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Fraud and abuse

We are committed to ethical business practices, including preventing, detecting and mitigating potential fraud and abuse.

What are fraud and abuse?

Fraud is the intentional deception or misrepresentation by a person for profit or to gain an unfair advantage.

Abuse is conduct inconsistent with fair, ethical, dental, business or fiscal practices and which could result in unnecessary costs and/or payments.

Examples

  • Using someone else's identification card to get care;
  • Concealing other insurance coverage;
  • Billing for services not rendered;
  • Billing for a service that is covered when a non-covered service was performed to gain payment;
  • Altering service or treatment in claims submission to obtain benefit payment for a different, more expensive, treatment; and
  • Altering the date of service to fall within eligibility;

Help prevent fraud and abuse

As a patient:

  • Treat your Delta Dental insurance member card like a credit card. Don’t let anyone borrow your card or use your ID number. If your card is lost or stolen call Customer Service at 877-841-1478.
  • Carefully review each Explanation of Benefits (EOB) you receive after a dental visit. Make sure the visit/service date are accurately stated on the EOB. If the date or services listed don't seem right, contact the dental office to ask for an explanation. If you want help reading the EOB, call Customer Service at 877-841-1478.

As a dental office:

  • Review claim forms prior to submission, making sure the treatment in the patient’s clinical notes is accurately reflected on the claim.
  • Make sure the dentist listed on the claim as the treating dentist is the one who actually performed the services.
  • Disclose all discounts or waivers of any co-payment.
  • Accurately file claims. Do not alter dates of services or file misleading treatment to maximize a patient’s benefits.

Suspect fraud or abuse? Report it!

Contact us immediately if you suspect fraud or abuse. You may remain anonymous or provide your contact information. Please describe the situation in detail so we can fully investigate your report.

Fraud and abuse report form

Use our online form to report suspected fraud or abuse.

Fraud report form

Contact us

About fraud or abuse

Compliance Manager