dental HMO plan

find a network provider

With an HMO you must visit a provider in the HMO’s network, otherwise your services aren’t covered (except for certain emergency situations).

overview

DeltaCare USA is the claims administrator for the Chevron Dental HMO Plan.

dental HMO ID cards

Prior to January 1, you should receive a confirmation from DeltaCare in the mail containing your primary care dentist name, your Enrollee ID, an ID card and a description of your benefits from DeltaCare. This package will also provide instructions about how you can change the primary care dentist auto assigned to you. Be sure you take action right away if you want to change to another DeltaCare USA network primary care dentist.

You don’t need an ID card to receive services even though you’ll receive one. Just tell your dental office that you’re covered by DeltaCare USA and provide your Name, Date of birth, Employer Name, and Enrollee ID number (or social security number). If you have enrolled dependents, tell them to provide your details, not their own.

what’s my enrollee ID?

Your social security number can be used to identify you, but we all want to avoid sharing that number whenever possible. Your Enrollee ID is a safer choice. Your Enrollee ID will be included in your welcome kit.

delta dental website

To register on the Delta Dental website or mobile app:

  • Go to www.deltadentalins.com/chevron.
  • Click on Register Today in the Online Services section.
  • You’ll need to provide some basic information to verify your enrollment account. You will provide your social security number as you will not yet have your Enrollee ID. This is a one-time request only. You’ll get to setup your own username and password as part of the registration process.

If you were enrolled in the Chevron Dental PPO or Dental HMO Plan in 2017*, we requested that you receive at least one preventive dental cleaning** between January 1 and December 31, 2017. If you did not participate in this preventive care measure in 2017, you will pay a dental surcharge - $120 more for your annual Dental PPO or Dental HMO Plan premium in 2018. Your Chevron dental plan and the HR Service Center has now completed a verification process to determine if the dental surcharge applies to you in 2018. You can view your dental surcharge status on the Benefits Connection website or by calling the HR Service Center

If it was determined that the dental surcharge does in fact apply to you in 2018, you will be mailed a revised confirmation statement from the HR Service Center by the end of the first quarter of 2018. If applicable, the $120 dental surcharge will be applied to your Chevron Dental PPO or Dental HMO Plan coverage over 20 pay periods beginning in March 2018. The dental surcharge will also appear as a separate payroll deduction line item on your pay statements. 

If you believe the dental surcharge was assessed to you in error, you may dispute the assignment as follows:

  • Contact your dentist for documentation related to the preventive treatment. To be considered, the documentation must include
    • Dental provider’s name.
    • Date of service in 2017.
    • Your name (the employee) as the patient.
    • An eligible procedure code of D1110, D4910 or D4355
  • Once you have the appropriate documentation, you must submit the documentation to the HR Service Center by either postal mail, or by uploading to the Benefits Connection website, as follows:
    • Login to Benefits Connection
    • Choose Upload Documents from the far upper right corner of the screen. 
    • Choose Upload New Document
    • Choose the Health and Welfare Category, and then Dental Cleaning Proof.
    • Your dispute will be reviewed and you’ll be informed of the results upon completion of the review.

* If you were hired on or after October 1, 2017 the dental surcharge does not apply to your Chevron dental coverage in 2018.

** For participants with dentures, receive at least one oral exam in lieu of a cleaning.

If you are currently enrolled in the Chevron Dental PPO or Dental HMO Plan in 2018, you're encouraged to take steps to protect your health and receive at least one preventive dental cleaning* between January 1 and December 31, 2018. If you do not participate in this preventive care measure in 2018, you will pay $120 more for your annual Dental PPO or Dental HMO Plan premium in 2019. It's still your choice to receive a cleaning or not, but if you choose to participate, you'll save money in 2019 and you'll be doing something good for your health.

  • The procedure codes of D4346, D1110, D4910 and D4355 are considered eligible preventive dental care; these procedures will satisfy the cleaning requirement to avoid the dental surcharge in 2019. 
  • Procedure codes D4341 and D4342, often referred to as deep cleaning, are treatments for periodontal disease; these procedures do not satisfy the cleaning requirement to avoid the dental surcharge in 2019.

You do not need to do anything to report completion of your cleaning. Delta Dental and the HR Service Center will conduct a separate verification process in early 2019 to determine if the dental surcharge applies to you. If it is determined that the dental surcharge does in fact apply to you in 2019, the Benefits Connection website will be updated and you will be mailed a revised confirmation statement by the end of the first quarter of 2019. If applicable, the $120 dental surcharge will be applied to your Chevron Dental PPO or Dental HMO Plan coverage over 20 pay periods beginning in March 2019. The dental surcharge will appear as a separate payroll deduction line item on your pay statements.

We know dental exams — like many other preventive care exams — are not exactly fun. But there’s a reason they are covered by your plan; they are important to good health. Chevron’s dental plans already cover at least two preventive dental cleanings per year; that will continue in 2018. And covered preventive dental services are generally 100 percent paid by your plan, with no annual maximum, deductible or copayment when you use a network provider (a copayment may apply for some dental HMOs).

* For participants with dentures, receive at least one oral exam in lieu of a cleaning.

network providers

A network is a group of independent dental care providers that have agreed with your dental plan claims administrator to charge contracted fees for services provided to plan members.

With an HMO you must visit a provider in the HMO’s network, otherwise your services aren’t covered (except for certain emergency situations). If your provider is not in the network, you will need to change providers or choose a new dental plan option to ensure that your dental services continue to be covered.

primary care dentist

You must visit your selected DeltaCare USA primary care dentist to receive benefits under your Dental HMO Plan. Most services not performed by your primary care dentist must be authorized by DeltaCare. You must select a DeltaCare USA network dentist in order to access benefits under the Dental HMO Plan. When you first enroll in the Dental HMO Plan, you will be auto assigned to a primary care dentist, when applicable, by DeltaCare. You will receive a confirmation in the mail containing your primary care dentist name, your Enrollee ID, and ID card and a description of your benefits from DeltaCare. This package will also provide instructions about how you can change the primary care dentist auto assigned to you. Be sure you take action right away if you want to change to another DeltaCare USA network primary care dentist.

understanding open access

If you’re enrolled in the Chevron Dental HMO Plan with DeltaCare USA and you reside in one of the states listed below, you’re in what is referred to as an open access state. When you’re in an open access state, there are a few procedural differences regarding your benefit that you should know about. Open access states for the Chevron Dental HMO include the following: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT, WY.

Please note: This page applies to U.S.-payroll employees. This page provides only certain highlights of benefits or program provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and legal plan documents, the legal documents will prevail to the extent permitted by law. This is not a plan text or a summary plan description. There are no vested rights with respect to Chevron health care plans or any company contributions toward the cost of such health care plans. Rather, Chevron Corporation reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to union represented employees.