| If the patient’s plan is: |
And you participate in the Delta Dental Premier network only: |
And you participate in the Delta Dental Premier and Delta Dental PPO networks: |
And you participate in the Delta Dental Premier and DeltaCare networks: |
| Delta Dental Premier |
Payment is made directly to you and is based on your profile fee (Usual and Customary) or the group specific fee schedule (Table of Allowance). For a fee schedule (Table of Allowance) plan, the patient is responsible for the difference between the fee schedule and your Delta Dental Premier profile fee. |
Payment is based on your Delta Dental Premier agreement. |
Payment is based on your Delta Dental Premier agreement. |
| Delta Dental PPO |
Payment is made directly to you as a participating dentist but reimbursement is based on the PPO out-of-network coverage. The patient may be billed the balance up to your charge. There is usually a $100 out-of-network deductible, regardless of level of service before benefit reimbursement is made (some exceptions may apply). |
Payment is made directly to you and is based on the Delta Dental PPO fee table. The patient may not be balance billed above the PPO fee allowance. |
If you do not participate in the PPO and you are a primary care office, payment is based on your Delta Dental Premier agreement.
Note: Specialists enrolled in the Delta Dental PPO are also enrolled in the DeltaCare specialty network. |
| Delta Dental PPO Plus Premier |
Dentists who only belong to the Delta Dental Premier network are considered participating but out-of-network for this plan. Payment is made directly to you and is based on your Delta Dental Premier fee profile. Claims are processed based on out-of-network benefits. Usually in and out of network benefits are paid at the same coinsurance level but in some instances the out-of-network coinsurance levels are reduced. |
Payment is made directly to you and is based on the Delta Dental PPO fee table. The patient may not be balance billed above the PPO fee allowance. |
Payment is based on your Delta Dental Premier agreement. |
| Delta Dental PPO Value Plan |
Payment is made to you for diagnostic and preventative services at 80% of your Delta Dental Premier profile, and the patient may be billed the balance up to your submitted charge. The patient is responsible for your full submitted charge for basic and major restorative services. |
Payment is made to you for diagnostic and preventative services at 100% of the Delta Dental PPO Table of Allowance. Basic and major restorative services are payable by the patient at 100% of the Delta Dental PPO Table of Allowance. |
Payment is based on your Delta Dental Premier agreement. |
| Delta Dental Pediatric Option Plan |
No benefits are available outside the Delta Dental PPO network. The patient is responsible to pay your submitted charge. |
Coverage is limited to diagnostic and preventative services for children up to 12 years old and reimbursement is made to you based on the Delta Dental PPO Table of Allowance. |
No benefits are available outside the Delta Dental PPO network. The patient is responsible to pay your submitted charge. |
| Massachusetts Public Employees Fund Indemnity Plan (formerly Open Plan) |
Payment is on your Delta Dental Premier agreement. |
For dates of service on or after 7/1/10 payment is based on your Delta Dental PPO agreement. Prior to 7/1/10 payment is based on your Delta Dental Premier agreement. |
Payment is based on your Delta Dental Premier agreement. |
| Massachusetts Public Employees Exclusive Provider Network Plan (formerly Closed Plan) |
This Plan has a separate network of providers and a specific Table of Allowance. Patients must have services rendered in an Exclusive Network office to receive benefits. |
This Plan has a separate network of providers and a specific Table of Allowance. Patients must have services rendered in an Exclusive Network office to receive benefits. |
This Plan has a separate network of providers and a specific Table of Allowance. Patients must have services rendered in an Exclusive Network office receive benefits. |
| DeltaCare |
Payment is made to the patient. You may bill the patient your submitted charge on the day of service. |
Payment is made to the patient. You may bill the patient your submitted charge on the day of service. |
Payment is made monthly in the form of capitation payments based on the number of DeltaCare patients assigned to your practice. You may collect the copayment amounts referenced in the Member Copayment Schedule from the patient as well as your office fee for any non-covered service. |
Notes:
- You may bill the patient on the day of service for any patient payment amounts including coinsurance, deductibles, and/or non-covered services
- Plan benefits unique to your patient can be found on the “Benefit Inquiry” behind security of the Dentist Section.
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