5.9 million members in Michigan
10.7 million claims processed in Michigan in 2021
Thank you for providing quality care to our members!
Because of you, more individuals have access to healthier smiles.
Get more with DOT
The Dental Office Toolkit® (DOT) empowers you to complete day-to-day tasks like submitting claims, looking up member benefits and updating office information, all without having to call customer service. This saves you valuable time and allows you to address needs faster.
You can submit claims to any Delta Dental plan through DOT, and our drop-to-pay rate in 2021 for Michigan, Ohio and Indiana was more than 95 percent. This means that the majority of claims submitted through DOT do not require any manual intervention!
DOT is free for you to use, and if you don’t already have an account, registration is simple. Visit our website to learn how you can set up your DOT profile, read FAQ, find how-to guides and more.
We continually look for areas of improvement in DOT that can make your experience even better.
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Breaking down NPIs
You may know that all covered health care providers, health plans and health care clearinghouses must use a 10-digit National Provider Identifier, but do you know which type of NPI you need and when you may need both?
- Type 1 NPIs are for individual health care providers who are sole proprietors (not incorporated).
- An incorporated individual is a single health care provider who forms and conducts business under a corporation. A sole proprietor isn’t an incorporated individual because the sole proprietor didn’t form a corporation. If you’re a sole practitioner or solo practitioner, it doesn’t mean you’re a sole proprietor and vice versa.
- Type 2 NPIs are for organization health care providers who are incorporated (incorporated individuals), group practices, clinics, county health departments and partnerships.
Learn more about NPIs.
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Participating in the MA network
When you sign on to participate in the Delta Dental PPO™, Delta Dental Premier® or Delta Dental EPO™ networks, you get one more advantage—automatic participation in the corresponding Delta Dental Medicare Advantage™ network.
You will be listed in the Medicare Advantage dentist search for those members, and services rendered are on the same fee schedule as the primary network you signed on to, whether that is Delta Dental PPO, Delta Dental Premier or Delta Dental EPO. The only difference when treating patients with Medicare Advantage versus a commercial plan is that you need to fill out a private pay form before providing any non-covered services.
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When Medicaid is a secondary carrier
Delta Dental is helping to reduce some administrative burden on dental offices whose members have Delta Dental Healthy Kids Dental or Healthy Michigan Plan as a secondary carrier.
When submitting claims for Delta Dental HKD and HMP members, we ask that you submit a claim to their primary carrier first, then provide that EOB to Delta Dental. If your patient fails to inform you of their primary coverage, we will send an information request notifying you of their primary coverage. We ask that you submit a claim to the carrier listed on the information request, then provide the coverage amount to Delta Dental so the secondary claim for Delta Dental HKD or HMP can be processed accordingly.
In the event a claim was paid with Delta Dental HKD or HMP as primary when it should have been paid as secondary, Delta Dental will work on the payment adjustment and no additional action is required on your part.
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Verifiying coverage
On the day a Delta Dental enrollee is to receive covered services, remember that you must verify their eligibility to receive those services and that you are responsible for informing them of any potential risks and/or benefits of recommended treatment and available alternatives prior to rendering services.
If that patient is a Medicare Advantage or Medicaid enrollee, don’t forget to obtain a signed private pay form from the patient if you will provide treatment that is not covered under their plan.
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Using provider pay form
If a Delta Dental Medicare Advantage or Medicaid member requires services not covered in their benefit plan, be sure to obtain a signed private pay form from that member before rendering services.
These members may be part of the Healthy Michigan Plan, Pregnant Women Dental program or MI Health Link program. If a procedure is not listed in Delta Dental’s fee schedule for the above programs, or if it exceeds an age or frequency limitation, it is not a covered benefit under that program.
Payment for non-covered services is the responsibility of the member or the responsible party. Before providing non-covered services, the fee must be discussed with the member or responsible party. Treatment can only be provided if and when they sign a private pay agreement, where they agree in writing to pay for the non-covered (or alternate) procedures.
You may use any form for the private pay agreement as long as it includes the fees associated with the non-covered service, the responsible party’s signature and the date. (See Delta Dental’s sample form here). Keep the signed form in your files as Delta Dental may request a copy.
The Delta Dental member’s or responsible party’s approval to proceed with non-covered services via the private pay form should be included in the patient’s record. If a member agrees to pay for a non-covered service, Delta Dental dentists will be held to the lesser of the submitted fee or the applicable Delta Dental fee schedule for any charges to the patient or responsible party.
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HKD timeline standards and foster care guidelines
Our Delta Dental Healthy Kids Dental (HKD) providers play a significant role in shaping a child’s future by addressing their gaps in oral health care. As part of your role, the Michigan Department of Health and Human Services requires you to see Delta Dental HKD members within specified time frames based on treatment urgency.
Those benchmarks can be found in your participation contract, but are listed here for general practitioners and pediatric dentists:
- Urgent care—see within 48 hours
- Routine services—schedule within 21 business days
- Preventive services—schedule within six weeks
- Initial appointment—schedule within eight weeks
For those Delta Dental HKD members who are in foster care, there are additional guidelines to consider. Click here view the foster care dental requirements.
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New Medicare Advantage partners
On January 1, Delta Dental of Michigan became the dental benefits administrator of choice for McLaren Health Plan, Reliance Healthcare and PHP (Physician’s Health Plan).
McLaren Health Plan: Operating since 1998, McLaren Health Plan delivers health care benefits to all counties in Michigan's Lower Peninsula.
Reliance Healthcare: Headquartered in southeast Michigan, Reliance is Michigan's only doctor-owned Medicare Advantage plan.
PHP (Physician's Health Plan): A Sparrow Health System company that became mid-Michigan's first brand-based independent practice association (IPA) in 1980.
*Member may identify as part of Covenant Retirees Advantage or City of Owosso.
You play a key part in serving these members. Be sure to keep this list of new plans close by for when members begin calling!
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