Enrollee forms delta dental for individuals and families. Deltacare usa provided by delta dental of new york. When you enroll in deltacare usa, you select a primary care dentist from the list of participating dentists. Offered through delta dental insurance company, the deltacare usa program is designed to encourage you and your. Getting the most from your deltacare coverage deltacare is designed to provide comprehensive, quality care through the deltacare network. Lingual deviation hld index california modification score sheet form. Deltacare offers members simplicity and value deltacare is an innovative dental plan that provides you with comprehensive care at a significantly lower cost than most other dental planswhich means great value for you. Delta dental individual and familysm benefit summary. Deltacare usa southern california ibewneca trust funds. Each plan provides coverage for services performed by outofnetwork dentists but this coverage is at a lower level, which means that youll pay more. Handicapping labiolingual deviation hld index score sheet. You may call our customer service department at 8004224234 for updates to the provider list. The deltacare usa network consists of private practice dental.
Coverage under delta dental enhanced premier, delta dental ppo. The hld provides a single score, based on a series of measurements that represent the degree to which a case deviates from normal alignment and occlusion. Deltacare usa provided by delta dental of california find a deltacare usa dentist select from among the many conveniently located deltacare usa contracted general dentists. Box 1803 alpharetta, ga 30023 8004224234 deltacare usa plan cam57 combined evidence of coverage and disclosure form dental hmo program. Handicapping labiolingual deviation hld index california modification score sheet you will need this score sheet and a boley gauge or a disposable ruler provider patient name. Or sccas14s24 welcome to deltacare usa quality, convenience, predictable costs deltacare usa administered by delta dental insurance company provides you and your family with quality dental bene. The deltacare usa individual dental program offered by delta dental of california provides comprehensive hmo dental care through a convenient.
New york state department of health bureau of dental. The deltacare usa program is designed to encourage you and your family to visit the. To find the most current listing of deltacare usa dental offices you can. The dentists are screened to ensure that the plan standards of quality, access and safety are maintained. Authorized agent for deltacare usa individual and family hmo dental insurance plans. You will pay an office visit fee and the listed copayment for the covered procedures you receive. With almost 2,600 general and specialist dentists, our network is one of the largest in california. An affiliate of delta dental plan of california select the customer service request for pmis deltacare and deltavision programs form. Handicapping labiolingual deviation hld index scoring instructions the intent of the hld index is to measure the presence or absence, and the degree, of the handicapped occlusion caused by the components of the index, and not to diagnose malocclusion. Pmi dental health plan 12898 towne center drive cerritos, ca 907038579. Or scgastd welcome to deltacare usa quality, convenience, predictable costs deltacare usa is a dental program that provides you and your family with quality dental bene. Once you have completed the required fields, select the submit button to send the form to pmis customer service department.
Deltacare usa provided by delta dental ofcalifornia. Deltacare usa plan features no deductibles, no clearly defined copayments no annual deductibles and no maximums low or no costs for many services such. Deltacare hmo dental plan southern california effective 11116111 services deltacare 10a deltacare b limitations preventive care periodic and comprehensive oral evaluation no cost no cost twice in a calendar year bitewing xrays no cost no cost twice in a calendar year for children through age 18, or once in a calendar year for adults ages 19 and over. Under the deltacare usa program, many services are covered at no cost, while others have copayments amount you pay your contract dentist for certain. These companies are financially responsible for their own products. Enroll in deltacare usa and youll enjoy these features. The plan is unique in its emphasis on preventive services, which are fully covered. If any office is closed to further enrollment, delta dental reserves the. All documentation must be completed, signed and dated by the treating orthodontistdentist. Participating deltacare usa dental offices consultorios. Box 1803 alpharetta, ga 30023 8004224234 combined evidence of coverage and disclosure form dental health care program f or eligible employees and dependents ca10a. Deltacare usa contract dentist after your plan effective date.
Administered by delta dental insurance company deltacare usa provided by delta dental of california find a deltacare usa dentist select from among the many conveniently located deltacare usa contracted general dentists. Deltacare usa delta dental smilecare deltas contracted dentists refuse to adhere to their agreement with delta. This condition is defined as the absence of incisal contact in the anterior region. Fill out the form, and well get back to you via email. Delta dental state of california delta dental insurance. Deltacare delta dental ppo university health plans. The program has been established and is administered in accordance with the provisions of a group dental service contract. The deltacare usa network consists of private practice dental facilities that have been carefully screened for quality. Delta dental of california 100 first street san francisco, ca 94105 administered by. You must receive treatment from your selected deltacare usa contract dentist.
This dental insurance plan provides coverage for one year. Please note that delta dental dentists are not necessarily deltacare usa dentists. Welcome to deltacare usa quality, convenience, predictable costs deltacare usa administered by delta dental insurance company provides you and your family with quality dental bene. Delta dental insurance company 1 sanctuary parkway, suite 600 alpharetta, ga 30009. Deltacare hmo dental plan southern california effective 11116111 services deltacare 10a deltacare b limitations preventive care periodic and comprehensive oral evaluation no cost no cost twice in a calendar year bitewing xrays no cost no cost twice in a calendar year for children through age 18.
Alpha dental of arizona, inc ca delta dental of california. Orthodontic services for children under the age of nineteen 19 for severe and handicapping malocclusion as defined by hld index score of 22 andor one or more auto qualifier. Welcome to deltacare usa quality, convenience, predictable costs deltacare usa administered by delta dental insurance company provides you and your family with quality dental benefits at an affordable cost. All measurements are made with a scaled millimeter ruler. The university of california this booklet is a combined evidence of coverage and disclosure form eoc for your deltacare usa dental hmo programprogram provided by delta dental of california delta dental. Record all measurements in the order given and round off to the nearest millimeter mm. Medical dental handicapping labiolingual deviation index.
With more than 3,800 general and specialist dentists, the deltacare usa network is one ofthe largest dental networks in california. The network is composed of established dental professionals. The intent of the hld index is to measure the presence or absence, and the degree, of the handicap caused by the components of the index, and not to diagnose malocclusion. Call customer service for help in finding a deltacare dentist. Deltacare usa family dental hmo for small businesses combined evidence of coverage and disclosure form provided by. The deltacare usa program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. Welcome to deltacare usa quality, convenience, predictable costs deltacare usa is a dental program that provides you and your family with quality dental benefits at an affordable cost.
Delta dental of california applicantdependent information. Deltacare usa is underwritten in these states by these entities. Deltacare usa network consists of private practice dental facilities that have been carefully screened for quality. When you enroll, you select a contract dentist to provide services.
Deltacare usa provided by delta dental of california. What if im currently seeing a dentist under one plan and i change plans to the deltacare usa plan, but would like to maintain the same dentist. My dentist is a delta dental dentist but is not on the list of deltacare usa dentists. Programprogram provided by delta dental of california delta. Delta dental of massachusetts ppo, premier and deltacare insurance products are offered by dental service of massachusetts, inc. Delta dental of california today announced a new preventive treatment service through virtudent, inc. All measurements are made with a boley gauge or a disposable ruler. Enroll online at or call 877888feds 8778883337, tty 8778895680. Handicapping labiolingual deviations form the hld index no. In florida, deltacare usa is underwritten and administered by delta dental insurance company.
Delta dental insurance company provides benefits as a prepaid limited health services organization as described in chapter 636 of the florida statutes. How to find a deltacare dentist california state university. Budgetfriendly costs with your deltacare usa plan, there are no surprises. Delta dental of california 17871 park plaza drive, suite 200. In california, deltacare usa is underwritten by delta dental of california and administered by delta dental insurance company. Deltacare usa individualfamily dental program caa54. Delta dental of california 17871 park plaza drive, suite 200 cerritos, ca 90703 administered by. Excluded employees 1, innetwork delta dental ppo dentists 2, outofnetwork non. As long as the dentist is part of the deltacare usa network and is.
With more than 3,800 general and specialist dentists, the deltacare usa network is one of the largest dental networks in california. Deltacare usa program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. Aug 30, 2012 deltacare usa delta dental smilecare deltas contracted dentists refuse to adhere to their agreement with delta. If medical necessity is based on a medical condition as stated in csr 7035. If a local contracted deltacare usa specialist cannot be found and the patient needs nonemergency specialty care, please mail or transmit the completed referral form and necessary xraysdocumentation to deltacare usa. Often create false codes for bogous charges cerritos, california general comment. Caa22 combined evidence of coverage and disclosure form provided by.