1. Participating Dentists will file your claim with Delta Dental. If you need a claim form for services provided by a Non-Participating Dentist you may contact Delta Dental which will provide you with a claim form. To be considered for benefits, a claim must be filed within 15 months of the date of service.
2. If you require emergency dental care, you may seek services from any dentist. Your out-of-pocket expenses may be less if you choose a Participating Dentist.
3. You may get an estimate of the cost of certain dental procedures before they are done. This estimate is referred to as a predetermination. You may have your dentist send Delta Dental a claim form detailing the projected treatment and Delta Dental will give an estimate of the benefits to be paid. A predetermination is not a guarantee of payment. Actual benefit payments will be based upon procedures completed and will be subject to continued eligibility along with plan limitations and maximums.
4. If you or your covered Eligible Dependent receive an injury requiring dental treatment because of the action or fault of another person, and if Delta Dental is unaware of other coverage, Delta Dental may pay benefits but would assume the subscriber’s or covered Eligible Dependent’s rights to recover from the other person. The subscriber and covered Eligible Dependent would be required to help Delta Dental in making such a recovery. This dental plan does not replace any workers’ compensation coverage.
5. If a subscriber or covered Eligible Dependent has two dental coverages, Delta Dental will coordinate benefits with the other coverage. The following rules will be used to determine which coverage should be primary.
1. The program covering the patient as an Retiree is primary over a program covering the patient as a dependent.
2. Where the patient who is a Child who is an Eligible Dependent, primary dental coverage will be determined by the date of birth of the parents. The coverage of the parent whose date of birth occurs earlier in the calendar year will be primary. For a Child who is an Eligible Dependent of legally separated or divorced parents, the coverage of the parent with legal custody, or the coverage of the custodial parent's spouse (i.e. stepparent) will be primary.
3. If there is a court decree stating that one parent has financial responsibility for a Child's dental care expenses, any dependent coverage of that parent will be primary to any other dependent coverage.
6. After a claim is processed, an Explanation of Benefits (“EOB”) will be sent to the subscriber. If any payment for services was denied, the EOB will give the reason why. If the subscriber disagrees with the denial, he or she must submit a request in writing asking that the claim be reviewed. Such request should include the reason why the subscriber believes the claim was wrongly denied. The request must be received by Delta Dental within 180 days of the subscriber’s receipt of the EOB. Delta Dental will make a review and may ask for more documents if needed. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for review.

If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of Delta Dental. This second level review request must be in writing and received by Delta Dental within a reasonable time after the subscriber receives the first level review decision. Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for second level review.

If the subscriber does not agree with the second level review decision, he or she may file civil action in court