How your Health Care Exchange (Marketplace) plan works

Dentegra dentists will handle all claims and paperwork for you. However, if you visit a non-Dentegra dentist, you may need to file the claim yourself.

If you need to file a claim form:
 

1. Download the  Dentegra claim form (PDF, 247 KB)
2. Obtain the following information from the provider( note that a Statement of Treatment provided by your dentist may not include all the information we need):
   
   
   • Dentist’s name, address and phone number
   • Dentist’s National Provider Identifier (NPI)
   • Tax identification number (TIN)
   • State license number
   • Specialty code
   • Description of each service that the dentist performed, along with the procedure code and provider’s fee
     
     
3. Complete and print the paper form.
4. Mail the completed claim form to:
   
   

   Dentegra Insurance Company (New York state residents: address to Dentegra Insurance Company of New England)
   P.O. Box 1850
   Alpharetta, GA 30023-1850

   Be sure to keep a copy of the form for your records.
   
   

If you have any questions about how to file a claim for reimbursement, contact Customer Service at 877-280-4204, Monday through Friday, 8 am to 9 pm Eastern time.

The standard filing is 12 months from the date of service. Our agreement with contracted dentists is that we may deny payment of a dental claim submitted more than 12 months after the date the service was provided.

To receive reimbursement for out-of-area emergency care, you simply submit a copy of the itemized treatment form from the attending dentist to Dentegra within 90 days of treatment. Depending on your plan benefits, copayments may apply. The deadline for submitting a specialty care or out-of-area emergency claim is 365 days, except in California where it is 410 days.

A retroactive denial is the reversal of a claim that Dentegra has already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment.

Retroactive denials may occur, for example, when a claim was paid during the second or third month of a grace period or when a claim was paid for a service for which you were not eligible.

To help avoid a retroactive denial:

• Pay your premiums on time and in full
• Talk to your provider about whether the service performed is a covered benefit
• Obtain your dental services from an in-network provider

Dentegra does not terminate coverage immediately for non-payment. We allow a grace period of 90 days if you receive an Advance Premium Tax Credit (APTC) and have paid at least one full month’s premium during the year. If you do not receive an APTC and have paid one month’s premium, the grace period is 30 days.

Claims do not go into a pending status.

A pending claim is a claim that has been submitted but not yet paid or denied.

You are required to pay your premium by the scheduled due date. If you do not, your coverage could be canceled.

For most individual dental insurance plans, if you do not pay your premium on time, you'll receive a 30-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium.

Any claims submitted for you during the grace period will be placed on hold. No payment will be made to the provider until your delinquent premium is paid in full.

If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, Dentegra will pay all claims for covered services you received during the grace period that are submitted properly.

For Health Care Exchange (Marketplace) plans with an advance premium tax credit

If you're enrolled in an individual dental insurance plan offered on the Health Care Exchange (Marketplace) and you receive an advance premium tax credit (APTC), you'll get a three-month grace period and Dentegra will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of the grace period, any claims you incur will be placed on hold.

If you pay your full outstanding premium before the end of the three-month grace period, Dentegra will pay all claims for covered services that are submitted properly for the second and third months of the grace period.

If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will be terminated and Dentegra will not pay for any on-hold claims submitted for you during the second and third months of the grace period. Your provider may bill you for those services.

If you believe you have overpaid your premium, contact us as soon as possible. If we identify that a refund is due, we'll issue it to you within 30 days.

Call 888-857-0328 (TTY: 711), Monday through Friday, 8 am to 9 pm Eastern time.

Or write:

Dentegra Insurance Company (New York state residents: address to Dentegra Insurance Company of New England)
P.O. Box 1850
Alpharetta, GA 30023-1809

If you have a pediatric dental plan and your child needs orthodontic services, your provider will need to obtain prior authorization from us to establish that the treatment is medically necessary. This could take up to two or three weeks, depending on the provider and treatment plan (Dentegra typically completes prior authorizations within three days on average).

Without prior authorization, claims for pediatric orthodontic services will be denied, even if they're medically necessary.

Pediatric plans that cover medically necessary orthodontic services require pre-authorization before treatment is started.

Your dentist will submit a request for pre-authorization to Dentegral, along with all necessary x-rays and records for the recommended specialty procedures. Once we receive the request for pre-authorization:
 

• A claims processor will verify the accuracy of the information and forward it for review.
• Either a dental auditor or dental consultant will review the request based on the level of clinical complexity involved. Dental procedures requiring professional judgment are reviewed by one of our in-house dental consultants to determine benefits. Dental consultants are practicing dentists employed by Dentegra.
• Once the dental auditor or dental consultant approves the request, we send an approval to your dentist.
• In the event of a dental emergency, we will give your dentist a specialist referral authorization over the telephone. The specialist is then advised of the approved procedure(s) and given instructions for claim submittal.
• When we receive the resulting claim, a claims processor verifies the accuracy of the information and enters the claim in the system for payment. Claims that have not been pre-authorized are denied.
   

If an oral surgeon, endodontist, periodontist or pediatric dentist is not available in your area, you are free to choose a qualified out-of-network specialist.

You'll receive a claims statement — sometimes called a benefits statement or Explanation of Benefits (EOB) — from Dentegra after you or a family member visit a provider and a claim is filed. The claims statement lists:

• Treatments and services you received
• Amount the plan pays
• Your financial responsibility for fees owed to your provider
  
  

After we process a claim, the claims statement is available in your online Dentegra account in the Claims section.

To set up email notifications so you know when an EOB is available for you to review, log in to your account, go to My account, then User settings. Under Go paperless, select Online. 

Know the terms in your EOB

Here are some terms you'll see in your claims statement/EOB:

Submitted fee. Cost of the procedure if you didn’t have insurance.

Accepted fee. The total owed to the dentist, including your share and the amount paid by insurance.

Maximum contract allowance. The total on which Dentegra bases its portion of the fee. Note: If you go to an out-of-network dentist, this amount may be lower than the accepted fee.

Contract benefit level. The percent of the maximum contract allowance that’s paid by your dental plan.

Total claim deductible. How much of your deductible you have fulfilled with the given procedure(s). Note: Not all plans include a deductible (a fixed dollar amount you are required to pay before your coverage applies). A deductible may also be waived for Diagnostic & Preventive Services.

Dentegra pays. The amount your dentist is paid through your dental plan.

Enrollee pays. How much you owe the dentist: This is what’s left over from the accepted fee after your insurance covers its portion.

Find more insurance terms and definitions on the Glossary page.