Delta Dental Ppo Application Form Instructions (Page 5 of 6) in pdf

DELTA DENTAL OF CALIFORNIA

Client Name: CEA/United Industrial Service Workers of America (UISWA)

Group No.:

BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO

Delta Dental offers you what no other dental plan can – The Delta Dental Difference

. Here’s what makes us a leading provider of

dental benefits:

Exceptional Cost Savings – Our networks protect enrollees from balance billing and prevent dentists from charging more by

•

“unbundling” services that should be billed as one service. Your costs are usually lowest when you visit a Delta Dental dentist.

Guaranteed Coinsurance/Copayment – Delta Dental dentists agree to accept our determination of fees. They won’t balance

•

bill over Delta Dental’s approved amount.

Professional Treatment Standards – Delta Dental reviews utilization patterns and office practices to ensure that Delta

•

Dental dentists meet professional standards for safety and quality of care.

The Delta Dental PPO program allows you the freedom to visit any licensed dentist, including a dentist from our Delta Dental

Premier

indemnity network. However, there are advantages to visiting a Delta Dental PPO network dentist instead of a Premier or



non-Delta Dental dentist. Consider the information below:

IN-PPO NETWORK

OUT-OF-PPO NETWORK

DELTA DENTAL PREMIER

DENTISTS &

DELTA DENTAL PPO DENTISTS

NON-DELTA DENTAL DENTISTS

You will usually pay the lowest amount for

You are responsible for the difference between the amount Delta Dental pays

services when you visit a Delta Dental PPO

and the amount your non-Delta Dental dentist bills. You will usually have the

dentist.

highest out-of-pocket costs when you visit a non-Delta Dental dentist.

PPO dentists agree to accept a reduced

Premier dentists may not balance bill above Delta Dental’s approved

fee for PPO patients.

amount*, so your out-of-pocket costs may be lower than with non-Delta

Dental dentists’ charges.

You are charged only the patient’s share at

Non-Delta Dental dentists may require you to pay the entire amount of the bill

the time of treatment. Delta Dental pays its

in advance and wait for reimbursement.

portion directly to the dentist.

Premier dentists charge you only the patient’s share** at the time of

treatment.

PPO dentists will complete claim forms and

You may have to complete and submit your own claim forms, or pay your

submit them for you at no charge.

non-Delta Dental dentist a service fee to submit them for you.***

Premier dentists will complete claim forms and submit them for you at no

charge.

SAMPLE CLAIM SAVINGS

IN-PPO NETWORK

OUT-OF-PPO NETWORK

DELTA DENTAL

NON-DELTA

PPO DENTISTS

PREMIER DENTISTS

DENTAL DENTISTS

$180.00

Dentist bills (submitted charge)

No fee agreement

$90.00

$130.00

Delta Dental’s agreed upon fee

with Delta Dental

$45.00

Delta Dental’s payment 50%

$45.00

$85.00

$135.00

Patient share*

Patient savings

$90.00

$50.00

N/A

(over non-Delta Dental dentist Patient Share)

Premier dentists may bill you the difference between the PPO fee and Delta Dental’s approved Premier fee amount, but they

may never balance bill you above the Premier fee allowance. Non-Delta dentists may balance bill you the entire amount of their

submitted charge.

Patient’s share is the coinsurance/copayment, any remaining deductible, any amount over the annual maximum and any

services your plan does not cover.

*** If you visit a non-network dentist, Delta Dental will send the benefit payment directly to you. You are responsible for paying the

non-network dentist's total fee, which may include amounts in excess of your share of your plan's contract allowance.

FORM # HLT PPO2 DDC STR

Rev#1 8/07

Delta Dental Ppo Application Form Instructions Page 5

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