one benefit program. The primary and secondary carriers coordinate the two programs, so that the primary carrier pays its portion first and the secondary carrier usually pays the remainder.

Enrollee: This word applies to the person who is covered under a Delta Dental program. An enrollee may also be referred to as a subscriber or patient.

E.O.B: (Explanation of Benefits): The statement you are mailed detailing how your claim payment was calculated.

Fee-for-service: A program design in which the dentist is paid for each service, rather than a fixed amount per patient, which is how many HMOs work. The fee-for-service method is the traditional way of delivering dental benefits.

Fee listing/filed fees: Every Delta Dental dentist submits a list of fees to Delta Dental. They are used to calculate Delta Dental's payment.

Maximum: A dollar limit that is applied to benefit payments. Some maximums apply to the lifetime of the benefit program; others apply to a particular period of time (calendar year, benefit year, etc.) or particular services (such as separate maximum for orthodontic benefits).

Maximum Allowable: Term for the maximum fee charged and collected for a given service by a particular dentist.

Network: Dentists who have contractually agreed to treat Delta Dental subscribers and accept payment according to those administrative guidelines.

Out-of-pocket costs: Any amount you are responsible for paying, such as copayments, deductibles and costs above your annual maximum.

Payment Protection: A feature of most programs that protects you from unexpected expenses. For example, in a DeltaPremier fee-for-service program that pays an 80 percent benefit on covered services, you are assured that your copayment will not be more than the remaining 20 percent, as long as you have gone to a participating Delta Dental dentist.

PPO: The abbreviation for Preferred Provider Organization. A program that allows you to choose any dentist but provides financial incentives to choose dentists who are part of the PPO network. DeltaPreferred Option is a PPO program.

Predetermination: Gives an estimate of how much of a proposed treatment plan will be covered under your dental program. A predetermination lets you figure your costs before you receive major treatment. Any enrollee can ask the dental office to submit a predetermination request.

DENTAL TREATMENT TERMS

Adjacent: Together, side by side

Allowable Charge: The maximum dollar amount on which benefit payment is based for each dental procedure

Alternate Benefit: A provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed.

Anterior Teeth: Permanent teeth 6-11 upper, 22-27 lower; Primary teeth c-h upper, m-r lower. Please consult with your dentist if you have any questions regarding tooth location.

Bi-lateral: Affecting both sides of the mouth.

Caps: Crowns

Completion Date: The completion date is the date of insertion for removable prosthetic appliances. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized.

Component Part: Procedure is considered part of final treatment and patient is not responsible for additional charges.

Consecutive Months: Example: January 5, 1999 and July 5, 1999 - patient is not eligible for this service again until January 5, 2000.

Deciduous Teeth: Baby/primary teeth; A-T

Denied: The fee for a procedure or service is denied and chargeable to the patient because the procedure or service is not a benefit of the patient’s plan. The fee charged is not payable by Delta Dental, but is collectable from the patient.

Disallowed: The fee for a procedure or service is disallowed; it is not benefited by Delta Dental or collectable from the patient by a Participating Dentist.

Extracoronal: To place an appliance on top or outside of tooth (orthodontic brackets)

Extraoral: Outside of the mouth

Fixed Prosthesis: An appliance, which is cemented; bridges.

I & D: Incisal and drain

Impression Date: Date on which a dentist takes an impression for a crown or complete denture/partial denture.

Initial: Beginning of a process; first denture or partial denture.

Inlay: A solid filling made to the precise shape of a cavity of a tooth and cemented into it.

Interim Partial/Denture: Temporary partial or denture designed to replace anterior teeth during the healing process or as an anterior space maintainer for children.

Intracoronal: To place the appliance into the tooth once a prep has been made; cemented into the prepared area.

Intraoral: Within the mouth.

Mandibular (mandible): The lower jaw

Maxillary (maxilla): The upper jaw

N.A.B: Not a Benefit, patient is responsible

N.N.A.: Need Not Apparent

O.H.I.: Oral Hygiene Instructions

Onlay: A crown like structure, which is placed on the tooth structure not to cover the entire, tooth and cemented on the tooth.

Permanent Teeth: Adult teeth, 1-32.Please consult with your dentist if you have any questions regarding tooth location.

Plates: Dentures

Posterior Teeth: Permanent teeth 1-5, 12-21 and 28-32, teeth which are behind the canine teeth, molars and bicuspids (premolars); Primary teeth A-B, I-L and S-T. Please consult with your dentist if you have any questions regarding tooth location.

Prep-Date: Date a tooth is prepared for a crown.

Primary: Baby teeth, A-T: deciduous teeth. Please consult with your dentist if you have any questions regarding tooth location.

Quadrant: One of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.

Re-base: To refit a denture by replacing the base material (acrylic) without altering the occlusal characteristics, reuse of false teeth. Done by lab only.

Reline: Replacing or resurfacing the lining of a denture. Applying more acrylic to inside of denture or partial. Can be done chair-side or lab.

Removable Prosthesis: Upper or lower partial or complete denture.

Replacement: Replacing of the first denture/partial denture or crown/filling.

Seat Date: Date in which the crown/bridge is cemented onto the tooth.

Sextant: One of the six relatively equal sections into which a dental arch can be divided, for example: tooth number 1-5; 6-11; 12-16; 17-21; 22-27; 28-32. Sometimes used for recording periodontal charting. Please consult with your dentist if you have any questions regarding tooth location.

Surfaces: M-Mesial, D-Distal, O-Occlusal, L-Lingual, B-Buccal, for anterior teeth I-Incisal, F-Facial.

T.M.J.: Temporomandibular Joint.

Unilateral: Affecting or occurring only on one side.