March 2024

Best Practice—Dentistry, business & policy—Delta Dental





Pen writing signatureUsing Private
Pay Form

If a Delta Dental Medicare Advantage member requires services not covered in their benefit plan, be sure to obtain a signed private pay form from that member or member’s guardian before rendering services.

If a procedure is not listed in Delta Dental’s fee schedule for the above programs, or if it exceeds an age or frequency limitation, it is not a covered benefit under that program and is considered a non-covered service.

Payment for non-covered services is the responsibility of the member or the responsible party. Before providing non-covered services, the cost of the non-covered service(s) must be discussed with the member or responsible party. Payment for non-covered services can only be collected when the member or member’s guardian signs a private pay form (to be signed on the day non-covered services are rendered), where they agree in writing to pay for the non-covered (or alternate) service(s). 

You may use any form for the private pay form and should include the cost associated with the non-covered service(s), the responsible party’s signature and the date. (See Delta Dental’s sample form here). The form should be maintained in the patient’s record. 


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Did you know Delta Dental offers free CE credits?

Continuing Education credits are a requirement for licensure and Delta Dental wants to make your CE efforts painless by offering free online courses through our Provider Learning portal.

Any dentist, hygienist, dental assistant or office staff member who is a Delta Dental participating provider or works for a Delta Dental participating provider may take these courses.

These courses are available 24/7 to help you conveniently and cost-effectively comply with ongoing regulatory demands so you can get quickly get back to what you would rather do—serve patients.

Courses include an informational video on each topic and an assessment. Complete them at your own pace. Upon completion, you will receive a certificate.

Let's hear it

In December, Delta Dental released the first issue of Best Practice, a journal of dentistry, business, and policy. We want to know what you think of it. Please take a moment to share your thoughts here.


Check out the latest course offerings for Ohio.

Person speaking to large group


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American Dental Association (ADA) logoAre you using the new ADA form?

A new version of the American Dental Association (ADA) form is now available and preferred.

While previous ADA claim form versions will still be accepted, Delta Dental is currently processing the new ADA claim form and it’s recommended you use the most up-to-date version.

You may now submit claims through Dental Office ToolkitTM(DOT) with form attachments.

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Want to team up with the Buckeyes?

TeamSmile, an advocacy group that partners oral health professionals and collegiate athletic organizations to provide life-changing dental care to kids in underserved communities is looking for dentists, hygienists and dental assistants in addition to general volunteer help for its July 16 event with Ohio State University.

The event, a partnership with Delta Dental Foundation, will be held at the Fawcett Center in Columbus, Ohio and will run from 8 a.m. to 3 p.m. and will feature members of OSU athletic teams while providing children free oral health education, screenings, and treatment.

To volunteer or for more information, visit

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