the Plan name and the group number. You will not have to hassle with sending in claim forms. Participating dentists complete claim forms and submit them directly to DDWA. They receive payment directly from DDWA. You will be responsible only for stated coinsurances, deductibles, any amount over the Plan maximum, and for any elective care you choose to receive outside the covered dental benefits. You will not be charged more than the participating dentist’s approved fee or the fee that the Delta Dental dentist has filed with us. ® There are two categories of Participating Dentists that you may choose: a Delta Dental Premier Dentist or a Delta Dental PPO Dentist. If you select a dentist who is a Delta Dental PPO Dentist, your benefits will likely be paid at the highest level and your out-of-pocket expenses may be lower. Delta Dental Premier® Dentists ® Delta Dental Premier dentists have contracted with DDWA to provide you with covered dental benefits at an agreed upon maximum allowable fee. Delta Dental PPO Dentists PPO dentists have contracted to receive payment based on their PPO-filed fees at the percentage levels ® listed on your Plan for PPO dentists, which are often lower than the Delta Dental Premier maximum allowable fees. Patients are responsible only for percentage coinsurance up to the PPO filed fees. Nonparticipating Dentists If you select a dentist who is not a Delta Dental Participating Dentist, you are responsible for ensuring either you or your dentist completes and submit a claim form. We accept any American Dental Association-approved claim form that you or your dentist may provide. You may also download a claim form from our website at www.DeltaDentalWA.com or obtain a form by calling us at 800-554-1907. Payment by DDWA to nonparticipating dentist for services will be based on the dentist’s actual charges or DDWA’s maximum allowable fees for nonparticipating dentists, whichever is less. You will be responsible for paying any balance remaining to the dentist. Please be aware that DDWA has no control over nonparticipating dentists’ charges or billing practices. Out-of-State Dentists If you receive treatment from a Non-Participating Dentist outside of the state Washington your coinsurance amounts will be based on the coinsurance percentage established for a Delta Dental PPO Dentist. Allowable amounts paid for covered services will be based on the maximum allowable fee for a Participating Dentist in that state, or their actual fee, whichever is less. Service Area The Uniform Dental Plan preferred provider organization (PPO) service area is all of Washington state. If enrollees need assistance in locating PPO providers in their areas, they should contact the plan. The out-of-PPO service area is any location outside of Washington state. If enrollees are treated by out-of-state dentists, they will be responsible for having the dentists complete and sign claim forms. It will also be up to them to ensure that the claims are sent to DDWA. For covered services, the plan will pay either the dentists’ actual charges or the maximum allowable fee normally paid to Delta Dental participating dentists for the same services, whichever is less. Uniform Dental Plan Providers Delta Dental of Washington has participating dentist contracts with nearly 3,400 licensed dentists in the state of Washington. 2024-01-03000-BB 6 LG PPOL 20240101