To use your State Dental Plan, follow these steps:

Please read this section carefully to familiarize yourself with the benefits, payment mechanisms and provisions of your State Dental Plan.

1. Make an appointment with the dentist of your choice and tell him or her that you are covered under the State Dental Plan, administered by Delta Dental Plan of Michigan. Claim forms are provided to every dental office in Michigan for your convenience. You or someone in the dental office must fill in the information portion of the claim form with the following:

• Your (employee’s) full name and address.
• Your (employee’s) Social Security number.
• The name and date of birth of the person receiving dental care.
• The group name (State of Michigan) and the group number (8700).

If your dentist is not located in Michigan or if your dentist cannot provide you with a claim form, claim forms are available by calling Delta Dental at 1-800-524-0150.

Claims, adjustment requests and completed information requests should be mailed to Delta Dental, P.O. Box 9085, Farmington Hills, Michigan 48333-9085.

2. If your dentist is not familiar with your dental plan or has any questions regarding the Plan, have him or her contact Delta Dental Plan of Michigan by writing to P.O. Box 30416, Lansing, Michigan 48909-7916 or by calling Delta Dental’s toll-free number 1-800-462-7283.

3. After a routine oral examination, your dentist will list any necessary treatment on your claim form. If the cost of these services is less than $200 or is limited to emergency care, predetermination is not necessary.

Your State Dental Plan requires that you have your dentist forward your treatment plan (claim form) to Delta Dental for predetermination before he or she performs any services where the total charges will exceed $200. This predetermination procedure will advise you and your dentist of what benefits are covered, the State Dental Plan financial obligation under the terms of your contract, and what you will have to pay.

Because predetermination requires a minimal amount of time, it normally will not interfere with scheduling your appointments. You and your dentist should review your Predetermination Notice before your dentist proceeds with treatment.

4. Once treatment has been completed, your dentist will submit the claim form to Delta Dental for payment.

5. Payment is made as follows:

a) If the treating dentist is both a PPO member dentist and a Delta Dental contracting dentist, Delta Dental will pay directly to the dentist the applicable percentage (as shown on page 11) of the following amount, whichever is less:

• the fee submitted by the dentist;
• the fee listed on the PPO member dentist’s schedule; or,
• the usual, customary and reasonable fee as filed with and accepted by Delta Dental under the standard plan.

b) If the treating dentist is a PPO member dentist, but not a Delta Dental contracting dentist, Delta Dental will pay directly to the dentist the applicable percentage (as shown on page 11) of the following amount, whichever is less:

• the fee submitted by the dentist; or,
• the fee listed on the PPO member dentist’s schedule.

c) If the treating dentist is a Delta Dental contracting dentist in the Standard plan but not a PPO member dentist, Delta Dental will pay directly to the dentist the applicable percentage under the Standard plan (as shown on page 11) of the following amount, whichever is less:

• the fee submitted by the dentist; or,
• the dentist’s usual, customary and reasonable fee as filed with and accepted by Delta Dental under the standard plan.

You will be responsible for paying the dentist any appropriate copayment.

d) If the treating dentist is not contracting in either the Standard or PPO plan, Delta Dental will pay directly to you the applicable percentage under the Standard plan (as shown on page 11) of the following amount, whichever is less:

• the fee submitted by the dentist; or,
• Delta Dental’s Non-contracting dentist fee.

You will be responsible for paying the dentist the amount charged.

e) For dental services rendered by an out-of-state dentist, Delta Dental will pay directly to you the applicable percentage under the Standard plan (as shown on page 11) of the following amount, whichever is less:

• fee submitted by the dentist; or,
• the usual, customary and reasonable fee in that area.

6. The State Dental Plan will not honor and no payment will be made for services if a claim for those services has not been received by Delta Dental more than one year following the year in which the services were completed.

7. If you have any questions about your State Dental Plan’s PPO and Standard benefits, please contact Delta Dental directly by calling toll-free 1-800-524-0150. This information is also available in alternative accessible formats upon request, call TTY/TDD at 1-517-349-6000.