Out-of-Country Claims Submission
As a Delta Dental of Arizona member, you can visit any licensed dentist anywhere in the world for your dental care. Even if you're out of the country when you receive dental treatment, you have peace of mind when you have Delta Dental of Arizona coverage.
In order to process an out-of-country claim for dental services (including diagnostic & preventive, restorative, and major), please follow these instructions carefully. Your dental plan includes covered dental services when they are performed and completed by a licensed dentist in a dental office.
Below is a list of information that is required to process your claim. Please request this vital information from your dentist prior to treatment or before completion of your treatment.
- Dentist's professional license (only when not already on file – contact Delta Dental of Arizona to verify at 1.800.352.6132)
- Superbill which would include dental practice letterhead
- Chart Notes A chart note records the reason for the current visit, an assessment of the patientís condition (including any changes since the previous visit), and additional treatment rendered or planned.
- Pre-operative and Post-operative X-Ray
- Insurance Claim form
The patient section of the insurance form must include:
The dentist section of the insurance form must include:
- Patient Name
- Member ID or SSN
- Patient date of birth
- Information on other coverage
The insurance claim form itemized treatment section must include:
- Dentist Name
- Dentist address
- Dentist telephone number
- Dentist's license number
If you require major services treatment, we strongly urge you to request a predetermination. We will process the predetermination and notify you if the recommended treatment is a covered benefit, how much Delta Dental of Arizona will pay, and of your financial obligation.
- Tooth number, when applicable
- Description of the service
- Date of service
- Procedure code
- Each procedure must be listed and priced separately; we cannot calculate benefits when services and fees are combined (please specify currency). The claim form must include the billed charges in that country's currency and a conversion fee into United States dollars.
- Orthodontic treatment must include total months of treatment and total treatment fee
- If the claim is for a crown, veneer, inlay, onlay, bridge, implant or partial denture, your dentist needs to indicate if this is initial placement. A copy of the pre-operative, diagnostic quality duplicate X-ray (not original) of the treatment area is required. NOTE: Predetermination of treatment is recommended.
- If it is not initial placement, your dentist needs to provide the initial placement date and the reason for the replacement. Please submit this information with your claim form.
Note: You are responsible for payment to the dentist at the time of service. The reimbursement check will be sent to your address.