Dental Plan

Filing Your Claim 

Following the instructions in this section will help to ensure the prompt payment of your claim. All claims must be submitted within one year of the date that the service is provided.

NETWORK CLAIMS
You do not have to file a claim form when you use a participating Delta PPO or Premier Network dentist. Your participating dentist will file your claim for you. 

The claim process for participating dentists is as follows: 

  • Provide the dentist with the information shown on your ID card.
  • The dentist will submit your claim to Delta Dental.
  • Delta Dental will send you an Explanation of Benefits (EOB). The EOB will show:
    • the amount Delta Dental paid; and
    • the remaining balance, which you pay directly to the dentist.                         

OUT-OF-NETWORK CLAIMS
You must file a claim form to receive reimbursement for an out-of-network claim. You can obtain a claim form by calling Delta Dental Customer Service at 1-800-872-0500. 

The claim process for non-participating (out-of-network) dentists is as follows: 

  1. Provide the dentist with the information shown on your ID card.
  2. Pay the fee directly to the dentist.
  3. Submit your completed claim form to Delta Dental at the following address:
       
        Delta Dental of Massachusetts
        PO Box 9695
        Boston, MA 02114 
  1. Delta Dental will reimburse you for your covered expenses, based on the claim form that you submit. 
If you receive a treatment that is not covered by the plan, you may be billed at the dentist’s normal rate. This also applies if you receive treatment after you have exhausted any annual or lifetime benefit maximums. To avoid unexpected out-of-pocket costs, contact Delta Dental Customer Service at 1-800-872-0500. You can also log on to their website at www.deltamass.com.

COORDINATION OF BENEFITS
If you or an eligible dependent is covered by more than one dental plan (or a medical plan that offers dental coverage), Delta Dental will coordinate benefits with the other carrier. The total payments from both carriers cannot exceed their allowable charges for the service. 

SUBROGATION
A special rule applies if: 

  • a third party is held liable and pays for an injury that requires you or an eligible dependent to receive dental care; and
  • you also received a claim payment from Delta Dental for that care.

In the above case, you will be required to reimburse Delta Dental for its claim payment.

DENIED CLAIMS
You can appeal a denied claim. The claim appeal procedures are described in the Administrative Information section of this Summary Plan Description (SPD).