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Delta Dental Tennessee 
Your Preferred Dental Organization
Member Handbook Dentist Directory
&
for Active Employees & Retirees
Delta Dental of Tennessee is committed to providing
benefits that are easy to use. These benefits will also
keep you healthy. See inside for more details on how
your benefits plan can protect your health.
2011
Sponsored by the State of Tennessee
Thank you for enrolling in the State of Tennessee’s PDO option.
Delta Dental is proud to be the administrator for this plan. This
booklet will provide you with information that will help you make
the most of these benefits.
What’s New
New Benefit Limitations
Access Your Information Online Anytime!
Every year the American Dental Association and
the Food and Drug Administration review current
health research. They make health and dental care
recommendations based on those studies. As a
result of their recommendations, there are new
limitations to your plan beginning in 2011.
It is very easy to look up your benefit information with
Delta Dental’s Consumer Toolkit. You can access the
toolkit 24 hours a day, seven days a week.
•Bite-wing x-rays:
- Bite-wing x-rays for adults will be
covered once in two calendar years.
- Bite-wing x-rays for members age 12 to 18
will be covered once in 18 months.
- Bite-wing x-rays for members under age 12
will be covered once in a calendar year.
With Consumer Toolkit, you can:
•Print ID cards
•Check eligibility
•Review up-to-date benefit information,
including available maximum
•Check current and previous claims
The Consumer Toolkit is fast and easy to use. To log in:
•Go to www.DeltaDentalTn.com/statetn .
Click on “For Subscribers.”
•Replacement of Crowns, Bridges and Dentures:
•Enter your ID number without extra spaces.
This is the ID number on your new ID card.
-
•Select your relationship to the subscriber.
The subscriber is the person whose name is
on the benefit package.
The replacement or repairs of crowns,
fixed bridges, and partial and complete
dentures will now be covered after
seven years instead of five years.
New ID Numbers
You will have a new ID number beginning
January 2011. Delta Dental will send you a new
ID card with the new number. You must use this
new ID number when using the Consumer Toolkit®*
online. You may also use this number at your
dentist’s office or when calling Delta Dental.
The State of Tennessee and Delta Dental are
making this change to better protect your
personal information.
*Consumer Toolkit is a registered trademark of Delta Dental Plan of Michigan.
•Enter your date of birth in mm/dd/yyyy format.
Once logged in, you can find the information you need
using the menu on the left side of the screen.
Need help? Click on the Help link or call Delta Dental
at (800) 223-3104.
Protect Your Overall Health
Your oral health and overall health are very closely
connected. Stroke, heart disease, diabetes and low
birth weight have all been tied to gum disease.
Plus, poor oral health makes it hard to consume
healthy foods, which affects your entire body. Learn
more about how your oral health affects your overall
health at www.DeltaDentalTn.com/OralHealth.
I
Benefit Summary
State of Tennessee’s PDO Option Plan
ACTIVE EMPLOYEE RATES
Employee Only. . . . . . . . . $19.14
Employee + Spouse. . . . . $36.20
Employee + Child(ren). . . $44.01
Employee + Family. . . . . . $70.84
RETIREE RATES
Retiree Only. . . . . . . . . . $24.72
Retiree + Spouse. . . . . . $46.75
Retiree + Child(ren). . . . $56.83
Retiree + Family. . . . . . . $91.48
Calendar Year Maximum amount per person per year for all
expenses from in-network and out-of-network providers combined.
Delta Dental
PPO Network
Benefits
$1500
Lifetime Orthodontics Maximum amount per person per lifetime
for all expenses from in-network and out-of-network providers combined. $1250
Annual Deductible
Deductible does not apply to Diagnostic and Preventive Services
No Deductibles
Diagnostic and Preventive Services
• Oral examinations – 2 in a calendar year
• Prophylaxis (cleanings) – 2 in a calendar year
• Bitewing x-rays – 1 set in 2 years for adults; 18 months for
ages 12 to 18; a calendar year for ages less than 12.
• Sealants to age 17
• Fluoride treatment to age 14
• Space maintainers to age 16
• Evidence-based benefits (up to 4 cleanings per calendar year for
certain members with high-risk health conditions)
100%*
80%*
Basic Services
• Restorative (fillings)
• X-rays
• Simple extractions
80%*
60%*
Major Services
• Denture repair
• Denture rebase & reline
• Endodontics (root canal therapy)
• Oral surgery (extractions including surgical removal of teeth)
• Periodontics (treatment of gums and bones supporting teeth)
• Implants 12-month waiting period
• Bridges (fixed and removable) 12-month waiting period
• Partial dentures 12-month waiting period
• Full dentures 12-month waiting period
• Crowns and cast restorations 12-month waiting period
50%*
50%*
Orthodontic Services 12-month waiting period
• For dependents to age 19
50%*
50%*
Waiting Periods: Waiting periods begin on your effective date.
*Maximum Plan Allowance (MPA) – You are not responsible for charges exceeding the MPA if you go to a
participating Delta Dental PPOSM dentist. You are responsible for charges exceeding the MPA if you go to a
non-participating dentist. The MPA charges are based on fees charged in your geographic area.
If you drop your coverage while eligible, you cannot re-enroll in the plan until the next annual enrollment
transfer period following 12 consecutive months without coverage, unless you have a life status change.
II
Out of
Network
Benefits
$100 Per Person
$300 Per Family
Frequently Asked
Questions (FAQs)
Q. Who Is Eligible For the PDO Plan?
Q. Where Do I Get Answers To Questions
About Dentists or Claims?
A. There are many ways to find answers to your
questions about dentists and claims.
A. You, your spouse and eligible dependents under the
age of 26 can get dental coverage under this plan.
Review your Employee Insurance Handbook to see if
your dependent is eligible. You can get a copy of this
handbook from your agency benefits coordinator.
Visit our Web site at
www.DeltaDentalTn.com/statetn to:
• Find out if your current dentist is in
the Delta Dental PPO network
• View your benefits
Q. What Dentists Can I Visit
• Print an ID card
• Check eligibility
A. You may choose any dentist with this plan.
It is best to visit a dentist in the Delta Dental
PPOSM network. Here are some reasons why:
• Check claims status
With This Plan?
•In-Network Benefits – You will save the most
money and get the most from this plan when you
visit a dentist in the Delta Dental PPO network.
•A Delta Dental PPO Dentist will fill-out and
submit claim forms at no charge to you. Dentists
who are not in the network may require you to
fill out forms or pay a service charge.
•Delta Dental pays dentists in the network an
agreed upon amount known as the maximum
plan allowance. You will only have to pay your
co-insurance amount if you see a Delta Dental
PPO Dentist. That means you are not responsible
for charges that exceed the maximum plan
allowance. There is no deductible when you
visit a Delta Dental PPO Dentist.
•Delta Dental PPO Dentists will not charge you
more than your co-insurance amount. You
do not have to pay the whole bill and wait for
reimbursement.
•A dentist outside the Delta Dental PPO network
may charge more than the maximum plan
allowance. If you see a dentist who charges
more than the maximum plan allowance,
you have to pay the difference between the
maximum plan allowance and the dentist’s
fees, plus your deductible and/or co-insurance.
You may also have to pay the entire bill in
advance and wait for reimbursement.
Contact Us By Phone
Call us at (800) 223-3104. Our automated
phone system is available to quickly answer your
questions 24 hours a day, seven days a week.
Should you need more help, our Customer
Service Representatives can answer your
questions Monday through Friday from
7 a.m. to 5 p.m. Central.
Talk To Your Dentist
Talk to your dentist and ask if he or she is
in the Delta Dental PPO network.
Q.How Do I Start Receiving Treatment?
A.On or after your effective date of coverage, you may
call your dentist and make an appointment.
If your dentist is in the Delta Dental PPO network,
he or she will complete and submit a claim for you
at no charge.
If you go to a dentist that is not in the Delta Dental
PPO network, you may have to submit your claim to:
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228
Q. How Do I Pre-Determine My Benefits?
A. You may want to know how much your dental
work is going to cost before treatment. Ask
your dentist to request a pre-determination.
A pre-determination will tell you how much the
services will cost. It will also tell you how much
you will have to pay. Pre-determinations are not
required and are not a guarantee of benefits.
III
Q. What is Balance Billing?
A. The dentists in the Delta Dental PPO network
have agreed to accept a maximum fee for covered
procedures. This is the maximum plan allowance
(MPA). Dentists in the network have agreed to accept
the MPA as full payment and will not bill you for any
fees above the MPA.
If you visit a dentist outside the Delta Dental PPO
network, you will have to pay for fees above the MPA.
This is balance billing. You will also have to pay for
your deductible and/or co-insurance.
Delta Dental “Safety Net”— You will save the most
money by visiting a dentist in the Delta Dental PPO
network. You can also save money by visiting a
dentist in the Delta Dental Premier network.
Delta Dental has negotiated rates with dentists
in the Premier network, which may save you and your
family money over seeing a dentist who is
not a PPO or Premier dentist. The amount you may
be balanced-billed is limited if you see a dentist
in the Premier network.
To find out if your dentist is a Delta Dental
Premier dentist, visit our Web site at www.DeltaDentalTn.com/statetn or call
your dentist’s office.
Q.What If My Family Is Covered By Two
Dental Programs (Dual Coverage)?
A. The first or ‘primary’ carrier is the one that covers
you as the primary enrollee. For example, if you and
your spouse have different dental plans, your primary
carrier is the one provided at your work.
If your children are covered by two or more dental
programs, the primary carrier is determined by the
“Birthday Rule.” The Birthday Rule means the dental
carrier of the parent or guardian whose birthday
comes first in the calendar year is the primary carrier.
This Birthday Rule may be superseded by a divorce or
court ruling.
Delta Dental will work with the primary carrier so
the costs for a treatment are not paid twice. Delta
Dental’s payment will be based on how much
remains after the primary carrier pays. Delta Dental
and the primary carrier will not pay more than the
total amount submitted by the dentist.
The purpose of this plan is to help you meet the cost
of dental care. It is not intended to provide benefits
greater than actual expenses that are incurred. In all
cases, the benefits under both plans will not total
more than the dentist’s billed fees.
IV
Q. What Is Not Covered?
A.Delta Dental of Tennessee does not pay
benefits for the following:
• Treatment for anything that would be covered by
Workers Compensation or Employer Liability Laws.
• Free services from any federal, state, or
local agency. Depending on state law, this may
not apply.
• Services performed for looks rather than health,
such as teeth whitening.
• Services for hereditary or developmental
malformations, such as cleft palate and upper
and lower jaw malformations. If orthodontic
benefits are provided, some of these services
may be covered.
• Treatment needed for wear on the teeth,
such as erosion due to teeth grinding.
• Treatment to rebuild or maintain chewing surfaces
when teeth are out of alignment, or treatment to
stabilize teeth.
• Fees associated with instruction on proper
oral hygiene and diet, treatment for drugs or
medication, unproven treatments, conscious
sedation and grafting of tissues formed outside
the mouth to oral tissues.
• Charges from a hospital or other surgical
treatment facility. Also includes dentist fees
for treatment at these facilities.
• Treatment for the jaw joint or myofacial
pain dysfunction.
• General Anesthesia or I.V. Sedation is only
covered when given by a licensed DENTIST.
The anesthesia or sedation must be given in
a dental office and must be used for a covered
procedure or when medically necessary
because of concurrent medical conditions.
• The original placement of a denture that
replaces natural teeth already missing when
the person’s coverage begins.
• Services by a dentist beyond the scope of
his or her license.
• Dental services for which the member
is not charged.
While this brochure highlights some of the features of
our plan, this is not a Certificate of Coverage (COC). You
will receive (or have already received if currently enrolled)
a COC that has complete details about your dental plan.
You may also review your COC online at
www.DeltaDentalTn.com/statetn.
PPO Directory
The following is a directory of licensed Tennessee dentists who have signed contracts to provide professional services
under Delta Dental. It is not to be considered a recommendation that a particular dentist be consulted for professional
care. Every effort has been made to prepare this list accurately, but Delta Dental assumes no responsibility for possible
mistakes or omissions. It should also be noted that the dentists in this directory may not participate in our network for
each location listed. We strongly recommend that you ask your prospective dentist about his or her current status
with Delta Dental, confirm the dentists’ status through our online directory (www.DeltaDentalTN.com/statetn), or
call customer service (800-223-3104) prior to your dentist office visit.
New PPO Providers
Brentwood
hermItAge
Lauren Wilburn
Regina Ferguson
GENERAL DENTIST
615-778-0810
GENERAL DENTIST
615-885-3525
8112 Isabella Lane
Suite 101
Brentwood, TN 37027
4761 Andrew Jackson Pkwy
Hermitage, TN 37076
CHATTANOOGA
Brittany S. Maynord
SNODGRASS KING
PEDIATRIC DENTAL
ASSOCIATES
Anuj Soni
GENERAL DENTIST
GENERAL DENTIST
423-305-6400
625 Morrison Springs Road
Chattanooga, TN 37415
4761 Andrew Jackson Pkwy
Hermitage, TN 37076
615-885-3525
Jay T. Rasmussen
AFFORDABLE DENTAL
OF TENNESSEE
CROSSVILLE
GENERAL DENTIST
615-340-8500
Don Flanagan
Orthodontist
931-484-3007
5045 Old Hickory Blvd
Suite 102
Hermitage, TN 37076
1720 West Avenue
Suite 106
Crossville, TN 39555
maryville
Mark Kalchthaler
Spring Hill
Rodric Miller
GENERAL DENTIST
901-373-5433
5124 Stage Road
Memphis, TN 38134
Anthony V. Price
CREATIVE SMILES
GENERAL DENTIST
1440 E Shelby Drive
Suite 5
Memphis, TN 38116
901-332-8729
2900 Kirby Road
Suite 9
Memphis, TN 38119
901-755-7392
Murfreesboro
Brittany S. Maynord
SNODGRASS KING
PEDIATRIC DENTAL
ASSOCIATES
GENERAL DENTIST
1747 Medical Ctr Pkwy
Suite 300
Murfreesboro, TN 37129
615-225-0700
ENDODONTIST
865-982-8000
Brittany S. Maynord
SNODGRASS KING
PEDIATRIC DENTAL
ASSOCIATES
312 High Street
Maryville, TN 37804
GENERAL DENTIST
memphis
125 Cool Springs Blvd
Suite 140
Franklin, TN 37067
615-771-1111
ORAL SURGEON
615-343-0633
Jonathan W. Hall
CHRIST COMMUNITY
HEALTH SERVICES INC
3601 The Vanderbilt Clinic
Nashville, TN 37232
GENERAL DENTIST
Jay T. Rasmussen
AFFORDABLE DENTAL
OF TENNESSEE
Bradley Greives
GENERAL DENTIST
615-824-7220
104 Hazel Path
Suite 1
Hendersonville, TN 37075
nashville
S
teven Evelhoch
2595 Central Avenue
Memphis, TN 38104
901-458-9088
2877 Poplar Avenue
Memphis, TN 38111
901-324-0093
3362 S 3rd Street
Memphis, TN 38109
901-271-6371
GENERAL DENTIST
5073 Main Street
Suite 240
Spring Hill, TN 37174
615-302-4200
Tullahoma
James Cantrell
GENERAL DENTIST
931-454-0001
1958 N Jackson Street
Tullahoma, TN 37388
FRANKLIN
Hendersonville
Brittany S. Maynord
SNODGRASS KING
PEDIATRIC DENTAL
ASSOCIATES
GENERAL DENTIST
615-340-8500
328 22nd Avenue N
Nashville, TN 37203
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90
Updated: 8/10
Printed in USA.
©2010 Delta Dental of Tennessee
All rights reserved.
127-0810
70K

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