2026 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 COC – DENCAP DHMO Group Plans
View COC – DENCAP DPOS Group plans (Prestige, Preferred, Choice)
View COC – DENCAP DHMO Individual plans (Individual, Sterling, Flex, Flex Plus)
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.
DPOS: 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 DPOS, 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.
DPOS: 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:
(313) 972-1400.
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.
Orthodontic Coverage
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
- DPOS: 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. You should also talk to your provider about whether the service performed is a covered benefit prior to receiving the treatment.
Premium Overpayment Recovery
As a DENCAP member, you can look at your bills and payment history anytime. If you think you were charged too much, please tell us as soon as possible. We will review your account to check. We may ask you for documents we cannot see, like a bank or credit card statement. With your help, we will find out if you were overcharged. If we did charge you too much, DENCAP will either add a credit to your account or give you a refund—whichever you prefer.
DHMO and DPOS: Call DENCAP at (313) 972-1400 or email info@dencap.com to start a full review of your account.
Prior Authorization & Medical Necessity
For some services with a specialist, DENCAP must give approval before the care is provided. This is called prior authorization. Prior Authorization means DENCAP reviews a request from your dentist or specialist before you receive a service to decide if it is medically necessary. This helps make sure the service is covered and that your benefits are available.
Your provider (dentist or specialist) must start this process with DENCAP. DENCAP will respond within 14 days after we receive all needed information. Urgent requests for emergency dental services are reviewed within 72 hours.
If you receive care that requires prior authorization and we do not have an approved request on file, your services may be denied.
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement from your insurance company that explains the costs for a recent visit. It shows what services were provided, what DENCAP paid, and what you may need to pay based on your plan. An EOB is not a bill.
It is important to review your EOB each time you receive one. Make sure the services and costs match the receipt or statement you get from your dentist.
DHMO
DENCAP does not send EOBs for most services under a DHMO plan. This is because DHMO plans use a capitation payment model. Under this model, DENCAP pays your selected general dentist a fixed monthly amount to provide covered primary dental care. Because these services are not billed or processed as individual claims, an EOB is not generated.
DENCAP will send an EOB only when you receive services from a specialist. To understand what services are covered and your costs, please review your Schedule of Benefits. If you have questions, contact the DENCAP Claims Department at (313) 972-1400 or by emailing claims@dencap.com.
DPOS
For DPOS plans, DENCAP sends an EOB to providers with all payments. Members will receive an EOB any time a service is denied. Members can also request an EOB at any time by calling DENCAP at (313) 972-1400 or by emailing claims@dencap.com.
You can also request a printed copy by mail if needed.
Coordination of Benefits (COB)
Coordination of Benefits (COB) is the process used when you have more than one dental plan. It helps decide which plan pays first (called the primary plan) and how much the other plan (called the secondary plan) may pay.
Your DENCAP DHMO plan may coordinate benefits with other dental coverage you have. In most cases, the plan that is considered primary will pay first, and the secondary plan may cover some or all of the remaining costs, based on its rules.
It is important to:
- Tell your provider if you have more than one dental plan
- Make sure your coverage information is up to date with each plan
For more details, review your Certificate of Coverage or ask your provider how they coordinate benefits between your plans.