Claims & Payments

Everything you need to know about submitting Delta Dental claims.

Claims Processing

Everything you need to know about claims and payments.

Delta Dental Premier® and Delta Dental PPO™ Claims

Mailing addresses for your Delta Dental Premier and Delta Dental PPO claims.

Delta Dental of New Mexico

100 Sun Avenue, NE, Suite 400

Albuquerque, NM, 87109

Here are some suggestions to speed up claim payments.

Anticipate questions related to policy

Dental consultants look for reasons to approve your claims. Anticipate what questions a dental consultant may have regarding a particular claim and provide the reason it should be paid.

Example: If you replace a crown that is less than five years old, anticipate the obvious question and explain what event or circumstance made the replacement necessary.

Dental consultants are licensed dentists, who share your depth of knowledge about dental treatment and disease. Your knowledge and expertise about dentistry will likely come across clearly if you remember that your audience is a dentist just like you.

Include all patient information on claims

Lack of sufficient information, especially the member’s ID number, is the most common reason for a delayed or denied claim. With electronic claims submission, your claims are automatically edited for missing or invalid information before they are sent to carriers.

Help the dental consultant review your claim

For extensive or unusual services, what would you need to understand why a patient needs a particular treatment? Dental consultants cannot directly observe a patient’s condition, so let them know what cannot be seen on an x-ray and any special circumstances unique to your claim.

Example: If you submit a claim for a crown that was placed to restore a tooth with a fractured cusp, be sure the fractured cusp is visible in the x-ray copy. If it is not, include a written narrative so that the dental consultant will understand the purpose of the crown.

Understand the difference between what is covered and what is needed

Some procedures are not covered under your patient's plan, no matter what documentation is submitted. In such cases, it’s important to understand that a recommended treatment may be perfectly appropriate. It’s just not a payable claim under the terms of the dental benefit contract.

Example: If you provide treatment for erosion, there’s a good chance the claim cannot be paid because erosion is a common exclusion under most dental plans. The same principle applies to treatments that address cosmetic needs rather than dental disease.

Use the Dental Office Toolkit (DOT) for free real-time claims with digital attachments and pre-treatment estimates. You’ll see Delta Dental’s payment and the patient portion when the claim or pre-treatment estimate processes, often within moments (when clinical review is not necessary).

First, log in to the Dental Office Toolkit. From there, you can transmit claims, digitized attachments and pre-treatment estimates with either of these tools:

Submit Claim: transmission is quick and efficient.
My Patients: your current patients are listed here and we add new patients as their claims are processed. Patient information is automatically entered on your pre-treatment estimate or claim.

You can also use FastAttach®, a service available through National Electronic Attachment, Inc. (NEA), to electronically transmit digitized x-rays, periodontal charts, Explanation of Benefits documents, photos and narratives.

If you are not submitting claims electronically, talk with your practice management system vendor about activating your system’s electronic claims component.

When you submit claims as soon as possible after treatment is completed, you help us process claims more efficiently, using the patient’s most current eligibility and benefits to determine payment.

Generally, claims received more than 12 months after the date of treatment may not be paid. However, some programs may require you to submit claims within a shorter period of time. To be sure, please refer to your dentist handbook. If you receive notification that no payment was made because of late submission:

The patient is responsible for their coinsurance/copayment portion only. The amount that would have been payable by Delta Dental may not be charged to the patient.

Fee discounts (including waiver of copayment/coinsurance) should be reflected in the total fee that is entered on the claim.

Example: If your fee for a service is $100 and you wish to give the patient a 20% discount, then $80 becomes the fee that is actually charged and $80 should be entered on the claim as the total fee.

By entering $80 on the claim, you ensure that Delta Dental calculates its payment based on the fee actually charged, as required under the terms of your agreement with Delta Dental.

Always notify Delta Dental of the actual fee charged. This helps ensure that you don’t contribute to higher costs that can potentially jeopardize patients’ dental benefits plans.

Maximum contract allowances are the total reimbursement amounts, under the member's benefit plan, on which Delta Dental calculates its payment and the patient’s financial obligation.

Example: If the dentist submits a fee on a claim for $120, and the maximum contract allowance is $100, Delta Dental will calculate its payment and the patient’s payment based on $100.

How maximum contract allowances are determined

Depending on the state, maximum contract allowances are derived from a variety of factors, including data from fees on claims, fee filings submitted by dentists (not applicable for Delta Dental of Pennsylvania), current economic factors and/or other data.
Allowances will differ depending on the type of plan. For example, allowances for Delta Dental PPO™ are different in most cases from those for the Delta Dental Premier® plan.
Maximum contract allowances will differ by 5-digit ZIP code. However, contracted Delta Dental dentists may not charge their Delta Dental patients more than the amount determined by Delta Dental to be the patient’s portion.

Delta Dental and its affiliate companies use MetaVance Benefit Administration Software as the claims editing software product to provide timely and efficient adjudication for dental claims. This software helps our enterprise streamline many interrelated systems and processes, as well as increase functionality for the benefit of our dentists, members and clients.