Client Administration Handbook · 2019-01-29 · Client Administration Handbook. Welcome to Delta...

Client Administration

Handbook

Welcome to Delta DentalWe’re happy you’ve joined us, and we’re ready to partner with you to make this your best benefits experience ever. This handbook will introduce you to Delta Dental and prepare you to work with us to administer your benefits. The handbook includes information on:

• Submitting information about your members

• Understanding your bill and making payments to Delta Dental

• Reports and other information we provide to you

• Documents you or your members may see

• Contact information

We hope you find this information helpful. If you have any questions that the handbook does not answer, please contact your Delta Dental account manager.

Contents

Benefit Manager Toolkit® ......................................................................................................................................... 3

Submitting information about your members ................................................................................................4

Submitting COBRA information ........................................................................................................................... 5

Managing member information ............................................................................................................................6

Submitting multiple terminations or reinstatements ................................................................................. 10

Client Knowledge ......................................................................................................................................................12

Understanding your fully insured or risk bill ................................................................................................. 14

Subscriber Listing .....................................................................................................................................................16

Billing Adjustments ..................................................................................................................................................18

Understanding your (per member) fully insured or risk bill .................................................................. 20

Subscriber Listing (per member) ......................................................................................................................22

Understanding your self-insured or ASO bills ..............................................................................................24

Statement of Account ........................................................................................................................................... 30

Submitting payment ...............................................................................................................................................32

Renewing your contract ........................................................................................................................................32

Making changes to your contract ......................................................................................................................32

How to read an Explanation of Benefits (EOB) statement .................................................................... 34

Consumer Toolkit® ...................................................................................................................................................36

Help your members benefit from their dental benefits ............................................................................37

Requesting information on your members ....................................................................................................38

Contact information ................................................................................................................................................39

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Benefit Manager ToolkitImmediate, secure changes to your member information and more!

Benefit Manager Toolkit (BMT) is your secure gateway into Delta Dental. With BMT, you see the results of your actions immediately. Member information is updated instantly, even while the patient is still at the dental office, so there are no corrections after the fact for you or your members. The Toolkit is easy to use, and there is extensive online help within the application.

Benefit Manager Toolkit allows you to:

• View current member and benefit information

• Enroll new members, update information on existing members, or terminate members, all in real time

• Download and print dentist directories

• View detailed billing information

• Print ID cards

• Access Client Knowledge to view on-demand reports (if available)

• View overage dependent reports

If you are not already registered, getting started with Benefit Manager Toolkit is easy. To get started, simply identify the BMT administrator for your company, go to any of our corporate websites and select Benefit Manager Toolkit from the drop-down box. Once at the Toolkit, click on the Register button to obtain a registration form.

• Indiana www.deltadentalin.com

• Michigan www.deltadentalmi.com

• North Carolina www.deltadentalnc.com

• Ohio www.deltadentaloh.com

Once the registration has been received, you will receive an email with information and instructions to register as your group’s client administrator.

As the client administrator you will have more control over your company’s accounts. The administrator will be able to easily and quickly set up new BMT accounts with passwords, assign appropriate security levels for your BMT users and disable accounts when a BMT user leaves your company.

View detailed benefit information

Benefit Manager Toolkit sign-in page

Submitting information about your membersThe most important information you give us is information about your members. Timely, accurate membership information, or eligibility, helps us process claims quickly and correctly and bill you accurately, saving you valuable time. Tell us as soon as possible when you have:

• Members or dependents to enroll

• Members whose coverage should be terminated

• New contact information for members

Anyone who meets the eligibility standards outlined in your Delta Dental contract is eligible to enroll in your benefit programs.

Remember, retroactive updates to eligibility are limited to six months from the date of receipt by Delta Dental. Also, retroactive termination will not be made when claims have been paid after the requested date of termination. Members’ coverage can only be terminated after the date of any dental services that have been paid under your plan.

Additionally, it is important to remember that any changes to eligibility will appear on your invoice based on eligibility cutoff dates. You can find a list of cutoff dates for each month of the year on our corporate websites (www.deltadentalin.com/billing; www.deltadentalmi.com/billing; www.deltadentalnc.com/billing; www.deltadentaloh.com/billing). Any eligibility changes made after the cutoff dates will appear on a future invoice—we are unable to rebill an invoice that has already been created.

Submitting information via electronic file

Submitting information about your members electronically is the most efficient and effective method. Electronic submission is fast, secure and reduces the chances for human error. When we load the information into our system, it automatically enrolls new members and makes changes to existing members, including terminations.

If you are interested in submitting information electronically, please contact your account manager for more information.

Submitting information online in real time

Benefit Manager Toolkit provides secure, immediate access to information about your members. With BMT, you can view and change member information in real time. This means the most current information about your members is available to those who need it, ensuring accurate benefit quoting, claims processing and billing.

Note that if you send member information to us via electronic files, that information may replace any changes made through BMT. So if you use both methods, make sure that any changes made through BMT are also made to your file, to ensure they remain permanent.

Enroll new members in real time

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Submitting information on paper

If you prefer, you can enroll new members or make changes to existing member information by filling out and mailing an Eligibility Enrollment/Update form. We have included a sample form for your reference. Instructions for completing the form are on the reverse. Please refer to them if you or your members have questions about how to complete the form. A few quick hints:

• Make sure that your organization’s (client) name and Delta Dental client-subclient number are at the top of the form

• Mark the correct state at the top of the form

• Have the member sign and date the form

• Review the form for accuracy and completeness before submitting

Please mail the original completed form to:

Delta Dental Attention: Eligibility Department PO Box 30416 Lansing, MI 48909-7916

Please do not send any member information changes with your billing statement or payment, as the changes may be delayed or missed altogether.

Submitting COBRA informationThe Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) includes a provision that requires most employers to offer extended health, dental and vision coverage to qualified beneficiaries who are losing their group coverage. Beneficiaries are responsible for the cost of this coverage.

If a member elects to continue coverage under COBRA, the member’s information must be updated. You can update COBRA information using any of the methods described earlier. If the member has covered dependents, those dependents will automatically move to COBRA coverage with the member. Also, when COBRA coverage expires, the member’s coverage should be terminated.

If a spouse or dependent child elects to continue coverage under COBRA due to a qualifying event such as divorce or death, you will need to enroll that individual as a new subscriber under his or her own Social Security number or member ID.

Managing member informationAdding a member

You have the ability to add a primary member (subscriber) or add family members to an existing subscriber. Log in and select Add from the Dental Benefit Manager submenu on the left side of the screen.

1 Enter the subscriber’s member number (SSN or client-assigned ID).

2 Enter the client-subclient information. Users may only add members into the client-subclient number that they have access to.

3 The Add Member screen will display. Fill in the member’s information, making sure to fill in any required fields, as well as the subscriber’s address.

4 Once submitted, the Family Composite screen will appear, displaying the new subscriber. At this point you are able to add a spouse and/or dependents.

Updating members using BMT

You can update a member’s name, address and other eligibility information in the Update Member screen. When you update certain subscriber information, such as Last Name and Eligibility Effective Date, you are given the option to apply these changes to the family members as well.

1 Enter the subscriber’s member number (SSN or client-assigned ID).

2 If the correct member is displaying, click the Update button on the far right, under Options.

3 The Update Member screen will appear and the member’s information can be updated.

4 The subscriber or family members can be terminated or reinstated on this screen using Eligibility Status.

• To terminate a member, change the Eligibility Status Reason to Inactive and enter the termination date in the Eligibility Effective Date box.

• When a subscriber is terminated, any members under that subscriber are also terminated with the same effective date.

• A member is not allowed to have a termination date earlier than the date of service on the last paid claim. If this is the case, the system will reset the termination date accordingly.

Add Member screen

Get Member Information screen

Family Composite screen

Update Member screen

6

Adding special attributes using BMT

BMT users will be able to update special attributes, (for example, student, handicap, etc.) for members and dependents within the client-subclient number that they have access to.

1 Once you select the member and/or dependent, the Update Member screen will appear.

2 Select the Add button next to Special Attribute.

3 You can choose the type of attribute from the drop-down and add the effective date for the attribute. If there is an end date that should be entered, update the Through Date field.

4 The attribute will appear in a list. Make sure the attribute is selected, then click Done.

5 The attribute will now show on the Update Member screen.

Special Attribute Information screen

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–Client Name: ____________________________________________ Client#/Subclient#

Enrollment/Corrections to Information (please fill in for spouse/dependents for first-time enrollment or corrections):SPOUSE Name (Last) (First) (M.I.)

Social Security Number Birth Date Status*

DEPENDENT #1 Name (Last) (First) (M.I.)








Eligibility Enrollment/Update

ABCDEF12 43 56

–

Check here if this is a new address

–

Plan Enrollment/Update Information (please indicate type of update and fill in appropriate information):

Type of Update: New Enrollment Reinstatement Change/Correction to Information Termination of Benefits Waive BenefitsGroup Transfer Rate Code Change* Change is for: From: Client/Subclient# To: Client/Subclient# From: To: Effective Date of Change Subscriber Dependent– ––

SexMaleFemale

– – Legal Surviving– –

SexMaleFemale

SexMaleFemale

IRS Dep. Surviving Disabled Sponsored


– – – –

– – – –

SexMaleFemale


– – – –

SexMaleFemale


– – – –

*See reverse side for instructions and explanation of codes. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Subscriber’s Signature_________________________________________ Date _________________________1314-55 (10-15)

–

–

Active COBRARetiree Surviving

SexMaleFemale

– – – – – –

Subscriber Information (please complete for all enrollments/updates:) Example:Subscriber Name (Last) (First) (M.I.) Status*

Subscriber Social Security Number Birth Date Coverage Effective Date Hire Date

Street Address Email

City State ZIP Code

Check: Indiana Michigan North Carolina Ohio

Please read the following information carefully before completing the other side of this form. You should fill out this form if you are enroll-ing for coverage or changing any information from an earlier enrollment. If you have any questions about filling out this form, your human resources or personnel department can help you.

Subscriber Information – This section must be completed for us to process your enrollment or update your records. All information should apply to you, the primary subscriber. Please print clearly or type.

Effective Date: The date that Delta Dental coverage takes effect for you and/or your dependents.

Status Definitions (Please select only one status):

Active: You are a current/active subscriber.

Retiree: You are retired and your group continues to provide you with dental benefits.

COBRA: You are no longer an active subscriber but you have continued self-paid coverage under COBRA. COBRA requires many employers to offer extended self-paid coverage to certain employees and qualified beneficiaries who lose group medical benefits coverage. Please check with your human resources or personnel department.

Surviving: The surviving spouse or child of a deceased subscriber.

Plan Enrollment/Update Information – This section should only be completed if you are: (1) Enrolling yourself or a family member for the first time, or (2) if your benefits were terminated and are not being reinstated or, (3) if you are making changes to your current enrollment information.

Enrollment: Check for first time enrollment for yourself or your dependents.

Reinstatement: Check for reinstatement coverage for yourself or your dependents.

Change/Corrections: Check if any changes are being submitted on the form.

Termination of Check only if you are terminating Delta Dental coverage forBenefits: yourself or a family member.

Group Transfers: When transferring from one group to another, all dependents will transfer unless otherwise indicated. This section should also be completed when transferring to COBRA.

When reporting a change or correction, the information that is incorrect or has changed should be listed on the line titled “from” and the correct information should be listed on the line titled “to”.

When changing a rate code, please refer to the following explanation to select the code that describes who is being covered by your Delta Dental program.

Rate Codes:Rate 1 Employee OnlyRate 2 Employee and spouseRate 3 Employee, spouse and childrenRate 5 Employee, one child, no spouseRate 6 Employee and more than one child, no spouse

Enrollment/Corrections To Information – This section should be completed when: (1) enrolling dependents or, (2) if you have checked Changes/Corrections and are changing information that was previously submitted to Delta Dental. Please include both first and last names of any individuals for whom you are enrolling or submitting a change or correction.

Dependent Status Definitions:

Legal: Your current spouse

Surviving: The surviving spouse or child of a deceased subscriber.

IRS Dependent: An individual who is your dependent child according to the U.S. Internal Revenue Code. This could include your unmarried dependent child who is attending a university, college, community college, junior college or trade school on a full-time basis and for whom you provide principal support.

Disabled: Your permanently disabled child.

Sponsored: A dependent for whom you are legally responsible. Sponsored dependents could include parents, grandparents and foreign exchange students, but only if specified in your group’s contract with Delta Dental.

Delta DentalAttention: Eligibility ProcessingPO Box 30416Lansing, MI 48909-7916

Submitting multiple terminations or reinstatementsIf you submit member information via paper, we offer a special form that makes it easier to terminate or reinstate multiple members at the same time. Use the Eligibility for Mass Termination & Reinstatement form (shown opposite) when you have a number of members whose benefits are terminating or reinstating. This form may be more convenient for you than completing an Eligibility Enrollment/Update form for each individual member.

When using this form to reinstate members, all family members who were terminated on the same date as the subscriber will be reinstated. An Eligibility Enrollment/Update form should be completed if a member does not wish to reinstate all of his or her dependents.

Please do not combine terminations and reinstatements on the same form, and use a separate form for each subclient. Please check the appropriate box (indicating terminations or reinstatements) at the top of the form.

Return the original form to:


Please retain a copy for your records.

Remember, when submitting member information...

• Benefit Manager Toolkit changes are immediate

• Electronic files are most efficient

• It’s important that all information is accurate and complete

• Prompt, accurate submission of member information is the best way for you to avoid questions related to claims, benefits or billing

• Retroactive changes are limited to six months and retroactive terminations will not be made effective prior to paid claims

• Observe eligibility cutoff dates to know when to expect changes to appear on your invoice

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Eligibility for Mass Termination & Reinstatement

Client Name: ______________________________________________ Client#/Subclient#

Check: Indiana Michigan North Carolina Ohio

EligMassTermReinstate (07-11)

Check one: Terminations ReinstatementsDo not combine terminations and reinstatements on the same form

Please use a separate formfor each subgroup

Employee InformationEMPLOYEE SOCIAL SECURITY NUMBER EMPLOYEE NAME (LAST) FIRST EFFECTIVE DATE

Comments

Signature Date Submitted

Return the original form to: Attention: Eligibility ProcessingDelta Dental27500 Stansbury Blvd.Farmington Hills, MI 48334

PLEASE RETAIN A COPY FOR YOUR RECORDS

–

Client KnowledgeUsing Benefit Manager Toolkit, you can access Client Knowledge, a web-based, data-driven tool that instantly gives you the information you need to evaluate your dental benefit plans. Client Knowledge is unique in the benefits industry and available only to Delta Dental customers and benefit professionals who qualify.

• At your convenience—reports are available on demand, 24 hours a day, seven days a week

• No phone calls, faxes or emails—you don’t need to make a request and wait for an answer, the data is at your fingertips

• Fast response—charts and reports load quickly, so you can get on with other business

• Easy to review—information is displayed in colorful, easy-to-understand graphs

• Cut and paste—if you need to perform your own analysis, you can get the data in a format that you can copy and paste into Excel or other spreadsheet programs

• Plain language—we use layperson’s terms rather than dental or insurance jargon, so you can interpret the information easily

• Many choices—you can choose a range of dates, subsets of an entire client, the level of detail you wish to see and much more, making Client Knowledge flexible enough to meet your needs

• We’re still here—if you need it, help is available for Client Knowledge and for interpreting the results

You do not have to use Benefit Manager Toolkit to maintain your member information in order to use Client Knowledge, but you do need to register. Not all clients qualify for these reports. Contact your account manager to find out if you qualify.

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The following are examples of reports available:

• Utilization of services and networks—Shows which treatments and provider networks your members are using. Layperson’s terms are used for treatments rather than dental jargon.

• Treatment savings—Shows how your dental benefits plan is saving you money on dental treatments.

• Demographics and financials—Shows the composition of your membership both by member type (employee, spouse, other dependent) and by coverage type. These reports also provide data needed for ERISA reporting to the federal government and other miscellaneous financial data related to your dental benefits plan.

• Peer group reporting—Compares your group to a group of peer organizations. The reports compare treatment utilization, cost per subscriber and cost per member.

• Delta Dental claims operations—Shows commonly requested statistics on our claims operations such as payment and financial accuracy, turnaround time, customer service average speed of answer, and abandonment rate. This report contains the same information as the corporate statistics that we post quarterly regarding performance guarantees.

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What networks are members using?Claims paid between 01-Nov-2014 and 31-Oct-2015Mid-Sized Insurance Company

For more information, contact your Delta Dental of Michigan Sales or Service RepresentativeDate report was run 20-Nov-2015 for report period ending 31-Oct-2015Utilization of services and networks report example Peer group reporting report example

Understanding your fully insured or risk billYour monthly invoice is a summary of your billing information. The bottom portion should be returned with your payment. See the information below and the sample invoice opposite to help understand your invoice.

Because your risk plan with Delta Dental is a prepaid plan, your bill is generated and mailed in advance of the month of coverage. You will receive your invoice approximately one week prior to the month being billed. Your payment is due by the 5th day of the month being billed. For more precise information on billing dates, see the billing calendar on our websites.

Compare the numbers below with those on the sample invoice to help understand your bill:

1 The address to which payment should be sent. (See page 32 for correct payment address.)

2 Your name and address.

3 The page number.

4 The invoice number and date, your client number, the payment terms, due date and billing period. This information helps us identify you when responding to billing questions.

Detailed billing line items:

5 Any debit or credit balance from a prior month’s bill.

6 If any member changes were made affecting prior billing periods, the net adjustment due to all of those changes.

7 For each coverage type, the quantity (number of members under that coverage type), the unit amount or rate (UOM), and the net amount due for that coverage type.

8 The monthly subtotal amount due.

9 The total amount due, including the current month and all prior month debit or credit balances.

Additional details supporting your bill are available through Benefit Manager Toolkit. Once you’ve accessed the Toolkit, select Billing—non-consolidated (for individual subclients’ invoices) or Billing—consolidated for a summary invoice of all subclients under your client number (if applicable and with approved access). Benefit Manager Toolkit online help can guide you from there.

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invoice

INVOICE

Page:1

Invoice No.:Client: Client ABCDate:Billing Period:

RIS0000017349MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYYClient No: MI000004321

Line Identifier Description Quantity UOM Net Amount

Balance Forward 2,744.78

1 Billing Adjustments 0.00 0.00 (0.46)

2 Subscriber Only 33.00 23.55 777.15

3 Subscriber and Spouse 7.00 42.58 298.06

4 Subscriber, Spouse, Children 15.00 76.14 1,142.10

5 Subscriber and One Child 6.00 46.87 281.22

6 Subscriber and Children 2.00 46.87 93.74

Current Monthly Total: 63.00 2,591.81

Total Amount Due: $ 5,336.59

For Inquiries on the following services, please call:

Eligibility/Claims/Address Correction/Rates(IN) 1-800-292-0626

Past Due Amounts/Payments/Customer Balances 1-800-838-8863

Changes made after MM/DD/YYYY will be reflected in the next billing cycle.

PLEASE RETURN BOTTOM PORTION WITH PAYMENT

REMIT

Invoice No:Invoice Date:

RIS0000017349 MM/DD/YYYY

Client Number: MI000004321Payment Terms: Due DateDue Date:Billing Period:

MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY__________________________________

Amount RemittedAMOUNT DUE: $ 5,336.59 Please Remit to:

Heartland SweetenersATTN: Mrs. Lois Franklin14300 Clay Terrace Blvd 249Carmel IN 46032-3629

Renaissance Life and HealthInsurance Company of America16181 Collection Center DriveChicago IL 60693

Attn: Accounts Receivable4100 Okemos RoadOkemos, MI 48864

1

3

4

6

Client ABCATTN: Mr. Joe Smith123 Anywhere StreetAnytown MI 12345

2

5

7

8

Attn: Accounts ReceivableP.O. Box 30416Lansing, MI 48909-7916

MM/DD/YYYY

DELTA DENTAL123 Anywhere StreetAnytown MI 12345

9

Subscriber ListingThe Subscriber Listing details all of the subscribers who are active in our system as of the eligibility cutoff date each month. This report is available through Benefit Manager Toolkit. Select Billing—non-consolidated from the menu once you’re in the Toolkit, and Benefit Manager Toolkit online help can guide you from there.

Compare the numbers below with those on the sample opposite to help you understand your Subscriber Listing:


2 Your Delta Dental client, subclient and contract numbers, which help us identify you when responding to billing questions, as well as your Delta Dental product, eligibility closing date (the last date through which member information changes are reflected), billing date (the date the invoice was created) and period for which you are being billed.

The information below is shown for each subscriber:

3 The subscriber’s name.

4 The last four digits of the subscriber’s ID, used to uniquely identify the subscriber. Generally, only the last four digits of each subscriber’s ID are included, to better protect your employees’ identities.

5 The subscriber’s coverage type.

6 The rate associated with that coverage type.

At the end of the report is a total for all subscribers listed.

If you have subscribers with COBRA coverage, a separate COBRA Subscriber Listing is available. It is identical to the Subscriber Listing except that it lists only COBRA subscribers and rates. The total dollar amounts for COBRA subscribers will be listed as separate line items (by coverage type) on your invoice.

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MM/DD/YYYYMM/DD/YYYY

MM/DD/YYYY MM/DD/YYYY

1 2

3 654

Billing AdjustmentsThe Billing Adjustments report is a list of all subscribers for whom changes were made retroactively (changes made during the current billing period that have also impacted one or more prior billing periods). Retroactive changes will generally not be processed for effective dates more than six months prior to the date received. This also means that any retroactive credits or charges included on your invoice will be limited to six months.

The Billing Adjustments report is available through Benefit Manager Toolkit. Select Billing—non-consolidated from the menu once you’re in the Toolkit. Benefit Manager Toolkit online help can guide you from there.

Compare the numbers below with those on the sample opposite to help you understand your Billing Adjustments report:


2 Your Delta Dental client, subclient and contract numbers that help us identify you when responding to billing questions, plus your Delta Dental product, the closing date (the last date through which member information changes are reflected), billing date and period for which you are being billed.




5 The subscriber’s coverage type.

6 The date the change became effective.

7 The type of change.

• Add—indicates a new enrollment.

• Term—indicates that a member’s coverage, along with any family members’ coverage, has been terminated.

• Status—indicates a change in coverage type.

• COBRA—indicates that a member changed to COBRA coverage or that a newly eligible family member was added to COBRA coverage.

• Active—indicates that a member or other family members changed back to regular coverage from COBRA coverage.

8 The total amount previously billed for this subscriber during the affected period.

9 The total amount that should have been billed for this subscriber during the affected period, based on the retroactive change.

10 The net charge (money due to Delta Dental) or credit (money due to you) for this change.

11 The total net adjustment due to retroactive changes for this period.

A Current Period Changes report, identical in format to Billing Adjustments, is also available. However, since these changes become effective in the current billing period, there are no dollar figures and no separate line item on your invoice.

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MM/DD/YYYY

MM/DD/YYYY


1 2

3 654 7 8 109

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Understanding your (per member) fully insured or risk billYour monthly invoice is a summary of your billing information. The bottom portion should be returned with your payment. See the information below and the sample invoice opposite to help you understand your invoice.

Because a per member risk plan with Delta Dental is a prepaid plan, your bill is generated and mailed in advance of the month of coverage. You will receive your invoice approximately one week prior to the month being billed. Your payment is due by the 5th day of the month being billed. For more precise information on billing dates, see the billing calendar on our websites.

Compare the numbers below with those on the sample invoice to help understand your bill:



3 The page number.

4 The invoice number and date, your client number, the payment terms, due date and billing period. This information helps us identify you when responding to billing questions.

Detailed billing line items:

5 Any debit or credit balance from a prior month’s bill.

6 For each age bracket, the quantity (number of members within that age bracket), the unit amount or rate (UOM), and the net amount due for that coverage type.

7 The monthly subtotal amount due.

8 The total amount due, including the current month and all prior month debit or credit balances.

Additional details supporting your bill are available through Benefit Manager Toolkit. Once you’ve accessed the Toolkit, select Billing—non-consolidated (for individual subclients’ invoices) or Billing—consolidated for a summary invoice of all subclients under your client number (if applicable and with approved access). Benefit Manager Toolkit online help can guide you from there.

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REMIT

Invoice No:Invoice Date:Client Number:Payment Terms:Due Date:Billing Period:

Please Remit to:

DELTA DENTAL16082 Collection Center Drive Chicago IL 60693

INVOICE

Page:1

Invoice No.:Client: Zeeland Vision Services, P.C. MBR0000014330Date: 02/01/2016Billing Period: 02/01/2016 Thru 02/29/2016Client No: MI057915261P

Line Identifier Description Quantity UOM Net AmountReminder: Billing details are only available online on Benefit Manager Toolkit

(www.toolkitsonline.com). If you do not yet have access, update your security

settings via the site ’’Register’’ page.

Balance Forward 0.00

1 Billable Members 0 to 19 years 1 27.01 27.01

2 State Claims Tax 0 0.00 0.18

Estimated State Tax 0.65% of Premium

Current Monthly Total: 1 $ 27.19

Total Amount Due: $ 27.19


Eligibility/Claims/Address Correction/Rates(MI) 1-800-482-8915


Changes made after 01/11/2016 will be reflected in the next billing cycle.


__________________________________Amount Remitted

AMOUNT DUE: $ 27.19

Zeeland Vision Services, P.C.ATTN: Mrs. Faith Weener300 S State St 15Zeeland MI 49464-1676

Accounts ReceivablePO Box 30416Lansing, MI 48909-7916

3

2

56

7

8

1

CAP0000012345MM/DD/YYYYIN000004321Due DateMM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

CAP000012345MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

4


Client ABC

MI000004321



Subscriber Listing (per member)The Subscriber Listing details all of the subscribers who are active in our system as of the eligibility cutoff date each month, with the number of billable members per subscriber. This report is available through Benefit Manager Toolkit. Select Billing—non-consolidated from the menu once you’re in the Toolkit, and Benefit Manager Toolkit online help can guide you from there.

Compare the numbers below with those on the sample opposite to help you understand your subscriber listing:


2 Your Delta Dental client, subclient and contract numbers, which help us identify you when responding to billing questions, as well as your Delta Dental product, eligibility closing date (the last date through which member information changes are reflected), billing date (the date the invoice was created) and period for which you are being billed.




5 The subscriber’s number of billable members (dependents).

6 The amount due for each subscriber.

At the end of the report is a total for all subscribers listed.

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Subscriber_Listing_Exchange (01-27-2014)

Name of Subscriber Subscriber ID Billable Members* Total Due

Current Month Billing

Client No.:Subclient No.:Contract ID:Product:Closing Date:Billing Date:

Billing Period:

01/12/2016

SUBSCRIBER LISTINGSUBSCRIBER LISTING

ZEELAND VISION SERVICES, P.C.ATTN: MRS. FAITH WEENER300 S STATE ST 15ZEELAND MI 49464-1676

57915261P1133460DELTA DENTAL PPO (POINT-OF-SERVICE)DELTA DENTAL PPO (POINT-OF-SERVICE)01/11/2016

02/01/2016 - 02/29/2016

$27.01

* This invoice was calculated using a maximum age limit of 19 based on the end of benefit period. The maximum number of billable dependent children for each subscriber is 3. The maximum number of members per subscriber billed may not reflect the total number of members each subscriber has enrolled in the plan.

BOCKS, NICOLE *5331 1 27.01

Page 1 of 1

2

3 654

01230001824737DELTA DENTAL PPO (POINT-OF-SERVICE)MM/DD/YYYYMM/DD/YYYY

MM/DD/YYYY - MM/DD/YYYY

MM/DD/YYYY

MM/DD/YYYY


1MM/DD/YYYY

MM/DD/YYYY


MM/DD/YYYY

MM/DD/YYYY


Understanding your self-insured or ASO billsYour monthly invoices are summaries of your billing information. The bottom portions should be returned with your payment. See the information below and the following samples to help understand your invoices. For more precise information on billing dates, see the billing calendar on our websites.

Under a self-insured plan (ASC/ASO), you can expect an invoice for your members’ claims, as well as a separate invoice representing the fees for administering your benefits. Administrative costs are calculated and billed by:

• Per subscriber/capita—an amount specified in your contract and billed for each eligible subscriber. Per subscriber/capita administration costs are billed on an invoice separate from your claims invoice, and mailed in advance of the month of coverage. You can expect to receive your invoice approximately one week prior to the month being billed. Your payment on this invoice is due by the 5th day of the month being billed.

• Percentage of claims—a percentage specified in your contract that is multiplied by the total amount of claims payments to determine the administrative cost for the billing period. Percentage of claims administration costs are billed on a separate invoice, and are due by the 20th of the following month.

• Per transaction—an amount specified in your contract that is charged for every transaction that occurred during the billing period (a claim paid, an adjustment, etc.). Per transaction administration costs are billed on a separate invoice, and are due by the 20th of the following month.

Compare the numbers below with those on the sample claims and administration invoices to help understand your bill:



3 The page number.

4 The invoice number and date, your client number, payment terms, due date and billing period. This information helps us identify you when responding to billing questions.

Detailed billing line items (NOTE: Not all invoice types will have all of the following line items):

5 The total paid out in claims for your members during the billing period.

6 The total amount of all adjustments to claims for your members during the billing period.

7 If any member changes were made affecting prior billing periods, the net adjustment is due to all of those changes.

8 For each coverage type, the quantity (number of members under that coverage type), the unit amount or rate (UOM), and the net amount due for that coverage type.

9 The administrative cost for administering your claims for this billing period. If calculated as a percentage of claims, the quantity will show the dollar amount of claims paid during the billing period and the percentage (UOM) of this amount used to determine the administrative cost or net amount for the billing period. If calculated as a per transaction, the quantity is the number of transactions (claims) and the dollar amount per transaction (UOM) used to determine the administrative cost or net amount for the billing period.

10 The billing period subtotal amount due.

11 The total amount due.

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Supporting billing detail

Claims details supporting your bill are available through Client Knowledge, our client reporting tool. Client Knowledge is accessed through Benefit Manager Toolkit. The claims listing contains a list of all claims for the period and includes the claim details, the patient and subscriber, and the plan and patient pay amounts.

If your administrative rate is calculated on a per member basis, you also have access to supporting member data. Additional details supporting your bill are available through Benefit Manager Toolkit. Select Billing—non-consolidated from the menu once you’re in the Toolkit. Benefit Manager Toolkit online help can guide you from there or contact your account manager for more information.

invoice

INVOICE

Page:1

Invoice No.:Client: Michigan Catholic Conference ASO0000005432Date: 09/30/2010Billing Period: 09/01/2010 Thru 09/30/2010Client No: MI092530002

Monthly PaidLine Identifier Claims UOM Total Amount Due

1 Claims Paid 426,663.55 1.00 426,663.55

2 Claims Paid (1,185.00) 1.00 (1,185.00)

Totals: 425,478.55 425,478.55





REMIT

Invoice No:Invoice Date:Client Number:Payment Terms:Due Date:Billing Period:__________________________________


Michigan Catholic ConferenceATTN: Ms. Karen LaRosa510 S Capitol AveLansing MI 48933-2306

DELTA DENTAL16082 Collection Center DriveChicago IL 60693


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3

4

2

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ASO0000012345MM/DD/YYYYMI000004321Due DateMM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

MI000004321

CLAIMS INVOICE SAMPLE

AS0000012345MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

invoice

INVOICE

Page:1






2 Subscriber Only 33.00 23.55 777.15












REMIT











INVOICE

Page:1

Invoice No.:Client: 1st Source Corporation CAP0000001096Date: 09/01/2010Billing Period: 09/01/2010 Thru 09/30/2010Client No: IN001040001


1 Subscriber Only 414.00 3.61 1,494.54


3 Subscriber, Spouse, Children 188.00 3.61 678.68



6 COBRA Subscriber Only 24.00 3.61 86.64

7 COBRA Subscriber and Spouse 4.00 3.61 14.44

8 COBRA Subscriber and One Child 1.00 3.61 3.61








REMIT



1st Source CorporationATTN: Ms. Patti Nemeth100 N Michigan StSouth Bend IN 46601-1630


Client ABC

INVOICE

Page:1



1 Subscriber Only 414.00 3.61 1,494.54















REMIT





INVOICE

Page:1



1 Subscriber Only 414.00 3.61 1,494.54















REMIT





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3

4

Client ABCATTN: Mr. Joe Smith123 Anywhere StreetAnytown IN 12345

2

CAP0000012345MM/DD/YYYYIN000004321Due DateMM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

Client ABC

IN000004321

invoice

INVOICE

Page:1






2 Subscriber Only 33.00 23.55 777.15












REMIT









871

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3

4

5

6

7

8

9

10

11

3,172.73

3,172.73

PER MEMBER ADMINISTRATION INVOICE SAMPLE

CAP000012345MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY



invoice

INVOICE

Page:1

Invoice No.:Client: Wright & Filippis ADM0000000170Date: 09/30/2010Billing Period: 09/01/2010 Thru 09/30/2010Client No: MI096250001


1 Admin. Fee % of Claims Paid 23,803.20 0.15 3,544.30

Current Monthly Total: 23,803.20 3,544.30







REMIT



Wright & FilippisATTN: Ms. Mary Donaghue2845 Crooks RdRochester Hills MI 48309-3661



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3

4

2

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Client ABC

MI000004321

ADM0000012345MM/DD/YYYMI000004321Due DateMM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

9

ADM0000012345MM/DD/YYYYMM/DD/YYYY

ADM0000012345MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY


PERCENTAGE OF CLAIMS ADMINISTRATION INVOICE SAMPLE


INVOICE

Page:1

Invoice No.:Client: Michigan Catholic Conference ADM0000000167Date: 09/30/2010Billing Period: 09/01/2010 Thru 09/30/2010Client No: MI092530002


1 Admin. Fee Per Transaction 2,432.00 11.99 29,159.68

Current Monthly Total: 2,432.00 29,159.68







REMIT



Michigan Catholic ConferenceATTN: Ms. Karen LaRosa510 S Capitol AveLansing MI 48933-2306



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2

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Client ABC

MI000004321

ADM0000012345MM/DD/YYYYMI000004321Due DateMM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY

ADM000012345MM/DD/YYYYMM/DD/YYYY Thru MM/DD/YYYY


PER TRANSACTION ADMINISTRATION INVOICE SAMPLE


Statement of AccountA Statement of Account is a summary of your account activity. It is not an invoice. A Statement of Account is mailed during the second week of each month, separate from your invoice. Please note that you will receive a Statement of Account if you have a self-insured plan and open balances on your account at the time that statements are produced. Risk contracts do not receive statements of account. Compare the numbers below with those on the following sample:


2 The statement number, statement date and your Delta Dental client number, used in answering statement questions, and our payment address.

3 The account name and number.

For each line item on the statement:

4 The date on which the entry was made.

5 The item ID and line, used internally to identify transactions within our accounting system.

6 The type of bill, if any.

7 The type of entry, such as “On Account” for a payment that has not been applied to an invoice or “Invoice,” etc.

8 The item activity, if any.

9 The balance, or transaction amount. A negative number indicates a payment to us; a positive number indicates an amount due.

10 The document number, if any, used to identify the transaction.

11 For payments, the check or EFT number.

12 The total of all items.

13 The statement total.

14 The total amount aged by the following categories: 0–30 days, 31–60 days, 61–90 days and more than 90 days, plus the total of all items.

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Statement Number: 2,153

11/11/2010Statement Date:

Account Number: MI001110000

16082 Collection Center DriveSend payment to:

Chicago, IL 60693

ATTN: Ms. Chris Farrell

MDMH Dental Treatment Fund For DD

109 W Michigan Ave

Lansing, MI 48913-0001

Statement of Account

A friendly reminder to let you know your account has open balances that require immediate resolution.

If your account has a balance due, claim payments for your members may be placed on hold. Please

call the Accounting Department at 1 (800) 838-8863.

This is not an Invoice

Acct. Date Item Id and Line Entry Type BalanceItem Activity Document: Check NumberBill Type

Account: MDMH Dental Treatment Fund For DD MI001110000 DDPM

0003862150 1,251.80Invoice 09/30/2010

ADM0000000012 138.50Invoice 10/31/2010

ASO0000000264 1,385.00Invoice 10/31/2010

Total for MDMH Dental Treatment Fund For DD 2,775.30

Statement Total

61 - 9031 - 600 - 30

1,523.50 1,251.80 2,775.30

Future Over 90 Total

Amount

2,775.30

For inquiries regarding Customer/Claims Services, please call:

Michigan (800) 482-8915 www.deltadentalmi.com

Indiana (800) 292-0626 www.deltadentalin.com

Ohio (800) 282-0749 www.deltadentaloh.com To access Delta Dental's Billing Calendar, please visit the Purchasers section of our website above.

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Client ABC MI000001234

MI000001234

ATTN: Mr. Joe SmithClient ABC123 Anywhere StreetAnytown, MI 12345

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3

4 5 6 7 118 9 10

MM/DD/YYYY OA-123456 On Account -700.00 0001234567 0000012345MM/DD/YYYY 0001234567 Invoice 3,675.00 253.00 MM/DD/YYYY 0001234567 Payment -3,422.00 0000023456MM/DD/YYYY CAP0000001234 Invoice 1,023.36 MM/DD/YYYY ASO0000000123 Invoice 5,094.00

Total for Client ABC 5,670.36

Statement Total 5,670.30

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5.094.00 1,023.36 253.00 -700.00 5,670.36

1

MM/DD/YYYY

Submitting paymentYour monthly payment to Delta Dental is due by the date indicated on your monthly invoice.

Checks submitted for payment should be made payable to your plan as indicated on the invoice. Please pay the amount shown on the Total Amount Due line of the invoice and indicate the amount of your payment under Amount Remitted. Please note that if an amount other than that indicated on your invoice is paid, or if payment is not received by the due date, your claims may be placed on hold until your account is paid in full.

Payments may also be made by electronic funds transfer or direct debit by (see next page). Please contact our billing department at 800-838-8863 for more information on paying by these methods.

Please note that as previously explained, adjustments for member information changes received after the eligibility closing date are reflected on subsequent months’ invoices and listed on the Billing Adjustments report for confirmation. Therefore, it is not necessary for you to manually compute a new invoice total. Instead, please pay the total amount due, listed on the invoice. Any monies due back to you as a result of retroactive changes will be promptly subtracted from future invoices, just as any charges due to Delta Dental will be added to future invoices.

Please do not send any member information changes with your payment as this may cause them to be delayed or missed altogether.

All initial binder check payments should be sent directly to the following address:


All standard bills should be sent to the following addresses:

Delta Dental of Michigan 16082 Collection Center Drive Chicago, IL 60693-0160

Delta Dental of Ohio PO Box 633198 Cincinnati, OH 45623-3198

Delta Dental of Indiana 16172 Collection Center Drive Chicago, IL 60693-0161

Delta Dental of North Carolina 32406 Collection Center Drive Chicago, IL 60693-0324

Renewing your contractIf you’re not making changes to your contract, our streamlined renewal process is effortless. Approximately two months before your current contract expires, we’ll send you a renewal letter with information about any rate changes. If you wish to continue your current benefit plan, simply continue paying your invoice and your benefits will continue.

If you wish to make changes to your benefit plan upon renewal, contact your account manager who will work with you to develop a revised benefit plan.

Making changes to your contractIf you wish to make changes to your current contract, we’ll be happy to work with you. Because contract changes are so important, we won’t make any changes to your contract until we receive written confirmation from you.

A simple email or letter from the person at your organization authorized to discuss and approve the changes helps ensure that your changes are correct and approved. If we haven’t heard from you in writing, we’ll contact you requesting a signature.

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ELECTRONIC FUNDS TRANSFER OR DIRECT DEBIT FORM SAMPLE

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How to read an Explanation of Benefits (EOB) statementAn Explanation of Benefits statement, is provided for each claim to explain how the benefits were administered on that claim. The numbers below correspond to the numbers on the following sample EOB, and are designed to help interpret your statement:

1 Patient information, including the patient’s name and date of birth, the patient’s relationship to the subscriber, and the subscriber’s name.

2 Provider information, including the business or provider name, license number and state, National Provider Identifier (NPI), check number, payment issue and receipt date, and claim number. The claim number in particular helps us answer any questions about the claim.

3 Client information, including the client and subclient numbers and names, the plan name, and the product name.

For each claim line:

4 Code identifying the part of the body, if applicable (such as tooth or tooth surface).

5 The date of service.

6 A brief description of the service.

7 The amount submitted by the provider.

8 The maximum amount we have approved for this service.

9 The difference between the amount the provider submitted and our maximum amount approved, indicating the savings due to the provider’s participation in one of our networks.

10 The amount allowed under your plan.

11 The amount of any deductible (D), patient copay (P) or office visit fee (OV).

12 The percent we paid on the line.

13 The amount we paid.

14 The amount the patient is due to pay.

15 Whether payment is made to the provider (P), subscriber (S), or custodial parent (C).

16 Totals for each column.

17 The phone number for inquiries.

18 The address for inquiries.

19 Our standard appeal, privacy and anti-fraud language.

20 The name and address for mailing.

Crack the case of the EOBYou can also read easy with the help of Max Ryan, a no-nonsense detective determined to understand his dental EOB in our “Solve the Mystery of the EOB” video. Detective Ryan and his confidential source will walk you through an EOB, and help to define terms and explain why it’s important to stay in network. This video is part of the “Benefit from Your Benefits” video series, exploring topics that invite anyone interested in dental benefits and oral health to better understand their benefits. Watch this and other videos on our websites.

EOB_Subscriber

Patient Name : Business/Dentist :

Date of Birth : License No. :Relationship : Check No. :

Issue Date :Receipt Date :Claim No. :

Area/Tooth Code/Surface

Date of Service

Procedure Description

Submitted Amount

Maximum Approved Fee

Contract DentistSavings

AllowedAmount

Deductible / Patient Co-Pay / Off ice Visits Co-Pay % Payment

Patient Payment

Pay To

Total

P a t i e n t C o p y

Explanation of Benef its(THIS IS NOT A BILL)

JANET DOE

MM/DD/YYYY SUBSCRIBER

Subscriber : JEFFREY DOE

FRITZ FLOSSMOOR, DDS

XXXXX / MI (NPI: XXXXXXXXX) XXXXXXXXXMM/DD/YYYYMM/DD/YYYYXXXXXXXXXX

Crack the case of your Explanation of Benefits (EOB) satement with a new video! In “Solve the Mystery of the EOB,” Detective Max Ryan helps you better understand your dental benefits by deciphering your Delta Dental EOB codes and fees. When you’ve solved the case, you’ll be ready to go paperless. Visit www.deltadentalmi.com/EOB today to learn more!

Pay To: C = Custodial ParentS = SubscriberP = Provider

LAUREN TESTING4100 OKEMOS RD OKEMOS, MI 48864

PRODUCT: DELTA DENTAL PPO (POINT-OF-SERVICE)PLAN: DELTA DENTAL PLAN OF MICHIGAN CLIENT/ID: XXXX ABC COMPANY SUBCLIENT: XXXX ABC COMPANY

FOR INQUIRIES: 1-800-524-0149

DELTA DENTALP.O. BOX 9085FARMINGTON HILLS, MI 48333-9085

Payment for these services is determined in accordance with the specific terms of your dental plan and/or Delta Dental’s agreements with its contracting dentists. For inquiries regarding contracting dentists, please call the number listed. Delta Dental’s payment decisions do not qualify as dental or medical advice. You must make all decisions about the desirability or necessity of dental procedures and services with your dentist. If your claim was denied in whole or in part so that you must pay some amount of the claim, upon a written request and free of charge, we will provide you with a copy of any internal rule, guideline or protocol or, if applicable, an explanation of the scientific or clinical judgment relied upon in deciding your claim. If you still believe your claim should have been paid in full, you may ask to have the claim reviewed. Your written request for a formal review must be sent within 180 days of your receipt of this EOB to the address listed. You may submit any additional materials you believe support your claim. A decision will be made no later than 60 days from the date we receive your request, or within a shorter time period if required by law. Failure to comply with such requirements may lead to forfeiture of a consumer’s right to challenge a denial or rejection, even when a request for clarification has been made. If your claim is denied in whole or in part after the review, you have the right to seek to have your claim paid by filing a civil action in court.Your privacy is important to us. To access our HIPAA Notice of Privacy Practices or our Gramm-Leach-Bliley Privacy Notice, log onto our website and select the “HIPAA” or “GLB Privacy” link from the home page, or call our Customer Service department to request a written copy.

ANTI-FRAUD TOLL-FREE HOTLINE: (800) 524-0147 Insurance fraud signifi cantly increases the cost of health care. If you are aware of any false information submitted to Delta Dental, you can help us lower these costs by calling our toll-free hotline. You do not need to identify yourself. Only ANTI-FRAUD calls can be accepted on this line.

www.deltadentalmi.com

NETWORK: DELTA DENTAL PREMIER DENTIST

05/01/15 CLEANING 150.00 72.00 78.00 72.00 100% 72.00 0.00 P

150.00 72.00 78.00 72.00 0.00 72.00 0.00

GENERAL MAXIMUM USED TO DATE: 72.00

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Consumer ToolkitYour members’ connection to Delta Dental.

Delta Dental’s easy-to-use Consumer Toolkit allows your members to stay current on their dental benefits. The secure online tool is designed to give members 24/7 access to important information regarding their dental benefits, including:

• Eligibility information

• Current benefits information (such as how much of the yearly benefit has been used to date, how much is still available to use, levels of coverage for specific dental services, etc.)

• Specific claims information, including what has been approved and when it was paid

The site also allows members to elect to receive EOB statements electronically, print claim forms and identification cards, and browse oral health information.

To help ensure confidentiality of their information, members must first register to gain access to the Toolkit. Privacy of online benefit information is assured through highly secure encryption technology.

Consumer Toolkit, like Benefit Manager Toolkit, is accessible through any of our corporate websites.

Going paperless is a smart option

Delta Dental offers an option for members to receive electronic EOB statements. Not only does this option help the environment by reducing paper, it also offers members better data protection and security.

By electing to use Consumer Toolkit to view and store EOBs, members are able to reduce the number of unauthorized people who could gain access to personal information in a mailbox or stored in a filing cabinet. EOBs are available to view immediately following claim submission and processing, and are stored perpetually.

Encourage your members to log in to Consumer Toolkit today to sign up for paperless EOB delivery.

Current benefits information is also available

Members can view eligibility information

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Help your members benefit from their dental benefitsFind a dentist

Staying in the Delta Dental network is smart, and finding participating dentists couldn’t be easier! Your members can use any of the methods listed below to locate participating dentists nearby.

• Consumer Toolkit—this secure online tool is designed to give 24/7 access to important information regarding a member’s dental benefits, a dentist directory, and the ability to print ID cards. Members can access the Toolkit from our websites, or go directly to www.consumertoolkit.com.

• Websites—our mobile-friendly dentist search tool is available from our corporate websites.

• Mobile smartphone app—The Delta Dental mobile app helps members get the most out of their dental benefits on the go, such as search for dentists.

• Customer service—call 800-524-0149 to get a list of participating dentists 24/7. The automated system allows the caller to listen to the directory or to have the list sent by fax. Representatives are also available to assist callers Monday through Friday from 8:30 a.m. to 8 p.m.

ID card not required

Delta Dental members are not required to show a personalized ID card to receive dental treatment. The dental office can verify eligibility and benefits by using the member’s Social Security number or alternate ID number.

However, if a member would prefer to carry an ID card (either in electronic form or paper), an ID card can be obtained by using the free Delta Dental mobile smartphone app, log in to Consumer Toolkit or call customer service.

Pre-treatment estimates

Delta Dental makes it easy to find out if a proposed dental treatment is covered, the amount the plan will pay and the member’s responsibility.

A pre-treatment estimate is a voluntary, optional service where Delta Dental issues a written estimate of benefits that may be available under the member’s plan for a proposed dental treatment. The dentist submits the proposed dental treatment to Delta Dental in advance of providing the treatment.

The Delta Dental mobile app

Members can use Delta Dental’s free smartphone app to get the most out of their dental benefits anytime, anywhere. Members can use the dentist search or toothbrush timer without logging in, or enter their username and password* to securely access a digital ID card and personal benefit information, such as plan type, benefit levels and more.

The Delta Dental mobile app is available for Apple iOS or Android users. Visit the App Store (Apple) or Google Play (Android) and search for ‘Delta Dental.’

* To register, go to www.deltadental.com and sign up for an account that will also work in the mobile app.

Requesting information on your membersWe take the safety and security of confidential and personal information very seriously, and this is reflected in our policies regarding the release of information about benefits and claims. In fact, we are fully compliant with strict federal HIPAA (Health Insurance Portability and Accountability Act) laws governing security and privacy to ensure that information is being given only to someone authorized to receive it.

For this reason, we ask you to provide the following information when inquiring on member benefits or eligibility for benefits:

• A valid client and subclient number (it does not have to be the member’s subclient number).

• The member’s identification number (usually the Social Security number).

• The member’s name and date of birth or address for confirmation.

If you are inquiring about a specific claim, we also ask that you have the member’s permission to discuss the claim with us if the member is not present when you call.

When your members contact us

Members can also contact us on their own behalf. When they do, they should be prepared to supply:

• Their member identification number, usually their Social Security number (we can work with only the last four digits of their Social Security number, though we can find them more efficiently with the entire Social Security number).

• The patient’s name and date of birth.

Members and their spouses can inquire on behalf of themselves and any underage dependents, and also on behalf of each other and any adult dependents with authorization from the other party.

Other situations

We understand that at times it may be necessary for other parties to inquire on benefits or claims. That party must have the member’s authorization to seek information on their behalf.

For example:

• Union representatives—must supply a valid client and subclient number and the member’s identification number (usually the Social Security number), and have the member’s permission to discuss any claims.

• Personal representative or power of attorney —must supply at least the last four digits of the member’s Social Security number and the patient’s name and date of birth.

• Ex-spouse—can inquire on their own behalf and on behalf of any underage or disabled dependents if they are the custodial parent or legal guardian.

We cannot release EOBs to a third party without written permission.

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Still have questions? Get in touch with us!Delta Dental knows that service is important—it is a hallmark of any Delta Dental benefits program. We also know that it is important to give you access to resources that can help you. We pledge to answer any questions you may have about your billing statements and invoices, member information, and benefits. Feel free to call us with your questions—we are here to help!

We have a number of oral health brochures designed for members. Contact your account manager for more information. We also provide oral health information online in the Wellness sections of our websites.

In addition to the information in this handbook, you can find the answers to many questions online at:

• www.deltadentalin.com

• www.deltadentalmi.com

• www.deltadentalnc.com

• www.deltadentaloh.com

Customer service

For questions regarding your benefits, your members’ information, and general procedures, call our customer service department toll free:

• Delta Dental 800-524-0149

• Anti-fraud hotline 800-524-0147

Written inquiries

Written inquiries should include the subscriber’s name, member ID, and client name and number. Send your written inquiries to:

Attention: Customer Service Delta Dental PO Box 9089 Farmington Hills, MI 48333-9089

Eligibility enrollment/update

Send forms to:


Claim forms

Send claim forms to:

Delta Dental PO Box 9085 Farmington Hills, MI 48333-9085

Billing

For questions regarding monthly statements, your account balance, payment information, or any billing concerns, call our accounting department toll free:

• 800-838-8863

Account Manager Contact InformationName: _____________________________

Email: _____________________________

Phone: _____________________________

Fax: _____________________________

Address: _____________________________

_____________________________

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Delta Dental Client Administration Handbook v3

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