Dental insurance information
and summary of benefits

General Information

Participating Dentists’ (Premier) Network
You’ll get the best value from your Northeast Delta Dental program when you receive your dental care from one of Northeast Delta Dental’s Participating Dentists:

No Balance Billing: Because Participating Dentists accept their usual filed fees for services, and agree not to charge any difference to their Delta Dental patients, you will typically pay less when you visit a participating dentist.

No Claims Paperwork: Participating Dentists will prepare and submit claims for you.

Direct Payment: Northeast Delta Dental pays Participating Dentists directly, so you don’t have to pay the covered amount up front and wait for a reimbursement check. You may be asked to pay up front any amount due for any deductible, coinsurance, or non-covered services.

To find out if your dentist is part of the Northeast Delta Dental network, try the following: call your dentist, check our Participating Dentists Directory, visit our web site at www.nedelta.com ., or call our Customer Service Department at 1-800-832-5700.

Claim Process for Participating Dentists
Present your ID card to the dentist at the time of your visit.

The dentist will submit your claim to Northeast Delta Dental (claims for any of your covered dependents should be submitted under your Social Security number).

Northeast Delta Dental will send you a Notification of Benefits (N.O.B.) detailing what has been processed under your plan’s coverage. You are responsible to pay any remaining balance directly to the dentist.

Non-Participating Dentists
Delta Dental provides coverage regardless of your choice of dentists, participating or not. When visiting a non-participating dentist, you may be required to submit your own claim form (available from your employer) and pay for services at the time they are provided. All claims should be submitted to Northeast Delta Dental. Payment for services rendered by a non-participating dentist will be based upon the amount that the majority of participating dentists charge for those services. The N.O.B. and claim payment will go directly to you (unless you assign benefits to your Maine Non-Participating Dentist). You will be responsible for any remaining balance.

Out-Of-Tri-State Area
Delta Dental provides coverage for treatment received outside the tri-state area of Maine, New Hampshire, and Vermont. When visiting a dentist outside the tri-state area, you may be required to submit the claim to Northeast Delta Dental and pay for the services at the time they are provided. Payment for these services will be based upon the dentist’s actual charge up to a maximum of the Reasonable and Customary allowance in the zip code in which the services were provided. The payment will be made to the dentist unless the claim Northeast Delta Dental receives is marked "Paid." You will be responsible for any remaining balance.

Identification Cards
Two identification cards from Delta Dental will be produced and distributed shortly after your enrollment. Both cards are issued in your name but can be used by any family member covered under your plan.

Dental Plan Description Booklet
You will receive a Dental Plan Description booklet shortly after your enrollment. This booklet describes your dental benefits and explains how to use them. Please read it carefully to understand the benefits and provisions of your Northeast Delta Dental benefits.

Coordination of Benefits
When a covered individual under this plan has additional group coverage, the Coordination of Benefits (C.O.B.) provision described in your Dental Plan Description booklet will determine the sequence and extent of payment. If you have any questions about C.O.B., please contact our Customer Service Department at 1-800-832-5700.

Special Claims
All claims must be submitted to Northeast Delta Dental within two years of the date of service.

If a claim is denied, you can request an appeal by writing to Northeast Delta Dental within six months of receiving your Notification of Benefits. Send appeals to: Northeast Delta Dental, P.O. Box 2002, Concord, NH 03302-2002. Consult your Dental Plan Description booklet for further details.

Where To Get More Information
If you have any questions, please contact Northeast Delta Dental’s Customer Service Department at 1-800-832-5700.

THIS INFORMATION SHOULD BE USED ONLY AS A GUIDELINE FOR YOUR DENTAL BENEFITS. FOR DETAILED INFORMATION ON YOUR GROUP’S TERMS, CONDITIONS, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO YOUR DENTAL PLAN DESCRIPTION BOOKLET.

Northeast Delta Dental
P.O. Box 2002
Concord, NH 03302-2002
www.nedelta.com

Summary of Benefits for the Episcopal Diocese of Maine

Group #6263

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