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Know your Health Care Exchange (Marketplace) plan

Know your Health Care Exchange plan

Review important information about out-of-network benefits, claims and premiums for your Health Care Exchange (Marketplace) plan.

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When the unexpected happens, you might need to seek care from a provider who's not in the Dentegra network. That means:

  • Out-of-network services may not be covered
  • You might need to pay the full amount up front
  • Fees may be higher than the contracted fees for in-network care

Review your benefits and know what's covered. Log in to your account (you'll need to register if you haven't already) or refer to your policy document for details.

Balance billing

In-network providers agree to Dentegra's contracted fees and can't bill you for a higher fee.

Out-of-network providers, on the other hand, are free to charge higher fees and bill you for the extra amount — that's considered balance billing. You're responsible for paying whatever your plan doesn't cover.

Emergency care

If you're away from home and have a dental emergency, you might need to pay the provider up front. Review your benefits carefully to determine if your plan covers out-of-network emergency dental care.

The out-of-network provider may not file a claim for you. To apply for reimbursement, complete and submit a  claim form (PDF, 247 KB) to Dentegra. 

If an out-of-network provider doesn't file the claim, you can file it yourself. 

  1. Download the  Dentegra claim form (PDF, 247 KB)
  2. Obtain the following information from the provider:

    • Name, address and phone number
    • Description of each service, along with the procedure code and provider's fee
    • Tax identification number (TIN)
    • State license number
    • Specialty code

  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.

 

File the claim as soon as possible after the service was provided. To ensure that you receive reimbursement, submit all claims within 12 months of the service.

If you don't pay your premium by the scheduled due date, Dentegra allows a grace period — the amount of time your plan will remain in force after the last unpaid premium was due. The grace period only applies if you paid your monthly premium at least once during the year.

The length of the grace period depends on whether you have an advance premium tax credit (APTC), sometimes called a subsidy.

Have an APTC?

Yes

Grace period after premium due date

90 days

Have an APTC?

No

Grace period after premium due date

30 days

If you pay all outstanding premium payments before the end of the grace period, you'll keep your dental coverage and all claims you submit for covered services during the grace period will be paid.

If you don't pay the outstanding premiums before the end of the grace period, Dentegra will terminate your coverage. The claims submitted during that period will be denied and you'll be responsible for paying for the services you received in full.

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.

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.

If you're covered by both your Dentegra plan and another dental plan (for example, your spouse's or partner's plan), check with the other insurance company to learn about their coordination of coverage policies.

Let your provider know if you are covered by another plan. Dentegra doesn’t coordinate coverage with other policies for individual plans. 

For more information about dual coverage, review your evidence of coverage. 

Questions?

Visit our FAQs page or contact us.