How Your Marketplace Plan Works

Visiting a Non-network Dentist

Exceptions to out-of-network liability

If you receive care from a non-network Dentegra dentist:

  • Out-of-network benefits apply.
  • Non-Dentegra dentists have no fee agreements with us. Claims costs are typically highest when you visit a non-Dentegra dentist.

Out-of-network financial liabilities

You may have additional out-of-pocket costs after receiving services from an out-of-network dentist (a non-Dentegra dentist). And you may need to pay the dentist before a claim is submitted. Please refer to your plan Policy or Evidence of Coverage for more details.

Balance billing

Dentegra dentists agree to accept Dentegra’s contracted fees and to not bill above those amounts. If a Dentegra dentist bills you for amounts above our payment and your coinsurance, the dentist is balance billing and violating his/her contract with us. Non-contracted dentists are under no obligation to limit the amount of their fees, so you can be balance billed.

Claim Submission

How to submit a claim

If you receive services from a non-Dentegra dentist who does not file a claim for you, you can submit the claim directly to us. Your dentist should provide the following:

  • Dentist’s name, address and phone number, and a description of each service, its procedure code and fee
  • Dentist’s National Provider Identifier (NPI)
  • Tax identification number (TIN)
  • State license number
  • Specialty code

Completed claim forms should be sent to:

Dentegra Insurance Company
P.O. Box 1850
Alpharetta, GA 30023-1850

New York enrollees should submit claims to:

Dentegra Insurance Company of New England
P.O. Box 1850
Alpharetta, GA 30023-1850

Time limit for submitting claims

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.

How to get a claim form

Download a claim form here: Dentegra claim form

How to contact us

Dentegra Insurance Company
P.O. Box 1850
Alpharetta, GA 30023-1850
Customer Service
800-471-0284
Monday through Friday between 7 AM to 8 PM, Eastern Time.

New York enrollees

Dentegra Insurance Company of New England
P.O. Box 1850
Alpharetta, GA 30023-1850
Customer Service
800-471-0284
Monday through Friday between 7 AM to 8 PM, Eastern Time.

Grace Periods and Claims Pending Policies

What is the grace period for Marketplace plans?

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 full month’s premium, the grace period is 30 days.

Explanation of claims pending

Claims do not go into a pending status.

How claims pay during the grace period

If you pay in full all outstanding premium payments before the end of the grace period, you can retain dental coverage and claims will be paid. If you fail to pay the amounts owed, Dentegra will terminate coverage and claims will be denied.

Enrollees with the Advance Premium Tax Credit:
Claims accrued during the second and third months of the 90-day grace period will be paid if you make your premium payment.

Enrollees without the Advance Premium Tax Credit:
Claims accrued during the 30-day grace period will be paid if you make your premium payment. Claims submitted after this timeframe will be denied if you haven’t made your premium payment in the 30-day grace period.

Retroactive denials of claims

Claims are not retroactively denied; they will either be paid or denied at the time of submission.

Recouping Overpayments

How to obtain a refund

Individual Plan:
If you believe you have overpaid your premium, please call or write to us. We look forward to clarifying any billing inquiries. If we identify that a refund is due, we will issue a refund within 30 days.

Group Plan:
If you believe you have overpaid your premium, please contact your local Marketplace/Health Care Exchange to research and remedy any overpayments.

Contact us at:

Dentegra Insurance Company

Customer Service
800-471-0284
Hours: 7 AM to 8 PM Eastern Time

TTY: 711

Claims

Dentegra Insurance Company
P.O. Box 1850
Alpharetta, GA 30023-1850

New York enrollees

Dentegra Insurance Company of New England

Customer Service
800-471-0284
Hours: 7 AM to 8 PM Eastern Time

TTY: 711

Claims

Dentegra Insurance Company of New England
P.O. Box 1850
Alpharetta, GA 30023-1850

Medical Necessity and Prior Authorization

Prior authorization

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

If prior authorization is not obtained

Claims for medically necessary pediatric orthodontic services will be denied.

Time frame for prior authorizations

The amount of time it takes to receive your prior authorization varies, depending on your dentist and treatment plan. Prior authorizations are completed by Dentegra within three days on average; however, the process can take up to two to three weeks. This timeframe may vary based on state-specific laws.

Information on Explanation of Benefits (EOBs)

What’s an Explanation of Benefits (EOB) and when is it sent?

An Explanation of Benefits (EOB) is a statement created after a dental visit. It lists the treatments and/or services you received, the amount the plan pays and your financial responsibility as outlined under your plan.

After a claim is processed, we will send you and the treating dentist an Explanation of Benefits (EOB) statement that explains the services provided, costs of the treatment and any fees you owe your dentist. Your claims information is automatically available online. For added convenience, sign up for “Online with Email Alerts” under “My Profile” to go paperless and receive an email when a new statement is available.

What’s in my Explanation of Benefits?

Here’s what you see on your EOB.

Submitted fee: How much the procedure would cost 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.

Amount applied to 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.

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

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

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

Coordinating Benefits with Two Dental Plans

What is Coordination of Benefits (COB)?

Coordination of benefits exists when you are covered by another plan and determines which plan pays first.

Dentegra doesn’t coordinate coverage with other policies for Individual plans. If you’re also covered by another plan issued by another carrier, other benefits may be available under your other carrier. Please check with your other carrier to learn about their coordination of coverage policies.

If you have a group plan, be sure to let your dentist know if you are covered under another dental plan, and the dentist will include COB information on the claim form. We will coordinate with your other carrier to share the cost of your treatment. We will process the claim based on the COB information and update our claims processing system.