Dental Expense Claim Form

Download a copy of the new Delta Dental form here and print it before going to the dentist.Please review the instructions on the back (page 2) of the form before completing it. Mail completed form with original bill to:

Delta Dental
P.O. Box 9085
Farmington Hills, MI 48333-9085

Want to appeal Delta's decision on your claim?

To request a formal appeal of your claim you must contact Delta Dental in writing. Your written request must be submitted within 180 days of the date on which you receive your notice of the adverse benefit determination you are asking Delta Dental to review to:

Dental Director- Delta Dental of Ohio
P.O. Box 30416
Lansing, Michigan 48909-7916

Indicate in your letter that you are requesting a formal appeal of your claim; include your name and address, the Subscriber’s Member ID number, the reason you believe your claim was wrongly denied, and any other information you believe supports your claim.

The Dental Director or any other person(s) reviewing your claim will assess the information, including any additional information that you have provided, as if he were deciding the claim for the first time. The Dental Director will make his decision and you will be notified in writing within 30 days of receiving your request for the review of Pre-Service Claims and within 60 days for Post-Service Claims.

A copy of the appeal process is available at www.benefitstrust.org or from UBT’s customer service.