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.
Members must have at least one full month premium paid, before the 90-day grace period applies. For example, if the initial payment was never received, the policy can be cancelled on the same day as the effective date.
Individuals receiving APTC have until the last day of coverage to pay for the next month. If no payment is received, the 90-day grace period begins.
The 90-day grace period starts with the first missed premium payment. The first 30 days of the period claims will continue to be paid. The next 60 days of the grace period claims will not be paid until payment is received. In addition, the provider will be notified.
If at any time during the 90-day grace period, the member has paid the premium in full, the 90-day grace period would no longer apply and would start over again with the next missed payment.
If at the end of the 90-day grace period any premium due remains, the member must then be termed back to the end of the first 30-day period or end the last period paid in full, whichever is most current. The member is responsible for any claims incurred after the first 30 days of non-payment.
APTC premium received beyond the termination date will be returned.
Pending Claim(s)
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
Retroactive denials
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 marketplace@deltadentalia.com 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:
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the procedure is not a benefit of your Policy;
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you did not receive an independent exam after we asked you to;
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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 claims@deltadentalia.com.