Delta Dental of IA Claim Form - Sioux City Community School District 2025

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The document is a dental claim form from Delta Dental of Iowa, designed for patients and dentists to submit claims for dental services. It includes sections for patient information, subscriber details, treatment descriptions, and dentist certification. The form captures essential data such as patient account number, relationship to subscriber, treatment specifics, and authorization for information release.

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Click ‘Get Form’ to open the Delta Dental of IA Claim Form in our editor.
Begin by filling out the Patient Section. Enter the patient's name, relationship to the subscriber, sex, and birth date. Ensure accuracy as this information is crucial for processing your claim.
Next, provide the Subscriber's details including their name, identification number, and contact information. This section helps verify coverage and eligibility.
In the Dentist Section, input the dentist's name, address, and relevant identification numbers. Be sure to include any necessary treatment details such as tooth numbers and descriptions of services rendered.
Finally, review all entries for completeness and accuracy before signing at the bottom of the form. Your signature authorizes the release of information related to this claim.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I appeal a Delta Dental claim?

You can appeal by calling or writing to us within 60 calendar days after you receive the denial, reduction or failure to pay notice. You must follow up a call with a written appeal. We will let you know we got your appeal and give you a summary of the process and timetable for resolving the appeal.

What is the timely filing limit for Delta Dental claim?

When you submit claims as soon as possible after treatment is completed, you help us process claims more efficiently, using the patients most current eligibility and benefits to determine payment. Generally, claims received more than 12 months after the date of treatment may not be paid.

What is the mailing address for Delta Dental of Iowa claims?

Our claims processing center (and corporate office) is located at 9000 Northpark Drive, Johnston, IA 50131. Claims should be mailed to Delta Dental of Iowa, PO Box 9000, Johnston, IA 50131-9000.

Is Delta Dental of Iowa Medicaid?

To find a dental provider who accepts Iowa Medicaid FFS coverage, visit the Iowa Department of Human Services Medicaid Provider Search webpage. Members of both the Dental Wellness Plan and Dental Wellness Plan Kids have the same two dental carrier options to choose from: Delta Dental of Iowa or MCNA Dental.

How do you appeal a dental claim denial?

A proper appeal involves sending the carrier a written request to reconsider the claim. Additional documentation should be included to give the carrier a clearer picture of why you recommended the treatment and why you feel the claim should be reconsidered.

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How do I correct an open dental claim?

Open the claim and change its status to Waiting to Send. Delete the claim. Edit or delete the procedures to use the correct providers. Recreate the claim, then send it.

What is the lawsuit against Delta Dental?

In December 2022, CDA filed legal action against Delta Dental in San Francisco Superior Court. This action was driven by the changes to Delta Dentals reimbursement rate structure and provider agreements that had a significant impact on many members.

How do I add a dependent to Delta Dental?

Add a family member to your plan If your plan is through an employer: Contact your organizations benefits administrator. If you purchased your plan through a health care exchange: Contact the exchange. If you purchased your plan directly from Delta Dental: Log in to your online account, or contact us.