Providers:
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For commercial providers only
Effective Jan. 1: Adult prophylaxis age criteria update
To better align preventive care guidelines with patients' dental development and oral health needs, Delta Dental of Ohio will change the age threshold for adult prophylaxis (D1110) from 14 years of age to 12 years of age, effective Jan. 1, 2027.
Submitting claims
Dates of service prior to Jan. 1 will continue to be processed under the current policy. A prophylaxis performed on a 13-year-old or younger member before the effective date will be considered a child prophylaxis and adjudicated according to the existing guidelines.
Providers should continue to submit claims using the appropriate CDT code based on the member's age and the applicable policy requirements at the time the service is rendered.
For all providers
News and information for all participating commercial, Medicaid and Medicare providers
Cracking the code: D0120 (periodic exam), D0140 (problem-focused exam) and D0150 (comprehensive exam)
Code D0120, Periodic Oral Evaluation, is used for periodic exams. This is an exam for an established patient where the dentist may check for cavities, gum disease and other changes since the patient’s last visit.
Code D0140, Problem-Focused Exam, is used when a patient presents with a specific concern or dental problem, including a toothache, broken tooth or lost crown.
Code D0150, Comprehensive Oral Evaluation, is used for a thorough, initial exam. This exam is typically for a new patient, a patient who hasn’t been seen in at least three years or a patient with a new oral or systemic health concern. The dentist may review the patient’s dental and medical history, evaluate the entire mouth (including an oral cancer screening) and establish a baseline for future care.
Better together: Your professional services representative and customer service
Access starts with awareness. When you know what's available, you can spend less time searching and more time getting results.
Your professional services representative is available to answer questions and provide guidance on a variety of topics, including EFT enrollment, network participation and understanding your contract or fee schedule.
For account-specific inquiries, claims questions and other detailed support needs, our customer service team offers additional resources and assistance at 800-524-0149.
Reporting provider, location or practice changes to provider records
Commercial providers should notify provider records by calling 800-656-6459 or emailing providerrequests@deltadentalmi.com when there is a:
- New provider joining the practice
- Provider leaving or retiring from the practice
- Change to office location
- Change to practice ownership
- Update to office contact information, including phone number, fax number and address
- Change to accepting new patients status
- Change to network directory status information
Medicaid providers must notify Delta Dental of any of these changes in the Ohio Department of Medicaid’s Provider Network Management (PNM) Module. Providers can access the PNM by visiting medicaid.ohio.gov/resources-for-providers/nextgeneration-pnm/nextgeneration-pnm. For questions, call the Provider Integrated Helpdesk at 800-686-1516.
To help ensure the most efficient and accurate help, all providers should include the following information in any phone or email communication regarding provider, location or practice changes.
- Office TIN
- Office location involved
- Provider name
- Provider NPI
- Effective date of the change (such as a provider termination, addition or location update)
Pre-treatment estimate vs. prior authorization
A pre-treatment estimate allows the office and patient to receive an estimate of how a proposed treatment may be covered under the member’s benefits before services are performed. It’s not a guarantee of payment, as final payment is based on the member’s eligibility, benefits and applicable plan provisions at the time services are rendered.
Prior authorization is different in that certain services or benefits may require review and approval before treatment is performed, depending on the member’s plan requirements.
Offices should verify the member’s benefits and requirements prior to treatment to determine whether prior authorization is required, or whether they are requesting an estimate of benefits.
For Medicaid and Medicare providers only
Coming up: CareSource food drive event
CareSource is hosting a food distribution event in Montgomery County from 10 a.m. to 2 p.m. Nov. 19. This event is designed to support individuals and families with access to nutritious food resources in their communities.
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