Administrative Manual
Delta Dental of Kansas’ Mission Statement:
Excellence. Service. Value. Making a difference for our constituents, communities, and employees.
-----------------------------------------------------------------------------------------------------------------------------------------------Delta Dental of Kansas
1619 N. Waterfront Parkway
P.O. Box 789769
Wichita, KS 67278-9769
Sales & Marketing:
Toll Free:
Fax:
(316) 264-8413
(800) 264-9462
(316) 462-3329
Table of Contents
General Administrative Information
Eligible Employees.............................................................................................................................................. 1
Eligible Dependents ............................................................................................................................................ 1
New Employee Waiting Period ............................................................................................................................ 1
Reporting Eligibility To DDKS ........................................................................................................................... 1
Adding A New Employee To The Plan ................................................................................................................ 1
Terminating An Employee From The Plan ........................................................................................................... 1
Loss of Eligibility for Employees Who Terminate Employment ........................................................................... 1
Eligibility Errors.................................................................................................................................................. 2
Continuing Coverage For Terminated Employees ................................................................................................ 2
Claim Forms ....................................................................................................................................................... 2
Description Of Dental Care Coverage Certificates ............................................................................................... 2
Identification Cards ............................................................................................................................................. 2
Online Customer Service ..................................................................................................................................... 2
How To Order Forms .......................................................................................................................................... 2
Monthly Dental Billing Statement
Statement Of Account ......................................................................................................................................... 4
Subscriber Update Listing ................................................................................................................................... 4
How Do We Process Billings With DDKS? ......................................................................................................... 5
SAMPLE: Statement of Account (Appendix 2-A) ............................................................................................... 6
SAMPLE: Subscriber Update Listing (Appendix 2-B) ........................................................................................ 7
Eligibility Transmittal Form
Eligibility Transmittal ......................................................................................................................................... 8
Eligibility Transmittal Form (Appendix 2-C) ....................................................................................................... 9
Change Form Information
SECTION 1 - Employee Information ................................................................................................................... 10
SECTION 2 - Dependent Information .................................................................................................................. 10
SECTION 3 - Other Insurance Information .......................................................................................................... 10
SECTION 4 - Changes ........................................................................................................................................ 10
SECTION 5 - Signature/Authorization for Enrollment/Change(s) ........................................................................ 10
Table of Contents
Change Form Information (Continued)
SECTION 6 - Waiver of Coverage ...................................................................................................................... 10
Enrollment/Change Form (Appendix 3-A) ........................................................................................................... 11
How To Use Your Dental Benefits Plan
Predetermination of Benefits ............................................................................................................................... 12
Dentist’s Payments .............................................................................................................................................. 12
SAMPLE: Explanation of Benefits (EOB) .......................................................................................................... 13
Explanation of Benefits - TERMS ....................................................................................................................... 14
Patient Expenses.................................................................................................................................................. 15
Continuation of Group Dental Coverage (COBRA)
COBRA Eligibility .............................................................................................................................................. 16
Self Administration of COBRA ........................................................................................................................... 16
DDKS Billing of COBRA ................................................................................................................................... 16
Termination of COBRA ...................................................................................................................................... 16
Application for Continuation of Group Dental Coverage (Appendix 4-A) ............................................................ 17
COBRA Billing Designation (Appendix 4-B) ............................................................................................... 18
Forms
How To Order Forms .......................................................................................................................................... 2
Group Supply Order Form (Appendix 1-A) ......................................................................................................... 3
Eligibility Transmittal Form (Appendix 2-C) ....................................................................................................... 5
Enrollment/Change Form (Appendix 3-A) ........................................................................................................... 10
Application for Continuation of Group Dental Coverage (Appendix 4-A) ............................................................ 17
COBRA Billing Designation (Appendix 4-B) ...................................................................................................... 18
Contact Information ................................................................................................................................... 20
General Administrative Information for
Delta Dental of Kansas (DDKS)
Eligibility Transmittals should be mailed to the attention
of the Eligibility Department at P.O. Box 789769,
Wichita, KS 67278-9769 or faxed to the attention of the
Eligibility Department at (316) 462-3394, along with all
supporting documentation (i.e. Enrollment/Change
forms).
ELIGIBLE EMPLOYEES
Eligibility requirements are established by your
Agreement to Provide Dental Care Benefits (contract),
Section III.
ELIGIBLE DEPENDENTS
ADDING A NEW EMPLOYEE TO THE
PLAN
Dependent eligibility is governed by the Agreement to
Provide Dental Care Benefits—Section III, paragraphs 3
and 4.
New employees should complete the dental
Enrollment/Change form (see Appendix 3-A) at the
same time they complete their other employment
papers.
Physically or mentally handicapped children over the
maximum age for dependent children may remain
eligible under certain circumstances as identified in
Section IV (3d) of the Agreement to Provide Dental
Care Benefits.
The completed Enrollment/Change forms along with the
completed Eligibility Transmittal form (see Appendix 2C) should be mailed to the attention of the Eligibility
Department at P.O. Box 789769, Wichita, KS 672789769 or faxed to the attention of the Eligibility
Department at (316) 462-3394.
Dependents in military service are not eligible for
benefits.
An individual may not be covered both as an employee
and as a dependent. If both the husband and wife are
covered as employees, the children can be covered
under either the father’s or mother’s coverage, but not
both.
TERMINATING AN EMPLOYEE FROM
THE PLAN
On the Eligibility Transmittal form (see Appendix 2C), list all employees terminated during the past month
or scheduled for termination in the future.
NEW EMPLOYEE WAITING PERIOD
See WAITING PERIOD FOR NEW EMPLOYEES -Section I, paragraph 3 of the Agreement to Provide
Dental Care Benefits.
Eligibility Transmittals should be mailed to the
attention of the Eligibility Department at P.O. Box
789769, Wichita, KS 67278-9769 or faxed to the
attention of the Eligibility Department at: (316) 4623394.
REPORTING ELIGIBILITY TO DDKS
Each month you will receive a billing statement, which
includes a Subscriber Update Listing, showing any
changes made during the previous month. The
premium payment should be returned to DDKS with
the Statement of Account sheet (included with your
billing).
DD6-004 (01/21/2013)
LOSS OF ELIGIBILITY FOR EMPLOYEES
WHO TERMINATE EMPLOYMENT
Loss of eligibility will occur on the last day of the
month in which the employee was terminated, unless
otherwise noted in the Agreement to Provide Dental
Care Benefits.
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ELIGIBILITY ERRORS
IDENTIFICATION CARDS
Mail the appropriate forms (Eligibility Transmittal,
Enrollment/Change forms) to the attention of the
Eligibility Department at P.O. Box 789769, Wichita,
KS 67278-9769 or fax them to the attention of the
Eligibility Department at (316) 462-3394. Be sure to
indicate the actual effective date or termination date.
All notification of termination dates for employees
MUST reach DDKS within 30 days of the termination
date. No credit will be given for notices of employee
terminations received after 30 days.
While identification cards are not necessary for proof
of coverage, they are provided, usually with the
Description of Dental Care Coverage certificates.
These cards are printed with the employee’s name,
their member identification number, group name and
policy number.
ONLINE CUSTOMER SERVICE
DDKS continues to develop ways we can better serve
our customers online. Among the services
www.deltadentalks.com offers are online enrollment
through which benefits managers can update and verify
subscriber eligibility; online billing to reduce
paperwork and mailing time; and online benefits and
eligibility so employers and subscribers can quickly
check benefits, print personalized ID cards and print
claim and eligibility forms. Our website also has a
“Frequently Asked Questions” section where
employers and employees can find basic benefits
information and it offers “Locate a Dentist” to help
individuals find a Participating Dentist near their home
or work.
CONTINUING COVERAGE FOR
TERMINATED EMPLOYEES
Under the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA), eligible
employers must offer an extension of certain benefits to
terminated employees. Additional information may be
found on page 16 of this manual.
CLAIM FORMS
Most Participating Dentists have DDKS claim forms in
their offices. We also provide a supply of claim forms
to the employer for those patients who see NonParticipating Dentists, who may have covered family
members located in another state, or for those
employees who want to take a claim form to the dental
office with them.
If your group is interested in setting up online
enrollment, please contact the Marketing Department at
(316) 264-8413, (800) 264-9462 or
[email protected]. Online
enrollment does require a username and password
protection and cannot be set up through the website.
Once the request has been received, the appropriate
forms will be sent to your office.
It is important to remember that there is no claims
administration by the employer. Completed claims
should be forwarded directly by the dentist’s office to
DDKS for processing. The employer does not need to
review or approve a completed claim form.
HOW TO ORDER FORMS
Many forms are available on our website:
www.deltadentalks.com. Additional forms, certificates
and identification cards may be ordered at any time by
notifying DDKS’ office at (316) 264-8413. Forms may
also be ordered by mailing a completed Group Supply
Order Form (see Appendix 1-A) to:
DESCRIPTION OF DENTAL CARE
COVERAGE CERTIFICATES
Description of Dental Care Coverage certificates are
provided to the employer by DDKS. These certificates
should be distributed by the employer to all employees
who have coverage.
DD6-004 (01/21/2013)
Marketing Department
Delta Dental of Kansas
P.O. Box 789769
Wichita, KS 67278-9769
Fax: (316) 462-3329
2
Delta Dental of Kansas
P.O. Box 789769
Wichita, KS 67278-9769
(316) 264-1099  (800) 733-5823
Fax: (316) 462-3329
Appendix 1-A
Group Number: ______________________________
Group Name: ________________________________
Group Supply Order Form
Type of Form
Quantity
*Claim Forms:
*COBRA Enrollment Forms:
*Enrollment/Change Forms:
*Eligibility Transmittal Forms:
Administrative Manual:
Benefit Summaries:
1
*Participating Dentist Directories:
(1-copy emailed or 1-copy forwarded)
Please mail supplies to:
Attn:
Company:
Address:
City/State/Zip
OR: E-mail Address:
______________________________________
Order Placed By:
Telephone Number:
______
* Available online at: www.deltadentalks.com
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Monthly Dental Billing Statement
Your group will receive a monthly billing from DDKS.
This billing reflects the number of eligible employees
reported for a month, adjustments made to the
employee’s records, and previous monthly billing and
payment information. Because DDKS’ billing is done
in advance, the billing is generated on the last day of the
month for the next coming month. Payment is due by
the 15th of that month. If you have questions regarding
a calculation or information on the billing, simply call
our Finance Department at (316) 264-1099 to clear up
any discrepancies.
Information on the Subscriber Update Listing includes:
1) Group #: The number issued to your group by
DDKS.
2) Billing Period: The time period the billing covers.
3) Group Name & Address: The name and address
of your company or organization.
4) Member #: The employee’s social security
number or DDKS-assigned member ID number.
Correct reporting of eligibility is very important. It will
aid you in maintaining accurate eligibility records,
reconciling your group’s billing, and ensuring the
correct billing amount for your group by DDKS.
5) Member Name: First and last name of the
employee.
6) Coverage Type: Designates the type of coverage
for the employee.
The monthly billing invoice your group receives is
divided into two sections for ease of understanding:
7) Effective Date: The date an employee’s coverage
began or changed. If this is a termination date, it
can be no further back than 30 days.
1. Statement of Account (see Appendix 2-A)
2. Subscriber Update Listing (see Appendix 2-B)
The following is an explanation of each section:
8) *Action Code: Represents the type of action
affecting an employee’s record. There are four
types of action codes:
STATEMENT OF ACCOUNT
The Statement of Account sheet (see Appendix 2-A) is
printed on the first page of your monthly billing
invoice. It should be mailed to DDKS along with your
premium payment.
1=Addition: Code 1 indicates that an employee
record has been added to your group. New hires or
reinstated employees are additions. An employee
transferring from one sub-location to another within
your group is also considered an addition.
Eligibility Transmittals should be mailed under separate
cover or faxed to the attention of the Eligibility
Department at: (316) 462-3394, along with all
supporting documentation (i.e. Enrollment/Change
forms).
2=Termination: Code 2 indicates that an employee
and dependents are no longer eligible for dental
coverage. An employee transferring from one sublocation to another within your group is also
considered a termination.
3=Effective Date Change: Code 3 indicates that a
previously reported effective date for an employee
was incorrect and has not been changed. Such date
changes can also apply to additions, reinstatements,
or terminations.
SUBSCRIBER UPDATE LISTING
The Subscriber Update Listing (see Appendix 2-B) is
the first section of the monthly billing invoice. It lists all
additions and/or changes that resulted in a premium
adjustment which have been processed since the last
monthly billing invoice.
DD6-004 (01/21/2013)
4=Coverage Type Change: Code 4 indicates that
an employee has added or terminated coverage for
dependents which changed the employee’s type of
coverage. When a coverage type change occurs, the
4
Subscriber Update Listing reflects the coverage
type of the employee.
HOW DO WE PROCESS BILLINGS WITH
DDKS?
9) Amount Due: The amount billed for each
employee for the month.
The Statement of Account copy of the billing
statement should be returned to DDKS with your
payment, and all necessary information, within 30 days
so eligibility verification on claims received is not
delayed.
10) Total Administration Adjustments: The total
amount adjusted based on the eligibility action
submitted. This is the net difference and can be
either a debit or a credit.
11) Current Billed: Total indicates the number of
employees and the total covered under each rate
type for the current period.
12) Maintenance Date: Date the change (addition,
termination, etc.) became effective.
13) Total Balance: Amount due on this billing taking
into account any adjustments and/or past due
amounts.
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EXAMPLE: Statement of Account -- Appendix 2-A
Delta Dental of Kansas
P.O. Box 3806
Wichita, KS 67201-6806
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SAMPLE: Subscriber Update Listing -- Appendix 2-B
DDKS’ billing system calculates premium adjustments for you.
PLEASE pay the statement as it is billed.
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Eligibility Transmittal Form
7) Employee Birthdate: The employee’s date of
birth.
ELIGIBILITY TRANSMITTAL
Once employees are initially enrolled,
Enrollment/Change forms are required for the addition
of a new employee, the addition of a spouse or
dependent(s), a coverage type change, or a change to
the employee’s name or address. All information on
these forms must be completed to ensure correct
eligibility is maintained. To help you, the original copy
of the form should be attached to a completed
Eligibility Transmittal (see Appendix 2-C). This
transmittal summarizes the information of the
Enrollment/Change forms and provides an area for
reporting subscriber terminations and effective date
changes.
8) Effective Date: The specified date of any action to
an employee’s record.
9) Coverage Type: Dependent upon the type of
coverage outlined in your group contract (i.e.
single, family, etc.).
10) Total: Total amount adjusted (can be either a debit
or credit).
Eligibility Transmittals and Enrollment/Change forms
should be submitted to DDKS. All changes received by
the 10th of the current month will appear on your next
month’s Subscriber Update Listing.
Information on the Eligibility Transmittal includes:
1) Group Number: The complete number issued to
your group by DDKS. If you are billed separately
by sub-location, one transmittal is necessary for
each sub-location number.
2) Group Name: The name of your company or
organization (please do not abbreviate).
3) Date: The date eligibility actions are reported to
DDKS.
4) Action Code*: Refer to the Action Codes listed on
the bottom of the transmittal form. 1 = Addition;
2 = Termination; 3 = Effective Date Change;
4 = Coverage Type Change.
5) Employee Soc. Sec. #: The employee’s social
security number.
6) Employee Name (Last, First): The employee’s
full legal name, last and first.
DD6-004 (01/21/2013)
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Appendix 2-C
ELIGIBILITY TRANSMITTAL
Delta Dental of Kansas
Please return this form along with
appropriate Enrollment/Change Form(s).
P.O. Box 789769
Wichita, KS 67278-9769
Phone (316) 264-1099
FAX (316) 462-3394
Group Number: __________________________________________________________
Group Name:
Action
Code*
Date: __
Employee
Soc. Sec. #
Employee Name
Last
First
Employee
Birthdate
Effective
Date
.
Coverage
Type
TOTAL
* Action Codes:
1 = Addition
3 = Effective Date Change
2 = Termination
4 = Coverage Type Change
Note: Appropriate Enrollment/Change form must be attached for all Additions and Coverage Type changes.
DD6-004 (01/21/2013)
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Total
Enrollment/Change Form Information
Information regarding eligible employees is reported to
DDKS on the Enrollment/Change form supplied to your
group by DDKS. All information on these forms must
be completed to ensure correct eligibility maintained for
the employee and any dependents of the employee who
are eligible for dental benefits.
the carrier should be provided here. This information is
critical for coordination of benefits–a key cost
management feature of your Delta Dental program.
SECTION 4—Changes
An Enrollment/Change form should also be completed
when an employee who is already enrolled is changing
status for any reason. When submitting an
Enrollment/Change form for the purpose of making a
change, the employee must mark all appropriate boxes
and indicate the effective date of the change. Check the
Change Authorization box at the top of the form and
sign in Section 5—Signature/Authorization for
Enrollment/Change(s).
Once your group initially enrolls, Enrollment/Change
forms are required only for the addition of a new
employee, the addition of a spouse, and/or
dependent(s); a coverage type change; or a change to
the subscriber’s name or address.
Enrollment/Change forms should be submitted to
DDKS, along with an Eligibility Transmittal. Advance
copies may be faxed at any time to DDKS at (316) 4623394. All changes received by the 10th of the current
month will appear on your next month’s Subscriber
Update Listing.
SECTION 5—Signature/Authorization for
Enrollment/Change(s)
The following is an explanation of the
Enrollment/Change form (see Appendix 3-A):
Whether an employee is a new enrollee or making
changes, Section 5 MUST be signed and dated.
SECTION 1—Employee Information
SECTION 6—Waiver of Coverage
This section requests basic information such as the
name, address and birthdate for the employee. Since the
employee’s social security number is often used as the
member identification number, it is very important that
this number is included. The employer should indicate
the hire date and eligibility date of coverage for the
employee. Please refer to the information found in your
Agreement to Provide Dental Care Benefits to identify
the waiting period for new hires. If you require your
billing to be separated by sub-locations, indicate this by
designating a location or code number in the
appropriate box.
If an eligible employee chooses not to enroll for
individual or family coverage, check the waiver of
coverage box at the top of the form and complete
Section 6 of the Enrollment/Change form. The waiver is
a means of verifying that an employee was offered
coverage for which they and/or their family are eligible,
but opted not to take the coverage, and the reason for
that waiver.
It is important to remember that most programs are
underwritten assuming 75% of the eligible
employees are enrolled. Voluntary employee
enrollment is normally not an option. If you have
any questions, please contact your DDKS Account
Representative.
SECTION 2—Dependent Information
List each eligible family member to be enrolled or who
is affected by changes being made to coverage; use a
second form if necessary. Please do not complete this
section when taking single coverage.
Enrollment/Change forms may be obtained by visiting
our website at www.deltadentalks.com or by contacting
our Wichita office at (316) 264-8413, or toll free at
(800) 264-9462.
SECTION 3—Other Insurance Information
If the employee’s spouse or dependent(s) has other
dental/medical coverage, all applicable information
regarding the spouse’s employer, type of coverage, and
DD6-004 (01/21/2013)
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Appendix 3-A
DD6-004 (01/21/2013)
11
How To Use Your Dental Benefits
PREDETERMINATION OF BENEFITS
Dentist for the dental procedure or ii) the Delta Dental
Participating Dentist Maximum Fee.
For extensive work, or anytime there may be a question
about payment or covered benefits, a predetermination
of benefits is recommended. Predeterminations are not
required; however, they can help answer questions and
avoid confusion.
If the planned treatment involves prosthetic procedures,
orthodontic procedures, individual crowns (except
stainless steel), gold restorations, surgical periodontics,
endodontics, or oral surgery (except for simple
extraction of a single tooth), the patient should ask the
dentist to submit a treatment plan to DDKS for a
predetermination of benefits. DDKS will determine how
much of the bill will be paid by the plan and what the
employee’s share of the cost will be. Benefits not
predetermined for these services could result in a higher
cost to the patient than anticipated.
DENTIST’S PAYMENTS
Before treatment is started, the employee should discuss
their financial obligation with the dentist. Under the
Agreement to Provide Dental Care Benefits, employees
are free to go to the dentist of their choice; however,
there may be a difference in the amount of payment
made by DDKS if the dentist chosen is not a
Participating Dentist with DDKS.
Following treatment, the Attending Dentist’s Statement
(claim form) should be forwarded by the dentist to
DDKS. Payment will be made directly to DDKS
Participating Dentists. DDKS will pay each covered
procedure based on the Delta Dental Maximum Plan
Allowance. Any difference in fees charged and the
Delta Dental Maximum Plan Allowance cannot be
charged to DDKS patients for covered services.
Non-Participating Dentists
For dental benefits and covered services provided by
Non-Participating Dentists, DDKS will pay Delta
Dental’s Non-Participating Dentist Maximum Fee. In
the case of Non-Participating Dentists, the MPA means
the lesser of: i) the fee submitted by the NonParticipating Dentist for the dental procedure or ii) the
Delta Dental Non-Participating Dentist Maximum Fee.
The “Delta Dental Non-Participating Dentist Maximum
Fee” for a Covered Procedure means the fee was
established by DDKS. The Delta Dental NonParticipating Dentist Maximum Fee is developed from a
number of sources, including but not limited to the
billed charges for the same procedures by dentists in
Kansas, and such other information as DDKS, in its sole
discretion, deems appropriate. Generally, the Delta
Dental Non-Participating Dentist Maximum Fee will
reflect a reduction of the Delta Dental Participating
Dentist Maximum Fee.
When a Non-Participating Dentist performs dental
services, payment is made directly to the employee,
along with an explanation of the benefit amounts. The
patient is responsible for payment to the dentist in
accordance with the dentist’s usual billing procedure.
Participating Dentists
In the case of Participating Dentists, the term
“Maximum Plan Allowance” or “MPA” means the
lesser of: i) the fee submitted by the Participating
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The “Delta Dental Participating Dentist Maximum Fee”
for a Covered Procedure means the fee was established
by DDKS. The Delta Dental Participating Dentist
Maximum Fee is developed from a number of sources,
including but not limited to the billed charges for the
same procedures by dentists in Kansas, and such other
information as DDKS, in its sole discretion, deems
appropriate.
12
Explanation of Benefits
An Explanation of Benefits (EOB) form is issued to
each subscriber when a claim is submitted for payment.
The EOB is an explanation of how the claim was
processed and paid. The EOB also indicates any
applicable deductibles and maximums used to-date.
Participating Dentists with DDKS will receive payment
directly from DDKS along with a voucher that shows
DD6-004 (01/21/2013)
the same claim payment information as that provided to
the patient. A patient who chooses to have services
performed by a Non-Participating Dentist will receive
the payment and voucher directly. It will contain the
same claim payment information as found on the
standard EOB form and will include the payment.
13
16. Billed Amount is the fee requested by the dentist
for the procedure.
Explanation of Benefits—Terms
1. Check No. is an individual number assigned to
identify the check and voucher.
17. Charge Approved Amount is the fee approved by
DDKS. If the submitted amount exceeds the
dentist’s pre-filed fee or Delta Dental’s Maximum
Plan Allowance, the dollar amount indicated
represents the adjusted fee.
2. Date of Issue is the date the check/voucher was
processed by DDKS.
3. Claim No. is an individual number assigned by
DDKS to identify the claim.
18. [Charge Approved] Code is an explanation of the
approved amount. The following coding system is
used to explain any adjustments to the submitted
amount and is found on the back of the voucher:
4. Member # is the employee’s social security
number or DDKS-assigned member ID number.
A = Payment based on dentist’s pre-filed fee with
Delta Dental Member Company.
B = Payment based on Delta Dental Member Company’s
Maximum Plan Allowance.
C = Manual pricing.
5. Group No. is the number assigned to the particular
employer group under which benefits were
provided.
6. Relationship Code is a numerical code which
describes the relationship of the patient to the
employee. The following coding system is used:
subscriber = 01; spouse = 02; dependent
children = 03 and up.
19. Contract Allowed is the amount that was used to
calculate DDKS’ portion of the payment based on
allowable benefits under the group contract.
20. [Contract Allowed] Code is an explanation of the
allowed amount. The following coding system is
used to explain any adjustments to the allowed
amount.
E = Payment was made for optional benefits based on
dentist’s filed fee.
F = Payment was made based on Delta Dental Member
Company’s Maximum Plan Allowance.
H = Charge was reduced based on the group’s coverage
with DDKS.
7. Patient Date of Birth is the month, day and year of
the patient’s birth.
8. DDS License No. is the number assigned to the
dentist by the state licensing board or DDKS,
followed by the state abbreviation and location
number.
9. Subscriber Name and Address is the name and
address of the employee, as listed in our current
records.
21. Deductible or Over Maximum indicates the
amount applied to the patient’s deductible for all or
a portion of the service. “Max” will print if the
patient has reached their annual maximum benefits
allowed. This information also prints at the bottom
of the voucher.
10. Patient is the first and last name of the patient who
received the dental treatment.
11. Provider is the name of the dentist who provided
services to the patient.
22. Co-pay % indicates the percentage used to
calculate DDKS’ portion of the payment as
identified in the terms of the subscriber’s group
contract.
12. Tooth No. or Letter identifies the tooth that was
treated.
13. Arch Surface Quad is the arch, surface, or
quadrant on which treatment was rendered.
23. Other Insurance (C.O.B.) indicates the dollar
amount paid by the primary carrier under
coordination of benefits, broken down by line item,
for the total claim. DDKS’ payment will be reduced
if the amount paid by DDKS and the primary
carrier exceeds 100% of the approved amount.
14. Description of Service is the description of the
treatment performed, as identified on the claim.
15. Date of Service indicates the month, day, and year
on which the dental procedure was rendered.
24. Patient Balance indicates the patient’s balance
owed to the dentist for the dental services rendered.
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14
25. Delta Payment is the amount of the claim paid by
DDKS to the dentist.
PATIENT EXPENSES
26. Ref. Code is a number that refers to the
corresponding reference code printed at the bottom
of the EOB that explains any limitation of benefits.
The patient’s share in the cost of their dental care will
depend upon the program the group purchaser selects.
These factors may involve a co-payment, a deductible,
and/or a maximum benefit allowance. An explanation
of each follows:
27. Totals indicate the total amount of the bill owed by
the patient and the total amount satisfied by DDKS.
The patient is responsible for the amount shown as
“Patient Balance” only.
Co-Payment: The co-payment is the percentage of
dental expenses covered by DDKS.
28. Annual Maximum indicates the amount of benefit
payments made by DDKS during the contract year
in which the claim was submitted. The dollar
amount includes the payment made on the EOB.
Deductible: The deductible is a contractual amount for
which the patient is responsible each benefit period
toward the cost of dental services. The deductible
applies individually to each member of a family until
the family maximum has been reached.
29. Annual Deductible indicates the amount of
deductible met this contract year by the patient
listed on the EOB.
Maximum: The maximum is the total amount payable
by DDKS during any one benefit period for all expenses
incurred.
30. Questions is a section provided for the patient to
make a written inquiry to DDKS concerning
questions about claims, procedures, or payments. It
can also be used to report address changes or
request information, etc.
Groups that have orthodontic benefits usually have a
lifetime orthodontic maximum that is inclusive of their
annual maximum.
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Continuation of Group Dental Coverage (COBRA)
The Consolidated Omnibus Budget Reconciliation Act
of 1986 (COBRA) includes a provision that requires
many employers to offer extended coverage for certain
benefits to qualified employees and/or qualified
beneficiaries who are losing their eligibility under their
group benefit plan. Under the current Federal law, this
is an employer responsibility. To verify information or
questions regarding COBRA, you should contact the
U.S Department of Labor, Employee Benefits Security
Administration at (866) 444-3272 or your corporate
attorney.
DDKS BILLING OF COBRA
If you elect to have DDKS bill and collect premiums
directly from your eligible COBRA participants, you
should notify us of this delegation prior to the COBRA
deadline. You must also notify us of terminations from
the group dental plan as soon as possible. The
Application for Continuation of Group Dental Coverage
Forms (see Appendix 4-A) should be given to any
qualifying employee. The employee needs to timely
complete the form and submit it to DDKS. It is the
employer’s responsibility to furnish COBRA
information, including deadlines, to the eligible
employee. When DDKS receives timely completed
COBRA ELIGIBILITY
To be eligible for COBRA coverage, an individual must
be covered by his/her group dental plan prior to the
COBRA event. COBRA coverage generally applies to
employer groups of 20 or more employees.
COBRA applications, the subscriber will be activated
and will be billed directly by DDKS. All premium
payments must be sent directly to DDKS.
TERMINATION OF COBRA
SELF ADMINISTRATION OF COBRA
Termination of COBRA related eligibility results when
ANY of the following occurs:
If you elect to maintain the COBRA participant on your
group plan for the duration of the COBRA participant’s
eligibility, simply continue to report eligibility to
DDKS in the usual manner. You will be responsible for
the collection of premiums from the participant and you
may keep the 2% administration charge added to
COBRA premiums. Premium payment for the COBRA
participant must be paid with your regular group’s
dental coverage payment regardless of whether you
have collected such premium from the COBRA
participant. When coverage ceases, for any reason,
simply report the cessation of coverage as a normal
termination.

End of the term of continuation coverage which is
dictated by Federal law;

Date on which former employer ceases to offer any
group dental plan;

Failure to pay premium for month of coverage;

In some instances, when the subscriber becomes
eligible for dental insurance with a new employer or
remarries and becomes eligible under spouse’s
dental plan;

Subscriber becomes eligible for Medicare.
PLEASE NOTE: COBRA law mandates certain
compliance and deadline issues that must be followed
by the employer, the eligible participant and/or the
group dental plan. We highly recommend you seek
legal counsel on COBRA issues.
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Appendix 4-A
Application for Continuation of Group Dental Coverage (COBRA)
With the passage of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), most employer-sponsored
group health plans are required to offer employees and dependents losing eligibility the option to continue their
coverage.
If you wish to extend coverage, you must complete this form and return it to DDKS within the deadline as established
by COBRA law.
To Be Completed By Applicant (Please Print or Type Legibly)
Name (Last, First, Middle Initial):
Social Security Number:
Date of Birth:
Male
Female
Home Street Address:
City:
State:
Zip:
Home Phone:
Please list below all persons who are to be covered.
Last Name (if different)
First Name
Middle
Initial
Sex
(M/F):
Date of Birth
Indicate if covered by
other dental insurance
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Signature of Applicant: ______________________________ Date: ________________________
Yes, I want to continue my dental coverage.
No, I do not want to continue my dental coverage.
Please mail form to: Delta Dental of Kansas • COBRA Eligibility • PO Box 789769 • Wichita, KS 67278-9769
To Be Completed By Employer
Subscriber’s ID # on previous Delta Dental coverage:
Date:
Group Name:
Date of Qualification:
Reason for Loss of Eligibility (Please check one. NOTE: Applications cannot be processed without this information):
Lay Off
Termination
Employer Signature:
Divorce or Legal Separation
Child Reached Age Limit
Reduction of Hours
Death of Employee
Title:
Retired
Other:
Date:
Applicant Eligible for _____months of coverage. COBRA eligibility to terminate on ________________________.
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Appendix 4-B
COBRA BILLING DESIGNATION
TO:
Delta Dental of Kansas, Inc.
FROM:
DATE:
We hereby agree to have Delta Dental of Kansas, Inc. process the billing for dental coverage continued under
the Consolidated Omnibus Budget Reconciliation Act (COBRA) legislation.
We will be responsible for informing any terminating employee and/or eligible dependents of their rights as
provided under the COBRA laws, and shall submit on a timely basis to Delta Dental of Kansas, Inc. all
eligibility information on employees electing or extending their COBRA dental coverage.
Delta Dental of Kansas, Inc. will be responsible for billing all eligible participants directly and collecting
premium as outlined in the COBRA statutes and regulations. These regulations include, but are not limited to,
maintaining the same coverage design for the COBRA enrollees; billing at the existing group rate plus an
administrative charge; and termination of COBRA enrollees for failure to pay required premiums by the due
date.
_____________________________
Company Name
_____________________________
Authorized Signature
_____________________________
Title
Please mail to Delta Dental of Kansas, P.O. Box 789769, Wichita, KS 67878-9769
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Contact Information
Customer Service/Claims:
(316) 264-4511
Customer Service/Claims Toll Free:
(800) 234-3375
Billing & Enrollment:
(316) 264-1099
Marketing Toll Free:
(800) 264-9462
Fax Number:
(316) 462-3393
Eligibility Fax:
(316) 462-3394
Website:
www.deltadentalks.com
Online Enrollment:
[email protected]
Email:
To contact DDKS staff via email, please use first initial and last
name. For example, [email protected].
Mailing Address:
Delta Dental of Kansas
P.O. Box 789769
Wichita, KS 67278-9769
Street Address:
Delta Dental of Kansas
1619 N. Waterfront Parkway
Wichita, KS 67206
Payment Address:
Delta Dental of Kansas
P.O. Box 3806
Wichita, KS 67201-3806
Overland Park Office:
Delta Dental of Kansas
9300 W. 110th, Bldg. 55, Suite 450
Overland Park, KS 66210
(913) 381-4928
Fax: (913) 381-8312
Topeka Office:
Delta Dental of Kansas
P.O. Box 5066
Topeka, KS 66605-5066
(785) 267-5111
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Delta Dental of Kansas
P.O. Box 789769
Wichita, KS 67278-9769
(800) 264-9462
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