Illinois Dentists: Collecting Payments Up Front from State of Illinois Dental Plan Members

In an effort to ensure all dentists are aware of our process in assigning benefits to network and non-network dentists (when requested by the member), we are issuing this update.

As a reminder, the State of Illinois is a self-funded plan and as such, Delta Dental of Illinois reimburses dentists once it receives funding from the State. Delta Dental of Illinois does not control the timing or funding of claims payments to State of Illinois dental members or the dentists who treat them.

Please note: Illinois state law and Delta Dental of Illinois’ network dentist policy regarding assignment of benefits and amounts that can be collected upfront from State of Illinois Group Dental Plan members have not changed.

Delta Dental Network Dentists

In accordance with the Delta Dental network dentist agreement, State of Illinois Group Dental Plan members who receive services from Delta Dental network dentists cannot be charged upfront for any other amounts other than the following:

• Applicable deductible
• Services not covered by the plan
• Amounts greater than the member’s Schedule of Benefits but up to the dentist’s contracted network amount
• Any amounts exceeding the annual benefit maximum

Non-Network Dentists

In accordance with State of Illinois legislation, if a State of Illinois Group Dental Plan member receives services from a non-network dentist and elects assignment to that dentist, the dentist cannot charge the member upfront for any other amounts other than the following:

• Applicable deductible
• Services not covered by the plan
• Amounts greater than the member's Schedule of Benefits but up to the dentist's contracted network amount
• Any amounts exceeding the annual benefit maximum

If a State of Illinois Group Dental Plan member uses a non-network dentist and does not elect to assign benefits, payments issued by Delta Dental of Illinois will be sent directly to the member and the member will be responsible for paying the dentist up front, if requested by the non-network dentist, for treatment rendered.

Background on SOI Network Policy, Claims Payments, and More

• State of Illinois Legislation Regarding Assignment of Benefits to Non-Network Dentists for State of Illinois Group Dental Plan

  According to state law, effective August 2012, State of Illinois Group Dental Plan members and their dependents can assign their dental benefits to non Delta Dental network dentists. The legislation states that if a dentist accepts assignment of benefits, he can only collect any deductibles, copayments or other charges that will not be reimbursed by the dental plan at the time of service.

  For self-insured groups such as the State of Illinois Group Dental Plans, Delta Dental of Illinois usually does not assign benefits to dentists who do not participate in our networks. However, as a result of this legislation, State of Illinois Group Dental Plan members may now elect to have reimbursement sent directly to a non-network dentist

  The member must consent to authorize payment of benefits directly to the non-network dentist and the non-network dentist must agree to not collect any payment from the member at the point of service other than any applicable fees such as deductibles, copayments and amounts over the Schedule of Benefits.

  If a member uses a non-network dentist and does not elect to assign benefits, payments issued by Delta Dental of Illinois will be sent directly to the member and the member will be responsible for paying the dentist up front, if requested by the non-network dentist, for treatment rendered.

• Delta Dental Network Policy

  Network dentists (dentists who are contracted to participate in Delta Dental PPO and/or Delta Dental Premier networks) will receive benefit payment directly from Delta Dental of Illinois for all patients covered by the State of Illinois Group Dental Plans, as they do now for all Delta Dental of Illinois members. The member is only responsible for the applicable deductible, services not covered by the plan, amounts greater than the member’s Schedule of Benefits but up to the dentist’s contracted network amount, and any amounts exceeding the annual benefit maximum. In accordance with the network dentist agreement, members cannot be charged upfront for any other amounts.

  The State has worked with Delta Dental of Illinois to support a network-based plan and has expedited claim reimbursement to Delta dental network dentists.

• State of Illinois Claims Payments

  Since the State has a self-insured/self-funded dental plan, Delta Dental of Illinois is only able to pay State of Illinois member’s claims when the State funds those claims.

  As you know a budget was approved in July 2018, and the State has started funding the backlog of claims. Claim payments are made when funding has been approved from the State for claims that are received and processed through specific dates, starting with the oldest claims first.

  We understand that the budget impasse has been extremely difficult for those impacted by the delay in passing a balanced budget. The budget delay and resulting backlog of bills has placed great strain on our State of Illinois dental plan members and the dentists who treat them. Again, we pay dental claims as we receive funding from the state.

  As a reminder, Delta Dental network dentists cannot bill you upfront for any charges other than applicable deductible and coinsurance amounts. However, non-network dentists may bill you upfront. If you need assistance locating a Delta Dental network dentist, please let us know. If a Delta Dental network dentist attempts to bill you upfront for any charges other than your applicable deductible or coinsurance, please notify us immediately.