Guide for Dental Providers in the DeltaCare USA Network

What is DeltaCare USA?

DeltaCare USA is a dental HMO (Health Maintenance Organization) plan offered by Delta Dental, designed to provide comprehensive dental care through a network of contracted providers. Unlike traditional PPO plans, DeltaCare USA requires members to select a primary care dentist from its network, and all covered services must be provided or referred by this dentist. Understanding the structure and requirements of DeltaCare USA is essential for dental offices to maximize patient care and streamline administrative processes.

Joining and Participating in the DeltaCare Network

Becoming a DeltaCare provider involves a credentialing process, contract review, and ongoing compliance with Delta Dental’s standards. Here’s how successful practices approach network participation:

• Credentialing: Submit all required documentation, including state licenses, malpractice insurance, and provider background information. Ensure accuracy to avoid delays.
• Contract Review: Carefully review fee schedules, covered CDT codes, and administrative requirements. Consult with a dental billing expert if needed.
• Onboarding: Train your front office and billing team on DeltaCare-specific processes, such as patient eligibility verification and referral protocols.

Key Considerations for DeltaCare Providers

DeltaCare USA operates differently from fee-for-service plans. Providers should be aware of:

• Capitation Payments: DeltaCare providers receive a fixed monthly payment per assigned patient, regardless of utilization. Monitor capitation reports to reconcile payments and patient rosters.
• Referral Management: All specialty care requires a referral from the patient’s primary DeltaCare dentist. Use standardized referral forms and track referral outcomes to ensure compliance and continuity of care.
• Patient Rosters: Review monthly rosters to confirm active DeltaCare patients. Address discrepancies promptly with Delta Dental to avoid billing issues.

Billing and Reimbursement under DeltaCare

Billing under DeltaCare USA differs from traditional indemnity plans. Here are best practices for efficient revenue cycle management:

• Insurance Verification: At each visit, verify DeltaCare eligibility and plan details using the Delta Dental provider portal. Confirm the patient’s assigned provider and covered services.
• CDT Code Utilization: Use the most current CDT codes for all procedures. Only bill for services covered under the DeltaCare contract; non-covered services require patient consent and payment arrangements.
• Encounter Forms and EOBs: Submit encounter forms for all visits, even if no additional payment is due. Review Explanation of Benefits (EOBs) for accuracy and reconcile with capitation payments.
• Claim Appeals: If a service is denied, follow DeltaCare’s appeal process. Submit supporting documentation, such as clinical notes and radiographs, within the required timeframe.
• Accounts Receivable (AR) Monitoring: Regularly audit AR to ensure all capitation and supplemental payments are received. Address underpayments or discrepancies promptly.

Resources for DeltaCare Dentists

DeltaCare providers can access a range of resources to support efficient practice management:

• Provider Portal: Use the Delta Dental provider portal for eligibility checks, roster downloads, and payment reports.
• Provider Manuals: Reference the DeltaCare provider manual for up-to-date policies, covered services, and billing guidelines.
• Continuing Education: Participate in Delta Dental webinars and training sessions to stay current on network updates and best practices.
• Support Contacts: Maintain contact information for DeltaCare provider relations and claims support to resolve issues efficiently.

By understanding DeltaCare USA’s unique structure and following proven billing and administrative workflows, dental practices can optimize patient care, minimize denials, and maintain a healthy revenue cycle within the network.