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FREQUENTLY ASKED QUESTIONS

 
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Can a Delta Dental provider charge the patient for services which are not covered under the Delta Dental plan?

Yes, Health and Safety Code section 1374.195 and Insurance Code section 10120.3(a) both authorize a dentist to charge his/her usual and customary fee for services not covered by the insurance plan. This applies to all private insurance plans, but not to Denti-Cal.

  1. Include the following language in your financial disclosures to the patient and obtain a signed acknowledgment by the patient:

    “IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at [insert appropriate telephone number] or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage document.”

  2. When you submit the claim form, identify all of the treatment that you intend to provide to the patient. If the insurance plan declines coverage for the non-covered services and instructs you not to charge the patient for the non-covered item, then you may challenge the finding by filing a dispute with Delta Dental (or other insurance provider) within 30 days and cite to your rights under Health and Safety Code section 1374.195 and Insurance Code section 10120.3(a).


If you want to file a provider complaint with the California Department of Managed Health Care, then we suggest you visit: https://bit.ly/33J324n