Dental insurance claims and payments

Delta Dental recommends that all dentists obtain and use a National Provider Identifier (NPI). This is a 10-digit random number unique to each health care provider or organization.

Who needs an NPI?

Every health care provider transmitting health information in connection with a standard transaction in electronic form must obtain an NPI. An NPI is required by the federal Health Insurance Portability and Accountability Act (HIPAA) for electronic transactions.

All individual health care providers (including dentists) and organizations such as dental clinics and group practices are eligible to obtain an NPI.

If you answer “yes” to any one of the following questions, you are considered a “covered entity” under the NPI standard and are required by federal law to obtain an NPI.

• Do you submit dental insurance claims electronically?
• Do you use a clearinghouse?
• Do you submit claims attachments electronically?
• Do you use the Internet to obtain eligibility and benefits information or check on the status of claims?
  
  

Benefits of an NPI

• Eliminates the need to maintain and match identification numbers to specific payers for transactions
• Allows you to relocate your practice or change specialties without requiring new identifiers from multiple payers
• Helps reduce costs and simplify health care transactions
• Contributes to more efficient coordination of benefits
  
  

The federal Health Insurance Portability and Accountability Act (HIPAA) requires you to obtain an NPI if you submit claims electronically or if you check claims status or access patient eligibility and benefits information online. However, some health plans may choose to require NPIs on all transactions.

Obtaining your NPI is simple and once obtained, it stays with you for life. To obtain your NPI, simply go to the National Plan and Provider Enumeration System (NPPES) and follow the instructions to complete the application.

There are two types of NPIs:

• Type 1 is for individual health care providers, such as dentists and hygienists. This is the only type of NPI you will need if you receive payments in your name or under your social security number as a solo practitioner. For practices with multiple dentists, obtain a Type 1 NPI for each dentist.
• Type 2 is for incorporated businesses, such as group practices and clinics. This also includes entities paid under their business or corporate name, or under their employer identification number (EIN).
  
  

How to tell which NPI you need:

• Solo practitioner: Type 1 only, if claims are transmitted in the dentist's name and social security number.
• Individual dentist at one practice location: Type 1 for the dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and Tax Identification Number (TIN).
• Multiple dentists, one practice location: Type 1 for each dentist and Type 2 for the practice, if claims are transmitted in the practice’s name and TIN.
• Multiple dentists, multiple practices: Type 1 for each dentist and Type 2 for each practice with a separate TIN.
  
  

On claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the dentist who provided the treatment.

Example:
On a standard ADA Dental Claim Form (#J400), the treating dentist’s NPI is entered in field 54 and the billing entity’s NPI is entered in field 49.

Applying for an NPI is a simple process:

1. Visit https://nppes.cms.hhs.gov
2. Complete the application and follow instructions to submit either online or by mail. Faxes are not accepted.
3. After confirmation of the receipt of your application, you should receive your NPI via e-mail within one to five business days if you submitted the application online. Mailed applications may require up to 20 days to process.
   
   

If any data related to your NPI changes (name, address, etc.), you are responsible for submitting an update to the NPPES within 30 days of the change.

If you need help with your application

The NPI Enumerator will help you with your NPI application and to update your information in the NPPES.

Contact the NPI Enumerator:

E-mail: customerservice@npienumerator.com

Telephone: 800-465-3203 / 800-692-2326 (NPI TTY)

Mail: NPI Enumerator
         P.O. Box 6059
         Fargo, ND 58108-6059

Additional information about NPIs

• US Department of Health & Human Services
• American Dental Association
• Delta Dental Plans Association
  
  

The information provided here is for educational purposes only and should not be interpreted as legal advice. Dentists are encouraged to seek their own legal advice about how the NPI pertains to their practices and circumstances.

Please register your NPI with Delta Dental by providing us with a copy of the confirmation containing your NPI that you receive from the National Plan & Provider Enumeration System (NPPES). Send it to your local Delta Dental by e-mail, fax or U.S. mail:

California:

E-mail: dentist_services@delta.org
U. S. Mail: Delta Dental of California, ATTN: Provider Onboarding, P.O. Box 997330, Sacramento, CA 95899-7330

Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas, Utah and U.S. Virgin Islands:

E-mail: ProfessionalServices@ddic.delta.org
U. S. Mail: Delta Dental Insurance Company, ATTN: Provider Onboarding, P.O. Box 1826, Alpharetta, GA 30023

Delaware, District of Columbia, Maryland, New York, Pennsylvania and West Virginia:

E-mail: ddpdentist_services@deltadentalpa.org
Fax: 717-774-1770
U. S. Mail: Delta Dental of Pennsylvania, ATTN: Provider Onboarding, P.O. Box 2106, Mechanicsburg, PA 17055

For other Delta Dental member companies, please check how they prefer to register your NPI. Simply submitting it on a claim will not ensure that it's entered into the Delta Dental system.

• Once you’ve registered your NPI with Delta Dental, you should begin using it on claims. Delta Dental recommends that the NPI be used on all claims.
• Enter the NPI of the billing dentist or dental entity, as well as the treating dentist’s NPI (if they are different).
• Use new claim forms that accommodate the NPI by providing a specific space for it. (This might require you to upgrade your software.)

If you don’t conduct any electronic transactions governed by HIPAA, you aren’t required to obtain an NPI. However, we strongly encourage you to get one, because you can use it as a single unique identifier with all payers.

The NPI replaces other identifying numbers used in electronic transactions, such as:

• Medicaid
• Blue Cross and Blue Shield
• UPIN
• CHAMPUS
• Certain other legacy numbers
  
  

The NPI will not replace these numbers, which are used for purposes other than general identification:

• Social Security
• DEA
• Taxpayer Identification
• Taxonomy
• Your state license

NPIs are issued by the National Plan & Provider Enumeration System (NPPES). The NPI contains no embedded intelligence – no coding that would identify the dentist’s state or license number, for example. It is simply a random number that does not expire.

Be sure to include the following information on dual coverage claims:

• ID numbers for both covered members
• Patient’s relationship to each member
• Birth date for the patient and each member
• If parents are divorced, the parent with whom the child lives
• When Delta Dental is the secondary carrier, Explanation of Benefits (EOB) from the primary carrier

For adults, the member's plan through his or her employment is primary. A spouse or domestic partner’s plan is secondary.

In less common situations, a member may have two plans, such as a plan through current employment and a retiree plan. In this case, generally, the plan through current employment is primary. If the member has two plans through current employment at two jobs, then the plan that has been in effect the longest is usually primary. However, specific plan provisions may dictate differently how dual coverage will be determined, so it is a good idea to check the member's Evidence of Coverage for details.

Example dual coverage scenarios:

• A full time job and a part time job: Coverage through the full time job is primary.
• Two jobs or two retiree plans: The plan that has covered the employee longest is primary.
• A retiree plan and a spouse’s active plan: Usually, the patient’s retiree plan is primary (a person’s own coverage is primary for himself/herself); however, check the Evidence of Coverage for the retiree plan – there may be a provision making it secondary to an active plan.
• A current spouse and an ex-spouse: The current spouse’s coverage is primary (unless a court order makes the ex-spouse’s plan primary).

Coverage received as an active employee is primary. For example, if a retiree is employed, the “active” coverage is primary; the coverage resulting from retirement is secondary. However, there are exceptions, such as the TRICARE Retiree Dental Program (TRDP), a federal plan that follows the effective date rule. When a patient has coverage through TRDP and another dental plan, the plan that has covered the member the longest is considered primary.

If a court order makes one parent more financially responsible, that parent provides primary coverage. Otherwise, the natural parent the child lives with provides primary coverage. In joint custody cases, the parent
whose birth date is earlier in the year provides primary coverage. When children are covered through remarriages/domestic partnerships, coverage is determined in this order:

• Primary coverage: natural parent the child lives with
• Second: natural parent’s spouse/domestic partner
• Third: non-custodial natural parent
• Fourth: non-custodial natural parent’s spouse/domestic partner
  
  

In the case of coverage through stepparents only: The stepparent the child lives with provides primary coverage. For joint custody, the plan that has covered either stepparent longest provides primary coverage.

Example:

If the father’s birth date is 10/3/67 and the mother’s birth date is 5/15/68, then the mother’s coverage is primary.

A medical insurance plan may be primary when an accident has caused the need for dental treatment (such as a broken tooth resulting from a fall or a car accident). Also, medical coverage would be primary if the group dental plan contract indicates that specific oral procedures are covered (such as a biopsy, oral surgery provided by a physician or dental treatment provided in a hospital). Checking the patient’s Evidence of Coverage for both plans will help you determine when a medical plan is primary.

A patient may have dual coverage through the same Delta Dental company (for example, your patient may have her own Delta Dental of California coverage and also be covered as a spouse through her husband’s plan, which is also a Delta Dental of California plan).

When this occurs, please submit only one claim to the Delta Dental company. Delta Dental will process the primary benefits, even if processing the secondary coverage must be delayed (for lack of eligibility data, for example). There is no need to resubmit the claim. You will be notified separately when processing of secondary coverage is completed.

Be sure to regularly review and update your patients’ dual coverage status. Patients may change their coverage, usually in the fall or spring, during their open enrollment periods.

It is a good idea to let us know when a patient no longer has dual coverage. You can ask the patient to advise us by calling our Customer Service department, or you can send a copy of the notice from the patient’s former carrier that includes this information.

Be sure to submit dual coverage information on claims for orthodontic procedures, even if the other insurance does not cover orthodontics. This is important because some services may be included in the patient’s basic coverage, even if the patient does not have specific orthodontic coverage. Also, this will help ensure that Delta Dental’s calculation of the patient’s portion takes into account all available benefit information.

When Delta Dental of California is the secondary carrier and is subject to the provisions of the California Health and Safety Code §1374.19, we pay the lesser of: (1) the amount we would have paid in the absence of any other dental benefit coverage; or (2) the member's out-of-pocket cost payable under the primary plan for benefits that are covered by the secondary plan.

Please indicate the total amount paid by the primary carrier on the face of a paper claim or in the comments/notes section of an electronic claim and attach a copy of the Explanation of Benefits from the primary carrier.

The combined payments by all plans may not exceed the total fee for the treatment. If you or the patient receives more than 100 percent of the fee, the amount in excess should be refunded to the secondary carrier.

Some Delta Dental groups that are not subject to the provisions of California Health and Safety Code §1374.19 have a non-duplication of benefits clause in their contract.

Such clauses means that the secondary plan will not pay any benefits if the primary plan paid the same or more than what the secondary plan allows for that dentist.

For example, if both the primary and secondary carrier pay for the service at 80% level but the primary allows $100 and the secondary carrier normally allows $80 for the same treatment, the secondary carrier would not make any additional payment. However, if the primary carrier only pays 50% of the dentist’s allowed fee, then the secondary carrier would reduce its payment by the amount paid by the primary plan and pay the difference. In this case, the secondary carrier would pay $14 ($80 x 80% - $50 = $14).

Before you start treatment, log in to your Provider Tools account and use the Submit Claim or My Patients tools to request a pre-treatment estimate. Pre-treatment estimates often process within moments (when clinical review isn’t required), so you can talk with your patients about treatment plans while they are still in your office. Pre-treatment estimates tell you about:

• Contractual limitations or exclusions that apply to your treatment plan
• Delta Dental’s estimated payment amount
• The patient’s estimated payment portion
  
  

Advantages

• Determine how best to plan treatment; for example, treatment may be done in segments, over weeks, months or years, to incorporate all available benefits
• Develop a payment plan for the patient, taking into account what Delta Dental is expected to pay
• Receive email notifications when new documents are available to review online (when you sign up to go paperless).

Log in to your Provider Tools account and select the My Patients tool or the Submit claim tool.

To use My Patients:

• First, select the patient. Then, select the Submit Claim icon under Actions.
• Next, under Type of Transaction, choose Pre-Treatment Estimate.
• Complete the claim information, select Continue, then Submit Claim.
  
  

To use Submit Claim:

• Enter your patient’s name and choose Existing (or enter a new patient’s information).
• Select the patient, then select the Submit Claim icon in the Actions menu.
• Next, in the Type of Transaction menu, choose Pre-Treatment Estimate.
• Complete the claim information, select Continue, then Submit Claim.
  
  

Use the My Claims tool to see Delta Dental’s estimated payment and the patient’s portion (often within moments when clinical review is not necessary).

Or, you may mail a paper claim to Delta Dental. Include all required x-rays, documentation and/or written narratives. You will receive by mail a pre-treatment estimate showing the amount Delta Dental is estimated to pay and the amount of the patient’s responsibility. Unfortunately, we cannot provide pre-treatment estimates by telephone.

Keep in mind, a pre-treatment estimate is not a guarantee of payment and it does not check the patient’s:

• Eligibility (until the date of service)
• Incentive levels
• Maximum or deductible
• Any additional coverage that may apply
  
  

At any time, you can review the patient’s current eligibility and benefits information, including remaining maximum and deductible amounts. Simply log in to your Provider Tools account (or register if you have not already done so) and use the Eligibility and Benefits tool.

When the services are complete and a claim is received for payment, Delta Dental will calculate its payment based on the member's current eligibility, amount remaining in his/her annual maximum and any deductible requirements.

Be sure to include:

• Banding date.
• Estimated treatment length.
• Amount of down payment.
• Dual coverage information, including the amount payable by the prime carrier.
• Monthly payment amount.
• Appliance name used to control harmful habit.
• Description of service.
• Indication if this is an initial claim or a transfer case.
• Description of any treatment prior to this claim (including treatment outside of Delta Dental coverage).
  
  

Dual coverage

When Delta Dental is secondary in dual coverage cases, please include the primary coverage’s total liability including copayment/coinsurance percentage and the explanation of benefits (EOB).

Work-in-progress

Include the amount paid by the previous carrier on the claim.

Charges for clear aligners (e.g., Invisalign®, SureSmile®) should be submitted using the appropriate orthodontic procedure code (D8010-D8090). The benefit is based on the approved fee for conventional orthodontics. Any additional fee for the nontraditional method is not billable to the patient.