2012-038 Human Resources - Delta Dental Claims & Administrative fees

Browse Search

Notice of Claim Forms Delta Dental does not require special claixn forms. However, most dental offices have claim forms available. Participating Dentists will fill out and submit your claims paperwork for you. Claims and completed information requests should be mailed to: Delta Dental P.O. Box 9085 Farmington Hills, Michigan 48333-9085 Written Notice of Claim/Time of Pavment Because the amount of your benefits is not conditioned on a Predeternunation decision by Delta Dental, a11 claixns under this Plan are Post-Service Claims. Once a claim is filed, Delta Dental will decide it within 30 days of receiving the proof of loss. If there is not enough information to decide your claim, Delta Dental will notify you or your Dentist within 30 days. The norice will (a) describe the inforxnation needed, (b) explain why it is needed, (c) request an extension of time in which to decide the claim, and (d) inform you or your Dentist that the information must be received within 90 days or your claim will be denied. You will receive a copy of any notice that is sent to your Dentist. Once Delta Dental receives the requested information, it will have 30 days to decide your claim. If you or your Dentist fails to supply the requested information, Delta Dental will have no choice but to deny your claim. Once Delta Dental decides your claim, it wili notify you within five days. Proof of Loss Written proof of loss must be given within one year after such loss. If it is not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason, provided proof is filed as soon as reasonably possible. In any event, proof of loss must be given no later than one year from such time unless the claimant was legally incapacitated. Concurrent Care Claims If you have been approved for a course of treatment and that course of treatment is reduced or ternunated before it has been completed, or if you wish to extend the course of treatment beyond what was agreed upon, Form No. 1752-NC 6 NCPPOpIus-A Ot/2o12 you may file a Concurrent Care Claim seeking to restore the remainder of the treatment regimen or extend the course of treatment. All Concurrent Care Claims will be decided in sufficient time so that, if your claim is denied (in whole or in part), you can seek a review of that decision before the course of treatment is scheduled to terminate. Authorized Representative You may also appoint an authorized representative to deal with the Plan on your behalf with respect to any benefit claim you file or any review of a denied claim you wish to pursue (see the Disputed Claims Procedure section). You should contact your Human Resources department, ca11 Delta Dental's Customer Service departrnent, toll-free, at (800) 662-8856, or write them at P.O. Box 9089, Farmington Hills, Michigan, 48333-9089, to request a form to fill out designating the person you wish to appoint as your representative. While in some circuxnstances your Dentist may be treated as your authorized representative, generally only the person you have authorized on the last dated form filed with Delta Dental will be recognized. Once you have appointed an authorized representative, Delta Dental will communicate directly with your representative and will not inform you of the status of your claim You will have to get that information from your representative. If you have not designated a representative, Delta Dental will communicate with you directly. Predetermination Estimate Delta Dental recommends Predetermination before your Dentist provides any services where the total charges will exceed $200. Predeternunation is not a prerequisite to payment, but it allows claims to be processed more efficiently and allows you to know what services may be covered before your Dentist provides them. You and your Dentist should review your Predeternunation Notice before treatment. Once treatment is complete, the dental office will enter the dates of service on the Predetermination Notice and submit it to Delta Dental for payment. Questions? Questions regarding your Plan or coverage should be directed to your Human Resources deparhnent or ca11 Delta Dental's Customer Service department, toll-free, at (800) 662-8856. You may also write to Delta Dental's Customer Service department, P.O. Box 9089, Farcnington Hills, Michigan, 48333-9089. When