Transparency in Coverage
As a part of the Affordable Care Act (ACA), Delta Dental of Iowa has outlined the following transparency in coverage.
Grace Period for Members with Advanced Premium Tax Credit
As part of the Affordable Care Act, members may qualify for Advanced Premium Tax Credit (APTC, a government subsidy) to help subsidize the cost they pay for their dental coverage. Even though the member qualifies for APTC, they are still responsible for paying a portion of the premium.
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual health care plans, if you do not pay your premium on time, you will receive a 30-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly. If you have an individual HMO plan in Iowa, we will pay your claims during the 30-day grace period; however, your benefits will terminate if your delinquent premium is not paid by the end of that grace period.
If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a 3-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the 3-month grace period, 2K-25 2024 QHP Application Instructions PY2024 URL Contents Minimum Requirements we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
Those claims which have been received by Delta Dental of Iowa for potential reimbursement under the terms of a member’s dental coverage. Claims may move into a pending status for a number of reasons. For example the claim may need review by Delta Dental of Iowa professional staff, usually for procedures requiring an x-ray, periodontal chart or narrative. A pending claim is part of the normal claims processing procedures and will be appropriately adjudicated in a timely manner. There are situations, see APTC described above, where a claim may remain in a pending status until premium payment has been resolved.
Out-of-network liability and balance billing
There is no Maximum Out Of Pocket limit for Covered Services provided by dentists who do not participate in the Delta Dental of Iowa (or a Delta Dental Member Company) network(s).
Delta Dental of Iowa does not have contracting relationships with nonparticipating dentists and they do not agree to accept their local Delta Dental PPO/Premier payment arrangement or any other payment arrangement. This means the member is responsible for any difference between their nonparticipating dentist’s Billed Charge and the PPO Schedule or the Premier Maximum Plan Allowance, as the case may be.
Enrollee claims submission
The member will need to file a claim if they do not see a Delta Dental dentist who does not agree to file the claim for the member. Participating Delta Dental dentists will file for the member. After the member receives services, they should file a claim only if their dentist has not filed one. Delta Dental may deny payment of a claim submitted more than 365 days after the date services were rendered. If you need a claim form or have any questions, please call us or visit our website www.deltadentalia.com. If you must file your own claim, send it to the following address:
Delta Dental of Iowa
P.O. Box 9000
Johnston, IA 50131-9000
Claims may be denied retroactively even after services have been obtained from the provider. In order to prevent denials, it is suggested premiums be sent on time and that prior authorizations be sent prior to the date of service.
Recoupment of overpayments
If the member feels that they have overpaid their Delta Dental premium, they can request a refund by contacting Delta Dental at [email protected] or by calling (888) 471-0878.
Medical necessity and prior authorization timeframes and enrollee responsibilities
The purpose of Treatment Plan Pre-Determination is to help control the cost of the members’ benefits, not to keep the member from receiving dentally necessary and dentally appropriate treatment. Delta Dental’s review is based on the treatment plan submitted by the member’s dentist and provides a determination whether services are dentally necessary and dentally appropriate and confirms the benefits of the policy. Failure to obtain a prior authorization can result in a denial of services if the services are determined not to be dentally appropriate or do not meet the benefits of the policy.
The member should notify Delta Dental of Iowa before receiving services in the following benefit categories:
- Complex Periodontal Surgery
- High Cost Restorations including Crowns, Onlays, and Bridges
- Dental Implants
- Any benefit category that will exceed $300.
Procedures that REQUIRE Delta Dental’s review and approval before they are performed:
- Orthodontics - Medically Necessary
The Treatment Plan Pre-determination Review
Once we receive the treatment plan and proper documentation, we will let you and your dentist know if the treatment plan is approved within 15 working days. We will take one of the following three actions when we receive your treatment plan:
- Accept it as submitted.
- Recommend an alternative benefit. If we ask you to receive an independent diagnosis from a dentist of our choice, we will pay for the exam.
- Deny the treatment plan because:
the procedure is not a benefit of your Policy;
you did not receive an independent exam after we asked you to;
or the procedure is not dentally necessary and dentally appropriate.
Drug exception timeframes and enrollee responsibilities
Does not apply to stand-alone dental policies.
Explanation of Benefits (EOB)
Members will receive an Explanation of Benefits (EOB) for all services received unless there is no patient liability. The EOB will indicate the amount of payment by Delta Dental and the amount of patient responsibility. The provider will also receive an explanation indicating the amount of patient responsibility. Delta Dental will send an EOB after receiving and processing the claim.
Coordination of Benefits (COB)
Members may have other insurance or coverage that provides the same or similar benefit(s) as their Delta Dental policy. If so, Delta Dental will work with the other insurance company or carrier. The benefits payable under the policy when combined with the benefits paid under your other coverage will not be more than 100 percent of either our payment arrangement amount or the other carrier’s payment arrangement amount. When the member receives services, they need to let Delta Dental know that they have other coverage. Other coverage includes: group insurance, other group benefit plans (such as HMOs, PPOs, and self-insured programs); Medicare or other governmental benefits; and the medical benefits coverage in your automobile insurance (whether issued on a fault or no-fault basis). To help Delta Dental coordinate benefits, the member should:
- Inform the dentist by giving him or her information about the other coverage at the time of services. The dentist will pass the information to Delta Dental when the claim is filed.
- Indicate that they have other coverage when filling out a claim form by completing the appropriate boxes on the form. Delta Dental will contact the member for any additional information if needed.
The member should cooperate with Delta Dental and provide requested information about their other coverage. If this necessary information is not provided, claims will be denied.
Overpayment for Services by Patient
You will receive an Explanation of Benefits (EOB) for all services received unless there is no patient liability. The EOB will indicate the amount of payment by Delta Dental and the amount of patient responsibility. Your provider will also receive an explanation indicating the amount of patient responsibility. If you overpay a provider, you will need to contact the provider to request a refund. For assistance working with your provider, you can contact Delta Dental at 800-544-0718 or [email protected].