A lot goes on between your visit to the dentist and when your claim is finalized. Here’s a look at what goes on behind the scenes in the life of a dental claim. This process happens every work day at Delta Dental Plan of Illinois (Delta Dental Illinois) and we’ve gotten pretty good at it.

It’s time for your appointment, and you arrive at the dentist office and inform him or her that you insurance carrier is Delta Dental Illinois.

Step Two – The claims process begins

You receive the necessary treatment and the dentist submits his or her claim to Delta Dental Illinois on your behalf. (If you visit non-network dentists, you may have to file your own claim). Approximately 40 percent of these claims are submitted to Delta Dental Illinois electronically; the other 60 percent are done on paper.

Claims submitted electronically are sent to a clearinghouse, where data is analyzed, edited and prepared for the next step in the process. The clearinghouse decides where the claim goes next.

Claims submitted on paper are received by the Delta Dental Illinois mailroom, where they are opened, scanned and the data is entered into our system.

At this point, all claim data has entered the Delta Dental Illinois system, either via a clearinghouse or by the paper claim being scanned. Claims received by either method are now adjudicated.

To adjudicate a claim, the data from the claim is "read" by adjudication software and compared to Delta Dental Illinois databases. Information pertaining to patients and their coverage, dentists, and networks are evaluated against benefits on record to see if the service received was covered. It is checked against any co-insurance and by the clearinghouse or the paper claim being scanned. Claims received by either method are checked against limitations before moving on to the next step.

Of those claims processed by the Delta Dental Illinois system, 85 percent are auto-adjudicated and have no human interaction before the claim is paid or rejected. Because the adjudication system is automated, Delta Dental Illinois can process claims quickly. In 2003, claim turnaround time was 2.57 work days, 99.6 percent of claims were paid within 15 calendar days, and 99.9 percent were paid within 30 calendar days.

The remaining 15 percent of claims, those that were not able to be auto-adjudicated, require a claims examiner’s attention and are processed manually by Delta Dental Illinois staff. Typically, claims that would not be auto-adjudicated include orthodontics, claims requiring coordination of benefits, and procedures requiring dental review

A claims examiner or dental consultant will review the information and prepare the claim for payment. Even when adjudicated manually, our claim turnaround time averaged less than three work days in 2003.

Payments to dentists and other oral health professionals are generated weekly by Delta Dental Illinois staff.