ACA Compliant Individual Dental Plans

Balance billing occurs when an out-of-network provider bills an enrollee for charges other than copayments, coinsurance, or any amounts that may remain on a deductible. There are no exceptions to out-of-network liability. DDAZ processes claims for all out-of-network services, including emergency services, the same as any other submitted claim.

Delta Dental Select Plan (High option) - Providers exclusively participating in the Delta Dental Premier Network (not a Delta Dental PPO participating dentist) may charge the covered person for any additional cost of treatment over the PPO fee but no more than the Premier allowable charge. In addition, Delta Dental Providers will submit claims directly to DDAZ and DDAZ will issue payment directly to the Delta Dental Provider. If the covered person receives services from a dentist who is not a Delta Dental Network Provider, the covered person will be responsible for any additional cost of treatment over the PPO allowable charge.

Delta Dental Essential Plan (Low option) - If the covered person receives services from a dentist who is not a Delta Dental Network Provider, the covered person will be responsible for any additional cost of treatment over the allowable charge.

An enrollee, instead of the provider, submits a claim to the issuer requesting payment for services that have been received.

Delta Dental Providers will submit claims directly to DDAZ and DDAZ will issue payment directly to the Delta Dental Provider.

• Sample Individual Claim Form (PDF)

Filing a Claim
To file a claim with DDAZ, the covered person may simply present his/her identification card to the receptionist at the dental office. Claims should be filed within 90 days after a covered person receives dental services. Covered persons claiming benefits under this policy must give DDAZ any facts that it needs to pay the claim.

We will send you notice regarding the claim within 30 days of receipt unless special circumstances require more time. This notice explains the reason(s) for payment or nonpayment of a claim. If a claim is denied because of incomplete information, the notice will indicate what additional information is needed.

If we need more information we will send you a notice within 15 working days after we receive your claim to let you know.

If you disagree with our claim payment or denial, you may file an appeal, as more fully described under "Description of the appeals process".

Claims can be submitted to:

Delta Dental of Arizona
Attn: Individual Plan Claims
P.O. Box 9092
Farmington Hills, MI 48333-9092

Customer Service (toll-free): 800.894.2961

•  A grace period is an amount of time allowed after the premium due date and before the cancellation of a policy.
• A pended claim is a claim that has been placed on hold for payment until the premium amount due has been received.

For every premium payment after your first premium payment, you have 31 days from the premium due date to remit the required premium (90 days if you have paid at least one month of premium and received advance payment of the premium tax credit). Claims will continue to be paid during the initial 31 day grace period. Claims may be pended in the second and third months of the grace period for enrollees who receive advance payment of the premium tax credit (APTC).

If premium is not paid, we will terminate your policy as of the last day of the premium period for which premium was paid (the last day of the first month of the grace period if you received advance payment of the premium tax credit). No grace period applies to your first premium. Your first premium must be paid before your policy becomes effective.

• A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment.
• If a claim is paid during a premium grace period and the policy is subsequently cancelled for non-payment, an enrollee may be responsible for that claim. Paying premiums on time is one way to prevent retroactive denials.

If DDAZ makes a payment that is inaccurate to you or makes an overpayment to you or on your behalf, DDAZ is entitled to reimbursement from you or the provider of dental services or may offset the amount owed against a future claim. Inaccurate payments are not a waiver of any future rights of DDAZ to deny payment for non-covered benefits.

DDAZ will recover any payment made that is more than the obligation determined by the terms and conditions of the policy and the rules of the coordination of benefits provision.

How to obtain a refund of premium overpayment: If you believe you have paid too much for your premium and should receive a refund, please call the member services number on the back of your ID card.

• Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.
• Prior authorization is a process through which an issuer approved a request to access a covered benefit before the insured accesses the benefit.

After an examination, your dentist may recommend a treatment plan. If the services involve crowns, fixed bridgework, implants, partial or complete dentures, surgical removal of impacted third molars, or medically necessary orthodontic services, ask your dentist to send the treatment plan to DDAZ. The available coverage will be calculated and printed on a predetermination of benefits form. Copies of the form will be sent to you and to your dentist. Predetermination/Preauthorization of benefits is required for medically necessary orthodontic services and surgical removal of impacted third molars. The Preauthorization should be sent to DDAZ as early as possible. We typically decide on requests for prior authorization for services within 3 days of receiving an urgent request or within 15 days for non-urgent requests. If the required preauthorization is not received, your claim may be denied. A predetermination of benefits is not required for other services, however, DDAZ encourages you to use this service.

Before you schedule dental appointments, you and your dentist should discuss the amount to be paid by DDAZ and your financial obligation for the proposed treatment.

"Medically necessary orthodontic services" does not include services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.

An explanation of benefits or "EOB" is a statement that DDAZ sends the enrollee to explain what dental services have been paid by DDAZ and the enrollee's financial responsibility pursuant to the terms of the policy. An illustration of an EOB along with instructions are provided in the link below:

• Understanding your EOB (PDF)

If DDAZ denies your claim or procedure, or reduces your payment, in whole or in part, including those due to eligibility to participate or utilization review, you will receive an EOB describing your liability for services received. If you have no liability and part of your claim is denied (included in the participating dentist agreement), you will not receive an EOB. The plan provisions that are relied upon for processing are included in your benefit booklet/policy. If the subscriber does not receive DDAZ's decision within thirty (30) days after DDAZ receives information required to process the claim, the subscriber will have an immediate right to request a review as if the claim had been denied.

If DDAZ denies any part of the claim, the subscriber will receive a written notice of denial containing:

• The reasons for the decision,
• A description of any additional information needed to support the claim, and
• Information concerning the subscriber's right to appeal the decision.

Coordination of benefits exists when an enrollee is also covered by another plan and determines which plan pays first.

Coordination of Benefits
DDAZ coordinates the benefits under this program with you or your dependents' benefits under any other group managed care program or insurance policy. Benefits under one (1) of these programs may be reduced so that your combined coverage does not exceed the maximum reimbursable amount or non-participating dentist allowable fee for the covered service. If this plan is the "primary" program, DDAZ will not reduce benefits, but if the other program is primary, DDAZ may reduce benefits. The reduction will be the amount paid under the terms of the primary program if it exceeds DDAZ's maximum reimbursable amount. Refer to covered dental services in the summary of benefits included in your dental benefits booklet or policy.

Determination of Primary Program
If a person is eligible for benefits under two (2) or more programs and more than one (1) of the programs provides coverage for an allowable benefit, DDAZ will pay according to the determination of the primary program stated below:

• The program covering the patient as a subscriber is primary over a program covering the patient as a covered dependent.
• When the patient is a dependent child, then the birthdays of the parents determine which program is primary. The program of the parent whose birthday (month and day, not year) occurs earlier in a calendar year is primary and will pay its benefits first. The program covering the parent whose birthday occurs later in the year is secondary.
• When the parents of a dependent child are legally separated or divorced, the program covering the parent with legal custody is primary. The program covering the spouse of the parent with custody (i.e. stepparent) is next. The program of the parent not having legal custody is last. However, if there is a court decree assigning the responsibility for healthcare expenses of the child to one (1) parent, then the program covering that parent is primary.
• If the patient is a member of a pre-paid dental plan or other capitation plan and is also a covered person under this policy then this policy is primary, without regard to the existence of such other plan. DDAZ will not be obligated to pay, however, for any dental services that are covered without charge under the prepaid or other capitation plan or to pay in excess of the amount of the co-payment obligation for the particular service under the prepaid or other capitation plan.
• The program covering the patient as an employee (or as that employee's dependent) is primary over the program covering the patient as a laid off or Retired Employee (or that employee's dependent).
• If the above rules do not apply, or if there are two (2) "primary" coverage plans due to retirement, then the program covering the patient longer is primary.

Right to Receive and Release Necessary Information
DDAZ may release or obtain information from any insurance company or other person(s) as necessary to meet the "coordination of benefits" provisions of the policy. DDAZ will determine the existence of, or amount payable under any other program, through the eligible person claiming benefits under the policy.

Note: Claims denied include such categories as duplicate submissions, enrollee ineligibility, non-covered benefits and exceeding annual maximum.