Enrollment Kit - delta dental
PLEASE NOTE: This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier’s underwriting guidelines for a complete list of requirements. Please use the latest version of forms.Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines the health plan’s case submission requests:
- A check for the first month’s premium made payable to “Delta Dental” or a completed ACH form.
- Group Application.
- Each eligible employee needs an Employee Enrollment/Change form or Enrollment List Form.
- If employer contributes 100% of the cost, all eligible employees must enroll.
- If enrolling less than 5 use 2-4 rates.
- Dual Choice PP0 and DeltaCare USA: Minimum of 2 enrolled in each plan. When enrolling less than 5 in PPO, use the 2-4 rates. Minimum of five primary enrollees in PPO for orthodontic coverage. Employer contribution percentage must be identical for both plans.
- Adult ortho is available with 25+ enrolled employees for employer paid groups and 50+ for voluntary groups.
- Child ortho is available with 5+ enrolled employees for employer paid and voluntary groups.
- Endodontics, Periodontics, Orthodontics, Oral Surgery and Major services are subject to a 12 month waiting period for voluntary groups. Waived for all initial employees on groups with proof of prior comprehensive dental coverage.
- Dependents are eligible up to age 26.
For other useful or older documents, please refer to the Forms database.