Non-Network Providers

Non-Network Providers

Do not contract to accept Delta Dental's allowable charge.

Bill the patient for ALL amounts not covered by the plan.

Are not under contract to file claims for the patient.

Benefit payments for non-network dentists are made to the Member.

The following displays three sample claims that illustrate examples of how the new Carpenters' Dental Benefits work.

SAMPLE 1:
Preventive Services

Sample
Provider Billed
Charge

Sample
Delta Dental PPO
Provider

Sample
Delta Dental Premier
Provider

Out-of-
Network
Provider

Periodic Oral exam/2 x-rays & adult prophylaxis
cleaning

$227.00

$139.00

$190.00

$139.00

Deductible for Preventive
(per calendar year)

 

NONE

-$50.00

-$75.00

Allowed after Deductible

 

$139.00

$140.00

$64.00

Carpenters Dental Benefit Percentage

 

100%

75%

50%

Carpenters Dental Benefit

 

$139.00

$105.00

$32.00

Member Pays

 

$0.00

$85.00

$195.00

Delta Dental Network Saves

 

$88.00

$37.00

$0.00

Note: The following samples assume that the claim was for the first services provided to the patient in the year and no deductible was taken yet for that calendar year. (Note that any deductible met for preventive will count toward the total annual calendar year deductible.)

SAMPLE 2:
Restorative Services

Sample
Provider Billed
Charge

Sample
Delta Dental PPO
Provider

Sample
Delta Dental Premier
Provider

Out-of-
Network
Provider

Amalgam one surface, resin composite one
surface, extraction

$495.00

$247.00

$400.00

$247.00

Deductible per Calendar Year

 

-$50.00

-$75.00

-$75.00

Allowed after Deductible

 

$197.00

$325.00

$172.00

Carpenters Dental Benefit Percentage

 

80%

50%

25%

Carpenters Dental Benefit

 

$157.60

$162.50

$43.00

Member Pays

 

$89.40

$237.50

$452.00

Delta Dental Network Saves

 

$248.00

$95.00

$0.00

SAMPLE 3:
Major Restorative Services

Sample
Provider Billed
Charge

Sample
Delta Dental PPO
Provider

Sample
Delta Dental Premier
Provider

Out-of-
Network
Provider

Root Canal and Crown - resin with high noble
metal

$1,800.00

$1,163.00

$1,580.00

$1,163.00

Deductible per Calendar Year

 

-$50.00

-$75.00

-$75.00

Allowed after Deductible

 

$1,113.00

$1,505.00

$1,088.00

Carpenters Dental Benefit Percentage

 

50%

40%

25%

Carpenters Dental Benefit

 

$556.50

$602.00

$272.00

Member Pays

 

$606.50

$978.00

$1,528.00

Delta Dental Network Saves

 

$637.00

$220.00

$0.00

Useful Links and Documents