Members

Frequently Asked Questions

 

Web Registration

How do I manage my Altus Dental plan online?
Registering to use our online services is a convenient and secure way to manage your Altus Dental plan. Log in to see your benefits, eligibility and claims information, and to register to receive e-mail notifications when you have a claim.

To get started, enter your first and last name, along with your Altus Dental identification number as it appears on your ID card. Click here to register.

If you don't have an ID card, you can use the following information to register:

  • First/last name
  • Date of birth
  • Number of people covered on your plan


What type of browser do I need to view my account?

Our online services are compatible with multiple browser platforms, including Safari, Chrome, Firefox, Edge, and Internet Explorer Version 11. We recommend using the latest version of your browser to get the most from our website features.


I lost my password or username. How can I access my online account?
You can re-set your password and/or user name. Click on Forgot user name or Forgot password in the log-in box and follow the instructions.


Eligibility

Who is eligible to receive services on my dental plan?
Your employer or plan sponsor decides who is eligible and what services your plan covers. Typically, an individual membership covers only you. A family membership covers you, your spouse, dependent children until they turn age 21 (or age 26, depending on your plan), and handicapped dependent children over age 21 who are mentally or physically incapable of earning their own living.


Is my dependent child covered after age 21?
Your employer or plan sponsor decides who is eligible to be covered by your plan. Some plans have extended dependent coverage to age 26, in keeping with Affordable Care Act guidelines. If your plan extends dependent coverage to age 26, we do not need any additional documentation for dependents over age 21.

Student Coverage
Some plans offer dependent coverage for students. If your employer or plan sponsor offers dependent coverage for students, you'll need to certify your dependent’s student status annually.

Note: You may need to re-certify your student once or twice a year. This process takes place when a dependent reaches the maximum age and during your plan’s annual re-certification process. Check with your Plan Administrator for program requirements. Your Plan Administrator can answer any questions you may have about who is covered under your plan beyond the dependent age limitations.


Benefits

What does my plan cover?
There’s no one answer to this question, since our plans are designed based on a group’s needs. The best way to learn more about your dental coverage is to register to use our online services. You can see your benefits, including these details:

  • Benefits & Eligibility: See a detailed summary of your benefits, including eligibility dates and who is covered under your plan. You can also verify your plan type and confirm whether deductibles apply to a particular dental service.
  • Time & Frequency: See how you’ve used any of your benefits that have time and/or frequency limitations (for example, how many cleanings or x-rays you've had to date, as well as the next time you're eligible for services).
  • Deductibles & Maximums: See your deductible and maximum amounts, as well as remaining balances for different types of services (for example, annual maximums and orthodontic maximums).

You can also print or order a new ID card online, and check the status of a claim in progress.


What happens when I reach the annual maximum on my dental coverage?
If you or any covered dependent receives services normally covered by your plan after you have exceeded your annual maximum amount, your participating dentist may charge you more than the Altus Dental approved allowance for that service. However, if Altus Dental makes even a partial payment for a covered service before you exceed the maximum, then your participating dentist can’t bill you more than the Altus Dental allowance for that service.


What if I don't use my entire annual maximum in a given year?
If you don’t use your entire annual maximum within a calendar or policy year (depending on your plan guidelines), you will lose any remaining balance on your annual maximum.


What is the difference between a lifetime maximum and an annual maximum?
A lifetime maximum is a specific one-time allowance that does not renew (Orthodontic coverage has a lifetime maximum). Annual maximums are based on a calendar year or a policy year, and renew annually. Check with your Plan Administrator about your specific plan’s coverage details.


Do you cover white (also called composite) fillings on back teeth?
Coverage for white (composite) fillings on back teeth is based on your group's policy. If your group offers this coverage, we will pay for a composite filling based on the coverage level determined by your plan. If you do not have coverage for composite fillings on back teeth and you choose to get one, we will pay up to what we would have paid for a silver (also called amalgam) filling. You will be responsible for the difference in cost between what Altus Dental allows for a silver filling and the dentist's submitted charge.


Orthodontic Benefits

How are orthodontic services (braces) covered?
Not all plans cover orthodontic services, so check with your Plan Administrator to see if this is a covered benefit for you under your plan. If you do have orthodontic coverage, please log in to your online account to read the Orthodontics section of our Utilization Review Guidelines for a complete overview of how we cover orthodontic services. We recommend a pre-treatment estimate for all orthodontic treatment plans. Some plans cover medically necessary orthodontics; treatment for medically necessary orthodontics must be authorized in advance or no payment will be made. The fee for orthodontic treatment includes all diagnostic procedures (exams, photographs, appliances, post-treatment stabilization, etc.).

Orthodontic benefits are available only for members under age 19, unless your employer group has purchased coverage for adult orthodontics. Orthodontic coverage ends on the day before the member's 19th birthday. Benefits are not payable for orthodontic services received prior to the effective date and/or after the termination date.


Participating vs. Non-Participating Dentists

Do I have to go to a particular dentist?
You’re free to choose any dentist, but it’s important to know that your out-of-pocket costs may be higher when you visit a dentist who does not participate with Altus Dental. Members who visit a participating dentist can expect:

  • Protection against “balance billing.” Participating dentists agree to accept our payment as payment in full – minus any applicable deductibles or co-insurances. You won't be billed for any remaining balances unless you’ve reached your annual maximum or the service is not a covered benefit for you.
  • Direct claim submission. A participating dentist will file your claims directly with us and handle any paperwork.

Note: Exams and consultations by some specialty dentists may not be covered by your plan. Check your benefits for full coverage details.


How do I find a participating dentist?
Use our Find A Dentist tool to see if your dentist participates with us or to find a new participating dentist near you. You'll need your Altus Dental ID card to see if you have access to the Connection Dental national network. Click here to log in and view or print your ID card.

Find A Dentist will give you the dentist’s name, address and phone number, as well as office hours, languages spoken, handicapped accessibility and tell you if the office is accepting new patients.


What happens if I visit a non-participating dentist?
If you choose to visit a non-participating dentist, your out-of-pocket costs may be higher. You may also have to pay the dentist upfront and file your claim yourself. Ask the dentist to complete a standard American Dental Association (ADA) claim form for you.

Claims should be sent to:
Altus Dental Insurance Co., Inc.
P.O. Box 1557
Providence, RI, 02901-1557


Will my Altus Dental plan cover me if I need care outside of the U.S.?
If you have a dental emergency when you are out of the United States, you can see any licensed dentist for services. Typically, you must pay at the time of service, and we will reimburse you directly based on the current rate of exchange. To help us process your claim in a timely manner, ask the dentist for a billing statement that includes the treatment you received, the tooth number, the date of service and the total cost of the service. If possible, have the billing statement translated into English. Click here to download a claim form.


Claims

Do I need to submit a claim form?
Participating dentists will file claims for you. Many non-participating dentists may submit claims on your behalf; call the dentist's office before you visit to make sure. If you need a claim form, you can download one here.

Claims should be sent to:
Altus Dental Insurance Co., Inc.
P.O. Box 1557
Providence, RI 02901-1557


Do any dental procedures require prior authorization?
Referrals and prior authorization are not required (except for medically necessary orthodontic treatment). However, we recommend that your dentist file a pre-treatment estimate with us for any service that is expected to cost $300 or more. We will review the treatment plan and let you and your dentist know in advance whether a particular service is covered under your plan.

For services that your dental plan does not cover at 100% (such as crowns, bridges and certain surgical procedures), a pre-treatment estimate lets you know what your out-of-pocket costs will be. The treatment plans for major restorative services like crowns and bridges need to be reviewed and approved to make sure that the service meets our Utilization Review Guidelines. It's always in your best interest to have your dentist obtain a pre-treatment estimate before doing the work.

Note: Coverage decisions on pre-treatment estimates are guaranteed for up to one year of receipt, and apply only to the dentist who submitted the pre-treatment request. Payment for the service is not guaranteed because pre-treatment estimates reflect your remaining benefit dollars at the time of the estimate. For example, if you had other dental services done after the pre-treatment estimate and have reached your annual maximum, you may not have any remaining benefit dollars to pay for the estimated service.


How can I check to see if my claim was paid?
Log in to your online account to check the status of a claim or to view a claim in progress. You can also see the following information online:

  • Pre-treatment estimates for the last three months
  • Explanation of Benefits (EOBs) for any processed claim
  • Summary of paid or in-process claims for the last six months

Or, call our Automated InfoLine at 1-877-223-0588 for a “fax back” summary of claims paid or in process for the past six months, as well as pre-treatment estimates for the last three months.


I received an Explanation of Benefits (EOB) and I'm not sure if I owe any money to the dentist.
An Explanation of Benefits (EOB) is a detailed description of the dental service(s) you received, the date the service was provided, the dentist's charge, what Altus Dental will pay and what – if any – payment responsibility you may have. Check the “Processing Policies” field for special messages explaining the reason(s) for any action we may have taken to approve or deny a procedure. You should always check with your dentist to determine if you owe additional payment. Finally, you should review the information on the EOB carefully to ensure that it accurately reflects the services you received.


Appeals Process

My claim submission was denied. How can I appeal this decision?
There are two types of appeals – Administrative Appeals and Utilization Review Appeals.
An Administrative Appeal asks us to reconsider a claim that we denied based on the provisions of your group's contract. A Utilization Review Appeal asks us to reconsider a claim that was denied or disallowed because of a decision about the dental necessity of the procedure, in accordance with Altus Dental's Utilization Review Guidelines.

Learn more about our Consumer Rights and Appeals process.

Log in to your online account to read our Utilization Review Guidelines.

Complaints Process

A complaint is when a member, authorized representative or provider tells us they are dissatisfied with any part of our practices or the quality of care received. A complaint can be made over the phone, in an email or in a letter.

A complaint differs from an appeal, which is when a member or provider asks us to review a decision not to authorize a service (known as an "adverse benefit determination," which can include denials, reductions, terminations or decisions not to provide or make a payment for a benefit). You can learn more about our appeals process and how to make an appeal in the Consumer Rights and Appeals document found in the Members and Dentists sections of our website. We also explain our appeals process on the back of every Explanation of Benefits and Pre-treatment Estimate form.

You can file a complaint in three different ways:

  • Send an email to customerservice@altusdental.com
  • Call (401) 457-7200 or (877) 223-0588
  • Send a letter to Altus Dental Insurance Company, Attn: Complaints, P.O. Box 1557, Providence, RI 02901-1557

We typically settle most complaints on first contact. Sometimes, we need to do more research, especially if a complaint is about the quality of dental care or if it might involve fraud or abuse. We will respond to complaints within 30 calendar days unless an extension is granted. Rhode Island residents or those who received services in Rhode Island and are not satisfied with the result of a complaint to us may contact the Office of the Health Insurance Commissioner.

Those who live in Rhode Island or received services in Rhode Island and need additional assistance with a complaint may contact the Rhode Island Resource, Education and Assistance Consumer Helpline (RIREACH) at 1-855-747-3224 or at 300 Jefferson Blvd, Suite 300, Warwick, RI 02888. Visit the RIREACH website at www.rireach.org for more information.


Coordination of Benefits (COB)

Do you coordinate benefits?
Yes, we coordinate benefits when a member is covered by more than one employer-sponsored dental insurance plan. We typically use standard insurance industry guidelines to decide the order in which plans will make benefit payments. Coordinating benefits helps you meet your out-of-pocket costs, such as co-insurance and deductibles. Generally, if your primary plan has paid for a dental service and there are no out-of-pocket costs remaining for you, your secondary carrier will not make a benefit payment.


Do you coordinate benefits for pre-treatment estimates?
We don’t coordinate benefits for pre-treatment estimates because these estimates are subject to change. Coordination of benefits happens after you have a dental service, based on any payment made by your primary plan.


What is a “non-duplication of benefits” clause?
Some employer group contracts include a “non-duplication of benefits” clause that specifies the “integration” of benefits, rather than coordination of benefits. With a non-duplication of benefits clause, total payments from both plans won’t ever be more than the amount the dental plan would pay if it was your only coverage — your benefits are never duplicated.

As an example, if you and/or your spouse's dental policy covers two dental exams, you can’t get two exams from the primary plan and two from the secondary plan. You may get a total of two exams.

Here’s another example of non-duplication of benefits:  Your primary dental plan covers crowns at 50%. Your secondary plan also covers crowns at 50%. In this situation, no additional payment would be made by the secondary plan and total coverage would be at 50%. But if your primary dental plan covers crowns at 50% and your secondary dental plan covers crowns at 80%, benefits would be coordinated to pay the additional 30%.


Individual Coverage

Does Altus Dental sell individual policies?
Altus Dental offers a few options for individuals. With Altus Dental for 1, you get access to cleanings and other preventive services that help keep your smile healthy, as well as coverage when dental problems arise, all for a one-time enrollment fee and low monthly premium. We also offer dental plans for individuals through our partnership with the Massachusetts Health Connector. Members of some organizations also have access to dental plans through our partnerships with certain Chambers of Commerce and AAA Dental Plan for Massachusetts residents.


Group Coverage

Altus Dental sells group plans to Massachusetts-based employers. We look forward to working with you to create a plan that fits the needs of your company and your employees. Contact Employer Support to speak with a member of our sales staff today.


Ordering ID cards

I've lost my Altus Dental identification card. What should I do?
Log in to your online account to print a paper copy of your ID card or to order a replacement card by mail. Allow five to 10 business days for processing and mailing. We provide one card for individuals and two cards for family plans. Remember: All ID cards are issued in the subscriber's name only.


Affordable Care Act

What is the Pediatric Dental Essential Health Benefit?
The Affordable Care Act (ACA) requires that health insurance plans cover 10 essential health benefits for individuals and small groups (employers with 50 or fewer full-time equivalent employees). Pediatric dental benefits are one of these 10 essential health benefits.

To learn more about the Pediatric Dental Essential Health Benefit, click here.


Who is eligible for Medically Necessary Orthodontia under the ACA?
The Pediatric Dental Essential Health Benefit includes coverage for orthodontic services that are considered medically necessary for children under age 19 with serious orthodontic impairment that results from congenital abnormalities that affect their daily ability to function (for example, eating and speaking). Under the ACA, there are no lifetime or annual maximum limitations for medically necessary orthodontia, which is covered at 50%. Click here for more details.