Your dental benefits are determined by the medical plan you are covered under:
Note: If you are a member of the CW/CE classification, your medical plan is the Flexible Choice Plan.
The dental benefits are designed to help you meet the expense of proper dental care. All plans cover preventive care at 100%. The dental coverage under the Building Trades Plan also provide benefits for other services.
You may visit any dentist you wish; however, you will likely pay less with an in-network provider. If you see an out-of-network dentist and they charge above the “Maximum Non-Participating Dentist Fee,” you will pay the coinsurance required PLUS the difference between what the dentist charges and the Maximum Non-Participating Dentist Fee (see chart below for details). If you are in the Building Trades Plan or Flexible Choice Plan, when you use a dentist in the Delta Dental Network, the calendar year maximum is higher.
Using The Delta Dental Network
When you or your eligible dependents need dental care, you have the option to use dentists who participate in the Delta Dental Network—a large, national network of dentists and specialists who have agreed to provide services at a negotiated rate. Here’s how it works:
- You can use either the Delta Dental PPO (PPO) Network or the Delta Dental Premier® Network.
- The PPO Network does not have as many participating providers; however, these dentists have agreed accept to deeper discounted rates.
- The Premier Network has a larger number of participating providers; however, their discounted rates are not as low as the PPO Network.
- Participating dentists and specialists in both networks have agreed to pre-negotiated rates as payment in full for dental care services. These rates can help reduce your out-of-pocket costs and be an important consideration if you are monitoring your expenses against the calendar year maximum (see links to charts above).
- Four out of every five dentists nationwide participate in the Delta Dental Network.
- If you reach the dental plan’s calendar year maximum, the charges you incur for the remainder of the year are your responsibility. However, if you use an in-network provider, you still pay the discounted rates.
- You may visit any dentist you wish; however, if you visit an out-of-network provider, the lower, Delta Dental negotiated rates do not apply, your calendar year maximum for benefits may change (if you are in the Building Trades or Flexible Choice Plans) and you will be responsible for any amount over the maximum non-participating dentist fee. The chart below shows how a member enrolled in the Building Trades Plan saves using an in-network provider.
|Delta Dental PPO||Delta Dental Premier||Out-of-Network|
|Dentist’s Billed Fee:||$100||Dentist’s Billed Fee:||$100||Dentist’s Billed Fee:||$100|
|PPO Fee Schedule Amount:||$70||Maximum Approved Fee:||$90||Maximum Non-Participating Dentist Fee:||$90|
|The Fund pays 75% of the PPO Fee Schedule Amount:||$52.50||The Fund pays 75% of the Maximum Approved Fee:||$67.50||The Fund pays 75% of the Non-Participating Dentist Fee:||$67.50|
|You Pay:||$17.50||You Pay:||$22.50||You Pay:||$32.50 ($22.50 + $10)*|
*If you seek care from an out-of-network dentist and that dentist charges more than the maximum non-participating dentist fee, you must pay the difference from your own pocket. This is called “balance billing.” In the above example, the difference (and subsequent out-of-pocket expense) is $10.00. The maximum non-participating dentist fee is based on fees charged by all dentists for similar services in a geographic area and currently provides, on average, payment for 90% of the submitted charge before deductibles, coinsurance, and over maximum charges.
Finding a Dentist in the Delta Dental Network
To see if your dentist participates in the Delta Dental PPO or Delta Dental Premier Networks or to find a local participating dentist, visit www.deltadentaloh.com and follow these instructions:
- Click the “Find a Dentist” tab or link.
- Click the “Delta Dental PPO and Delta Dental Premier” network link.
- You can filter your search results by network, distance and dental specialty.
- Click “Find Dentists” to view your results.
- Select “More Options” to filter results by office hours, languages spoken, provider gender and more.
You may also call Delta Dental’s Customer Service department at (800) 524-0149 to obtain a customized list of participating dentists. Representatives are available Monday – Friday, 8:30 a.m to 8:00 p.m. Delta Dental’s Automated Service Inquiry (DASI) system is available 24 hours a day, seven days a week. If your current dentist does not participate in Delta Dental PPO or Delta Dental Premier but is interested in learning how to join, you can recommend your dentist for membership. Just go to www.deltadentaloh.com, click the “Refer Your Dentist” link under “Find a Dentist,” and fill out the online form.
Filing Dental Claims
If you seek care from a dentist who participates in Delta Dental PPO or Delta Dental Premier, your dentist will fill out and file your claims for you. Out-of-network dentists may not fill out and file claims for you. If this is the case, you can print a claim form at www.deltadentaloh.com and send the necessary documentation to:
P.O. Box 9085
Farmington Hills, MI 48333
If you are not eligible for benefits at the time you obtain services from the dental care provider, or in the event the desired service is not covered under the Plan, you will receive a written Notice of Adverse Benefit Determination that contains the following:
- The specific reasons for the adverse benefit determination;
- The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
- A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
- The notice of any internal rule or guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
- A notice of your right to a written explanation of any exclusion which affects your claim; and
- A description of the Appeals Procedure.
Claims Review Procedure
If you receive notice of an adverse benefit determination, and if you think that Delta Dental incorrectly denied all or part of your claim, you can take the following steps:
1. You or your dentist should contact Delta Dental’s Customer Service department at their toll-free number, (800) 524-0149, and ask them to check the claim to make sure it was processed correctly. You may also mail your inquiry to the Customer Service department at P.O. Box 9089, Farmington Hills, Michigan, 48333. When writing, please enclose a copy of your Explanation of Benefits and describe the problem. Be sure to include your name, your telephone number, the date, and any information you would like considered about your claim. This inquiry is not required and should not be considered a formal request for review of a denied claim. Delta Dental provides this opportunity for you to describe problems and submit information that might indicate that your claim was improperly denied and allow Delta Dental to correct this error quickly.
2. Whether or not you have asked Delta Dental informally, as described above, to recheck its initial determination, you can submit your claim to a formal review through the Claims Appeal Procedure described here. To request a formal appeal of your claim, you must send your request in writing to:
P.O. Box 30416
Lansing, Michigan 48909
You must include your name, address and ID number, the reason you believe your claim was wrongly denied, and any other information you believe supports your claim, and indicate in your letter that you are requesting a formal appeal of your claim. You also have the right to review the Plan and any documents related to it. If you would like a record of your request and proof that it was received by Delta Dental, you should mail it certified mail, return receipt requested.
You or your authorized representative should seek a review as soon as possible, but you must file your appeal within 180 days of the date on which you receive your notice of the adverse benefit determination you are asking Delta Dental to review. If you are appealing an adverse determination of a Concurrent Care Claim, you will have to do so as soon as possible so that you may receive a decision on review before the course of treatment you are seeking to extend terminates.
The Dental Director or any other person(s) reviewing your claim will not be the same as, nor will they be subordinate to, the person(s) who initially decided your claim. The Dental Director will grant no deference to the prior decision about your claim. Instead, he will assess the information, including any additional information that you have provided, as if he were deciding the claim for the first time.
The Dental Director will make his decision within 30 days of receiving your request for the review of pre-service claims and within 60 days for post-service claims. If your claim is denied on review (in whole or in part), you will be notified in writing. The notice of any adverse determination by the Dental Director will (a) inform you of the specific reason(s) for the denial, (b) list the pertinent Plan provision(s) on which the denial is based, (c) contain a description of any additional information or material that is needed to decide the claim and an explanation of why such information is needed, (d) reference any internal rule, guideline, or protocol that was relied on in making the decision on review and inform you that a copy can be obtained upon request at no charge, (e) contain a statement that you are entitled to receive, upon request and at no cost, reasonable access to and copies of the documents, records, and other information relevant to the Dental Director’s decision to deny your claim (in whole or in part), and (f) contain a statement that you may seek to have your claim paid by bringing a civil action in court if it is denied again on appeal.
If the Dental Director’s adverse determination is based on an assessment of medical or dental judgment or necessity, the notice of his adverse determination will explain the scientific or clinical judgment on which the determination was based or include a statement that a copy of the basis for that judgment can be obtained upon request at no charge. If the Dental Director consulted medical or dental experts in the appropriate specialty, the notice will include the name(s) of those expert(s).
3. If your claim is denied in whole or in part after you have completed this required Claims Appeal Procedure, or Delta Dental fails to comply with any of the deadlines contained therein, you have the right to seek to have your claim paid by filing a civil action in court. However, you will not be able to do so unless you have completed the review described above. If you wish to file your claim in court, you must do so within the timelines established by the Plan.
4. Following the conclusion of the appeal process through Delta Dental, you have the option to request an informal review by the Board of Trustees. The appeal to the Board is strictly voluntary and only available once you have pursued the mandatory appeal with Delta Dental. The request for review must be in writing and submitted to the Board within 180 days of the final decision on appeal from Delta Dental. The request should state your name, address, Social Security number and a copy of any documents you would like the Board to consider. The material should be sent to:
Board of Trustees
4th District IBEW Health Fund
3150 U.S. Route 60
Ona, WV 25545
The Board will consider your optional appeal at its next regularly scheduled quarterly meeting. You will be notified of the decision of the Board as soon as possible, generally within 5 days after a decision is made. You are under no obligation to pursue a voluntary appeal before filing a civil action and the Plan waives any defense relating to your failure to exercise this option. Additionally, any defense the Plan may have based on timeliness is tolled while you are pursuing the voluntary level of appeal.