Using Private
Pay Form
If a Delta Dental Medicare Advantage member requires services not covered in their benefit plan, be sure to obtain a signed private pay form from that member or member’s guardian before rendering services.
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 and is considered a non-covered service.
Payment for non-covered services is the responsibility of the member or the responsible party. Before providing non-covered services, the cost of the non-covered service(s) must be discussed with the member or responsible party. Payment for non-covered services can only be collected when the member or member’s guardian signs a private pay form (to be signed on the day non-covered services are rendered), where they agree in writing to pay for the non-covered (or alternate) service(s).
You may use any form for the private pay form and should include the cost associated with the non-covered service(s), the responsible party’s signature and the date. (See Delta Dental’s sample form here). The form should be maintained in the patient’s record.
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Did you know Delta Dental offers free CE credits?
Continuing Education credits are a requirement for licensure and Delta Dental wants to make your CE efforts painless by offering free online courses through our Provider Learning portal.
Any dentist, hygienist, dental assistant or office staff member who is a Delta Dental participating provider or works for a Delta Dental participating provider may take these courses.
These courses are available 24/7 to help you conveniently and cost-effectively comply with ongoing regulatory demands so you can get quickly get back to what you would rather do – serve patients.
Courses include an informational video on each topic and an assessment. Complete them at your own pace. Upon completion, you will receive a certificate.
Check out the latest course offerings for Indiana.
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Are you using the new ADA form?
A new version of the American Dental Association (ADA) form is now available and preferred.
While previous ADA claim form versions will still be accepted, Delta Dental is currently processing the new ADA claim form and it’s recommended you use the most up-to-date version.
You may now submit claims through Dental Office ToolkitTM(DOT) with form attachments.
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Lend us your voice
We’re listening: Join Delta Dental’s oral health advisory panel
We’re looking for providers, hygienists, assistants and office managers interested in helping to shape the next iteration of provider relations and communications efforts, including the recently launched Best Practice journal.
Whether you represent Michigan, Ohio, or Indiana, we want to hear from you. Meetings will be held virtually and participants will earn $200 per session, and we’ll conduct up to six per year.
If you’re interested in joining us to collaborate, share feedback, experiences and ideas for making positive change in the dental benefits industry now and into the future, visit this link and let us know. One individual per dental office is eligible to participate.
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