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Health Fund

Claim Example (Dental Benefits)

Janet has a toothache and it is beginning to interrupt her work. She contacts her dentist to make an appointment and was informed that her dentist is retiring. Janet decides to try a DPO dentist, to take advantage of the lower, negotiated rates.

Janet chooses a dentist online using Delta Dental's website and finds Dr. Cooper, who is part of the DPO network, and is accepting new patients. After examining the tooth that has been bothering Janet, Dr. Cooper recommends a crown. The following examples illustrate the cost difference between a Delta DPO dentist and a non-Delta dentist:

Charge for crown
Janet's deductible
- $ 75.00
Plan pays 80% of the remaining $100
- $ 80.00
Janet pays 20%
$ 20.00
Janet's cost with a DPO dentist (deductible + her coinsurance The percentage of eligible expenses you're responsible for paying.)
$ 95.00
Charge for crown
Delta-approved fee for a crown (R&CReasonable and Customary Charge - The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges.)
Janet's deductible
- $ 75.00
Plan pays 70% of the remaining $100
- $ 70.00
Janet pays 30%
$ 30.00
Plus the difference between non-Delta dentist submitted fee and Delta-approved fee
Janet's cost with a non-Delta dentist
(deductible + amount over R&C + her coinsurance)
Janet's cost with a non-Delta dentist
Janet's cost with a DPO dentist
- $ 95.00
Janet's savings with a DPO dentist

Note: Costs cited in this example are for illustrative purposes only. Your own costs may be different.

Predetermination Of Benefits

The Plan has a feature called Predetermination of BenefitsThe process of obtaining certification or authorization from a plan for a procedure before it's performed.. It lets you know in advance how much the Dental Plan will pay before your dentist actually begins the dental work he/she is recommending. Predetermination of benefits allows you to have your questions answered before you incur an expense and may help to prevent any misunderstanding about your financial responsibilities.

You and your dentist should consider obtaining a Predetermination of Benefits if the total charges for the planned course of treatment are expected to be more than $300 — or if extensive services, such as crowns or bridges, are being recommended. While Predetermination of Benefits is recommended, it is not required.

Here's how Predetermination of Benefits works: when deciding on a treatment plan, your dentist should submit an Attending Dentist's Statement to Delta Dental specifying the proposed course of treatment. Delta Dental will send your dentist a Notice of Predetermination, which estimates how much of the proposed charges you will have to pay.

Predetermination of Benefits doesn't guarantee that benefits will be paid. Actual benefits may differ from the estimated benefits, depending on:

  • The actual services provided;
  • The amount of the deductible;
  • Whether you have met the plan-year benefit maximum; and
  • Whether you're covered by more than one dental plan.

If you have any concerns about the Predetermination of Benefits, you may contact Delta Dental before your treatment begins.

Alternative Benefit Provision

If you or your dentist selects a treatment plan that is more expensive than the treatment normally provided, you may be responsible for additional out-of-pocket costs. The Dental Plan will pay the applicable percentage of the least expensive professionally acceptable treatment plan. If you choose a more expensive treatment plan, you will be responsible for the remainder of the dentist's fee after the plan pays benefits.

For example, you choose a gold crown when one made of semi-precious metals would restore the tooth just as well. Because you've chosen a more expensive treatment, you would be responsible for the cost above and beyond what the Plan would pay for a crown made of semi-precious metals.