Delta Dental PPO™ Participation FAQs
What is Delta Dental?
Delta Dental is a nonprofit, group dental benefit administrator. For more than 60 years, Delta Dental has helped remove financial barriers to oral health services for more Americans than any other dental benefits carrier. We educate and empower people to take responsibility for their oral health. Delta Dental provides dental benefits for one of every four Americans with dental coverage.
What is Delta Dental PPO™?
Delta Dental PPO™ is a fee-for-service program. Delta Dental PPO™ participating dentists are reimbursed on the basis of their submitted fees, not to exceed the amounts published in the Delta Dental PPO™ fee schedule, as payment in full when treating eligible Delta Dental PPO™ patients.
What is the Delta Dental PPO™ network?
With 115,000 dentists participating throughout the United States and its territories, Delta Dental PPO™ has one of the country’s largest networks of participating dentists. Participation in this program offers dentists opportunities to attract new patients to their practice and ensures direct payment to the dentist by all Delta Dental member companies.
-Delta Dental Plans Association, 2020
Is Delta Dental PPO™ a capitation/DHMO or PPO program?
Delta Dental PPO™ is not a capitation/DHMO program. Delta Dental pays participating dentists directly for each covered service rendered based on the lesser of the submitted fee or the fee published in Delta Dental’s PPO fee schedule, rather than a monthly dollar amount. Patients eligible for benefits can receive care from any dentist they choose, but they can lower their out-of-pocket costs by choosing a Delta Dental PPO™ participating dentist.
What are the advantages of participating in Delta Dental PPO™?
Delta Dental offers great service and support, fast and accurate payments, and a means of retaining current patients and attracting new patients into your practice. And you receive the Delta Dental check at your office, which reduces your collections efforts. All you have to collect from your Delta Dental-covered patients are their copayments, if applicable.
What do I agree to when I sign an agreement?
Participating dentists agree to follow the Uniform Requirements (which can be reviewed prior to signing an agreement); abide by the processing policies (which can be reviewed prior to signing an agreement); charge enrollees their applicable copayments; and accept payment directly from Delta Dental.
How often is the Delta Dental PPO™ fee schedule reviewed and updated?
The Delta Dental PPO™ fee schedules are reviewed annually and updated accordingly.
Can the patient be billed the difference between the fee schedule and my usual fee?
No, that difference is not chargeable to the patient. Reimbursement may come from Delta Dental, the patient or a combination of both parties, but the total amount collected cannot exceed the PPO fee schedule amount.
How do I know if the Delta Dental PPO™ fee schedule will be acceptable for my practice?
You have the opportunity to review the Delta Dental PPO™ fee schedule prior to signing an agreement.
How do I know if a patient is eligible for Delta Dental PPO™ benefits?
You can verify eligibility and access benefits and claims information online through the Dental Office Toolkit® or by calling 800-524-0149 and using DASI, our automated voice response system. You may also request a summary of dental benefits by selecting the FaxBack option. For patients that have dental coverage through a national group, visit the Delta Dental portal at www.deltadental.com.
What happens if a Delta Dental PPO-covered patient is treated by a nonparticipating dentist?
Plan purchasers determine how out-of-network claims are handled, so Delta Dental encourages dentists to verify coverage before treatment is rendered. Delta Dental PPO™ plan payment options include:
Delta Dental PPO™ (Point-of-Service): Members are covered by Delta Dental Premier® for treatment rendered by a dentist who does not participate with Delta Dental PPO.™ The dentist is paid based on his or her participation status in Delta Dental Premier®.
Delta Dental PPO™ (Standard): Benefits may be limited, or there may be no coverage for services rendered by a nonparticipating PPO dentist.
Delta Dental PPO™ (Standard): Payments may be based on a nonparticipating dentist fee schedule. This schedule is lower than the published PPO fee schedule.
Am I expected to file claims for Delta Dental-covered patients?
Yes. To make things easier for you, Delta Dental offers several convenient solutions. For submitting claims electronically at no charge, use the Dental Office Toolkit®. You may use a clearinghouse that will usually charge a per claim or monthly fee, or you may mail paper claims to:
PO Box 9085
Farmington Hills, MI 48333-9085
Do I need approval to refer a patient to a specialist?
No. Prior approval is not required when you refer a patient to a specialist. However, we do suggest that you refer your patients to a Delta Dental PPO™ participating specialist to minimize your patients' out-of-pocket costs. To get a list of participating specialists in your patients' area, use our online dentist directory, or call DASI, our automated voice response system, at 800-524-0149.
How do Delta Dental-covered patients and members know that I am a Delta Dental PPO™ participating dentist?
To assist new and existing Delta Dental members in locating your office, we provide listings of participating dentists on our websites, our online Member Portal and through DASI, our automated voice response system.
If I sign an agreement, how long do I have to remain participating? Am I free to terminate the agreement at any time?
The agreement remains in effect until you decide to terminate it. We require participating dentists to provide a 30-day written notice before resigning from the Delta Dental program.
Can I participate in more than one Delta Dental program?
Yes, you can participate in one or both our programs: Delta Dental Premier® and Delta Dental PPO™.
If I have further questions about participation, whom do I call?
Our professional relations representatives are available to give you all of the information about participating with each Delta Dental program, facilitate the contracting process and assist staff with Delta Dental claims administration. To schedule a personal visit to your office or request more information, contact your Provider Relations Representative listed on this territory map.