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Dental Claims

Delta Dental Claim Process

How do I file a claim for dental charges?
There are several easy ways to submit a claim. Your dentist can complete a Delta Dental claim form or an ADA (American Dental Association) approved form and mail it to:

Delta Dental of New Jersey
P.O. Box 222
Parsippany, NJ 07054-0222

The claim form may also be faxed to 1-800-324-7939. If your dentist files claims electronically through his or her computer, no claim form is required. This method also speeds processing time.

Delta Dental Claim Form

Each individual patient must have his or her own claim filed separately from another family member’s claim. Also, each different dentist visited must submit a separate claim. However, an individual dentist may submit a claim for payment and a Pre-Treatment Estimate on the same claim form.

What must the claim form contain?

The claim must contain the treating dentist’s signature and either the covered person’s signature or a representation from the treating dentist that the covered person has signed a written authorization for the dentist to submit the claim. The claim must also name the patient, the specified date of service and fee charged, and request approval for payment of a specific treatment, service or product.

Is there a time limit for submitting dental claims?
Yes, in most cases, you have one full year from the date of service to submit your dental claims. If there is coordination of benefits involved and Delta Dental is not the primary carrier, you have one year from the date on which the primary carrier(s) issues a statement of benefits. If the claim is submitted after these time frames, then the services are not covered.

When will Delta Dental communicate its benefit determination?
Delta Dental will notify you of its benefit determination for urgent care claims as soon as possible but not later than 72 hours after receipt of the claim, providing sufficient information was received. If the claim is not complete, then Delta Dental will notify you or your representative within 48 hours after receipt of the claim. Delta Dental will notify you of its benefit determination for post-service claims within a reasonable period of time, but not later than 30 days after receipt of the claim. If Delta Dental needs to extend their decision another 15 days, they will notify you of the reason for the extension and estimated determination date prior the initial 30-day period.

What will Delta Dental do if there is an adverse benefit determination?
If the benefit determination is adverse, Delta Dental will notify you in writing. The notice will specify the reason(s), refer to the specific plan provision, guideline or protocol upon which the determination was based, describe any additional material or information neededfor you to complete the claim and explain why such documentation is necessary, and describe the initial appeal process and time limits. In addition, if the adverse determination was based on medical necessity or exclusion for experimental treatment, the notification will either provide an explanation or offer to provide one free of charge upon request.

What can I do if I am dissatisfied with the initial adverse benefit determination?
You can file a request for informal review within 60 days of the adverse determination. You would send it to:

Delta Dental of New Jersey, Inc.
Attn: Appeals Department
P.O. Box 222
Parsippany, NJ 07054

Your request must include the claim number, name and address of the employee, name of the employer, date of service and description of service, your signature and date of signature, date you received Delta Dental’s adverse determination, reason(s) why you think the determination was incorrect and any relevant documents and information. The person making the decision at Delta Dental will be a person who did not make the initial determination and who is not the subordinate of the initial reviewer. The decision-maker for a determination based in whole or in part on medical judgment will consult with a health care professional who has training and experience involved in medical judgment and whowas not consulted in the earlier determination(s). Delta Dental will notify you in writing of its determination within 72 hours for urgent care claims and within 30 days for pre-service claims. If the benefit determination is adverse, the notice will specify the reason(s), refer to the specific plan provision, guide or protocol upon which the determination was based, inform you of your right to receive free of charge, upon request, all relevant documentation, and describe any voluntary, external appeal procedures as well as your right to bring civil (court) action. In addition, if the adverse determination was based on medical necessity or exclusion for experimental treatment, the notification will either provide an explanation or offer to provide one free of charge upon request.

What can I do if I am dissatisfied with the informal appeal decision?
You or your dentist must request a formal review in writing within 240 days of receipt of the original adverse benefit determination (whether or not you requested an informal review) and send it to:

Delta Dental of New Jersey, Inc.
Attn: Correspondence Department
P.O. Box 601
Parsippany, NJ 07054

The request for a formal review must include the dentist’s name, office name, address and license number, the employees name, subscriber’s ID number and date of birth, the patient’s name, date of birth, the claim number, the reason(s) why Delta Dental should change its initial decision and the specific decision you are seeking, any relevant information or diagnostic materials, and/or a copy of the claim for the determination you are appealing. You must also sign the request. If the dentist is authorized to act on your behalf he/she must state that and include a DOL authorization form. Delta Dental will notify you in writing of its determination within 72 hours for urgent care claims, and within 30 days for pre- and post-service claims.

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