Effective July 1, 2011, the Local Care Health Plan (LCDP) will be offering two separate networks of dentists in addition to the option of going out-of-network. The two networks are the Delta Dental PPO℠ and the Delta Dental Premier℠.
- The maximum benefit paid for eligible services is listed in the Dental Schedule of Benefits. Services not listed in the Schedule of Benefits are not covered by the plan.
- Plan participants are responsible for any amount over the maximum benefit.
- Dental procedure codes not listed in the Schedule of Benefits are considered noncovered services and are not eligible for payment.
- Plan participants may go to any dentist of choice; however, plan participants may pay less out-of-pocket when they receive services from a network dentist.
- Claims must be filed with Delta Dental listed in the current Benefit Choice Options booklet.
- Plan participants may obtain claim forms and identification cards from Delta Dental.
- The benefit Plan Year is July 1 through June 30.
The annual plan deductible is $100 per participant per plan year.
Maximum Benefit Levels
Once the deductible has been met, the plan participant has a maximum annual dental benefit of $2,000 for all dental services. The maximum lifetime benefit for child orthodontia is $1,500 and is subject to course of treatment limitations. Members are responsible for all charges over the scheduled amount and/or the annual maximum benefit.
NOTE: Total benefit reimbursement for any and all dental services combined may not exceed the maximum benefit level each plan year.
A pretreatment estimate assists plan participants in determining the benefits available. To obtain a pretreatment estimate contact Delta Dental.
Preventive and Diagnostic Services include, but are not limited to:
- Two periodic oral examinations per person per plan year.
- Two adult or child prophylaxis (scaling and polishing of teeth) per person per plan year.
- Two bitewing radiographs per person per plan year.
- One full mouth radiograph is covered once in a period of three plan years.
Prosthodontics are subject to the following limitations:
- Prosthodontics to replace missing teeth are covered only for teeth that are lost while the person is covered under this Plan.
- Immediate dentures are covered only if five or more teeth are extracted on the same day.
- Permanent dentures to replace immediate dentures are covered only if placed in the person’s mouth within two years from the placement of the immediate denture.
- Replacement dentures are covered only under one of the following circumstances:
- Existing denture is at least 5 years old, or
- Structural changes in the person's mouth require new dentures.
- Replacement crowns are covered only when the existing crown is at least 5 years old.
- Replacement bridges are covered only when the existing bridge is at least 5 years old.
The lifetime maximum benefit for child orthodontics is $1,500. The benefit is based on the length of treatment. This lifetime maximum applies to each plan participant regardless of the number of courses of treatment.
- The course of treatment (initial banding) must begin before age 19.
- For a detailed description of your current dental plan benefits see the FY13 Orthodontia Schedule of Benefits. For covered orthodontic services contact Delta Dental.
- The plan year deductible will apply to the orthodontic benefit if it is the initial claim processed in a plan year except for preventive or diagnostic procedures.
Reimbursement of Benefit: 25% of the applicable maximum benefit, based on the length of treatment, is reimbursed after the initial banding. The remaining benefit is prorated over the remaining length of treatment.
Claim Filing Deadlines
All claims should be filed promptly. The dental plan administrator requires that all claims be filed no later than one year from the ending date of the plan year in which the charge was incurred.
Claim Filing Procedures
All communication to Delta Dental must include the member’s social security number (SSN) or alternate member identifier (AMI) and appropriate group number as listed on the identification card. This information must be included on every page of correspondence.
- Complete the Deltal Dental of Illinois Claim form for claims on or after July 1, 2011.
- Attach the itemized bill from the provider of services to the claim form. The itemized bill must include name of patient, date of service, diagnosis, procedure code and the provider’s name, address and telephone number.
- If the person for whom the claim is being submitted has primary coverage under another group plan or Medicare, the explanation of benefits (EOB) from the other plan must also be attached to the claim.
- The dental plan administrator may communicate directly with the plan participant or the provider of services regarding any additional information that may be needed to process a claim.
- The benefit check will be sent and made payable to the member (not to dependents), unless benefits have been assigned directly to the provider of service.
- If benefits are assigned, the benefit check is made payable to the provider of service and mailed directly to the provider. An EOB is sent to the plan participant to verify the benefit determination.
- Claims for services incurred on or after July 1, 2011, must be filed with Delta Dental.
Benefits for Services Received While Outside The United States
The plan covers eligible charges incurred for services received outside of the United States. All plan benefits are subject to plan provisions and deductibles.
Payment for the services may be required at the time service is provided and a paper claim must be filed with the dental plan administrator. When filing the claim, enclose the itemized bill with a description of the service translated to English and converted to U.S. currency along with the name of the patient, date of service, diagnosis, procedure code and the provider’s name, address and telephone number.