Certificate of Coverage (COC)
As a DENCAP Member, your best resource for information about your coverage is your plan’s Schedule of Benefits and Fixed Co-Payments and the Certificate of Coverage. If you have any questions about your coverage, please contact DENCAP directly.
View DENCAP Group DHMO Certificate of Coverage
View DENCAP Individual DHMO Certificate of Coverage
View DENCAP PPO Certificate of Coverage
View DENCAP DHMO Certified Plans Limitations and Exclusions (for Sterling, Individual Value, Flex, Flex Plus, Merit, Dynamic, DENCAP Choice Dental, Hallmark, Grand and Ultra plans)
View DENCAP DHMO Limitations and Exclusions (for City of Detroit, Advantage, and Valor)
Out-of-network Liability and Balance Billing
Your Certificate of Coverage and Plan Schedule of Benefits and Fixed Co-Payments or Benefit Summary outlines out-of-network coverage available for you and covered dependents.
DHMO: When seeing an in-network dentist, fees for non-covered services are the responsibility of the patient, and the provider may bill the patient directly for them.
The nature of DENCAP’s coverage does not extend to providers that are not part of the DENCAP Network. When seeing an out-of-network provider, all fees, even those for covered services, are the responsibility of the patient (balance billing).
DENCAP does not offer out-of-network coverage, except in the case of an emergency. When you or your covered dependent is 50 miles or more away from your selected in-network dentist, DENCAP will reimburse you 50% up to $100 for services that alleviate pain. Should you need to utilize this benefit, the member is responsible to submit a claim and paid receipts in a timely manner to DENCAP Dental Plans 45 E. Milwaukee Ave. Detroit, MI 48202.
DPPO: When seeing any dentist, fees for non-covered services are the responsibility of the patient, and the provider may bill the patient directly for them.
If the dentist does not participate in DENCAP Dental PPO, DENCAP Dental will base payment on the lesser of:
- The Submitted Amount
- The Nonparticipating Dentist Fee
- The Maximum Allowable Amount
Enrollee Claim Submission
DHMO: The DENCAP DHMO model does not receive primary care (general dentistry) claims at all. The provider is reimbursed monthly by capitation payments sent from DENCAP, and then at the time of service by patient co-payments. There is no need for a member to submit a claim to DENCAP, except in the case of emergency treatment as described above and in the Certificate of Coverage and Schedule of Benefits and Fixed Co-Payments.
DPPO: Members who wish to file a claim for reimbursement can do so by:
- Download the Dental Reimbursement Form; Section A of the form must be completed in its entirety.
- If available, provide a copy of the claim, itemized bill or the dentist’s Statement of Treatment that includes:
- The name and address of the facility where services were rendered
- Tax ID, State License and NPI number of dental provider
- Tax ID, State License and NPI number of dental provider
- Date the service(s) was performed
- Description of service and procedure code
- Total charge (fee) of each service performed (If you have already paid for services, include paid receipts)
- If you are enrolled for other coverage you must include the name of the other insurance carrier(s).
- If the information is not provided on the Itemized Bill or Statement of Treatment you will need to provide the treating Dentist name (Physician name), Dentist NPI, and Dentist license number by completing Section C of the form.
- Make a copy of the completed reimbursement form and all other documents to keep for your personal records.
- Mail the completed form and the Dentist’s Statement of Treatment and all pertinent documents to DENCAP Dental Plans P.O. Box 2548 Detroit, MI. 48202.
If you have any question or concerns, please contact our Customer Service Department at:
You or your dentist must file a claim for benefits within 1 year of the date that dental services were completed. Claims are processed within 45 days unless additional information is required from you or the dentist.
Grace Periods and Claims Pending
DENCAP offers enrollees receiving Advance Payment of Premium Tax Credits (APTC) a three-month grace period upon the event that a premium in whole or part is unpaid by the enrollee. A grace period is a special circumstance that allows enrollees to pay premiums after they are due without penalty. Only enrollees receiving APTC qualify for a grace period. During this grace period DENCAP will continue to collect APTC on behalf of the enrollee to apply to member premium, or if the grace period is exhausted return APTC payments to the Department of the Treasury. DENCAP will pay claims on behalf of the member for the first month of the grace period, and pend claims for the second and third month of the grace period. Pended claims are held to allow the enrollee to catch up on their missed premium payments. If the premium remains unpaid, the pended claims will be denied.
If you or an eligible member of your family has started orthodontic treatment under a previous plan sponsored by an employer/organization, you may be able to continue that coverage when you switch to a DENCAP Dental Plan or if your converting from a DENCAP Dental Plan to another plan.
How to complete a Continuous Orthodontic Coverage Form:
- Download the Continuous Orthodontic Coverage Form.
- Completely fill out all the information on the Continuous Orthodontic Coverage form.
- In addition, include the following required documents and information:
- Completed claim form, including the banding data.
- Explanation of benefits showing how much the previous plan has paid to date and amount remaining.
- Mail the completed form and documents to
- DHMO: DENCAP Dental Plans 45 E. Milwaukee St., Detroit, MI 48202
- DPPO: DENCAP Dental Plans P.O. Box 2548 Detroit, MI 48202.
Once all required documents are received the standard review process takes 45 days. You will receive notification once a determination has been made.
If you have any questions or concerns, please contact our Customer Service Department.
Retroactive Coverage Termination
In the event of a retroactive termination, DENCAP will review already evaluated claims for possible retroactive denial. In the event of a retroactive denial, DENCAP will receive reimbursement from the provider for the claim that was paid, and the patient will be responsible to pay the provider for services rendered. The best way for a member to avoid a retroactive denial is to pay premiums in a timely manner and communicate eligibility and billing changes to DENCAP as soon as possible so that DENCAP records are always up to date.
Premium Overpayment Recovery
As a DENCAP subscriber, you have the right to review your billing statements and history at any time. If you find that you have been overbilled by DENCAP, please let us know as soon as possible. We are happy to do an investigation. We may require documentation from you that we do not have access to (i.e. bank statement, credit card statement), and with your cooperation will determine if you have been overbilled. In the event overbilling has occurred, DENCAP will credit your account or refund you, as you prefer.
DHMO: Contact DENCAP at (313) 972-1400 or firstname.lastname@example.org to begin a detailed review of your account.
DPPO: Contact DENCAP at (844) 433-6227or email@example.com to begin a detailed review of your account.
DHMO: For some procedures at the Specialist, DENCAP requires prior authorization. Prior Authorization is a process through which DENCAP reviews a request from a provider for a member to access a covered benefit before the benefit is delivered to the member. The provider is responsible to initiate the process with DENCAP. DENCAP responds to providers within 14 days of receipt of the prior authorization information. If a member receives care that requires prior authorization which was not initiated by the provider, the member is responsible only for the portion of the fee they would have been if the prior authorization had been approved and member benefits are available. The provider is responsible for DENCAP’s portion. It is the responsibility of the provider to communicate with DENCAP about DENCAP patients and to make sure that procedures are approved and benefits are available before beginning treatment. Details about procedures that require prior authorization can be found in the Certificate of Coverage.
Explanation of Benefits (EOB)
An (EOB) is a statement sent to a patient by an insurance company to explain all the costs associated with your recent visit. The statement will typically detail what procedures and/or services were rendered, the amount paid by the insurance company, and the amount the patient is responsible to pay as defined by the member’s policy, if applicable. An EOB is not a bill.
DHMO: DENCAP does not generate an Explanation of Benefits (EOB) to send to members that are enrolled in a DHMO plan. DENCAP does not receive, or pay claims to providers for members enrolled in a DHMO. DENCAP pays participating providers a monthly capitation fee to cover the costs of services that members may receive. To understand what services are covered and costs associated to each, please refer to your Schedule of Benefits. Questions about claims and claim statements can be directed to the DENCAP Claims Department at (313) 972-1400.
DPPO: DENCAP provides members with access to an online member portal that allows them to view and print their most recent explanation of benefits (EOB) at any time. The member must register for access to the portal, and once approved will be able to view the EOB online. Members can request to have their EOB printed and mailed. If you would like to have your EOB mailed, contact DENCAP at (844) 433-6227 or email firstname.lastname@example.org.
Coordination of Benefits (COB)
Your DENCAP DHMO Plan may coordinate with other dental insurance or coverage that you may have. To learn more, review the Certificate of Coverage or ask your provider about their billing practices utilizing both of your plans.