CDA Practice Support continues to hear from member dentists impacted by Delta Dental of California’s contractual change under Participating Dentist Rule 2, Basis of Fees that took effect September 15, 2018. This rule change results in dental practices being compensated at the applicable Delta Dental PPO fee when a “Premier Contracted Fee” is not on file for a specific procedure.
In a letter mailed to participating providers in January 2018, Delta Dental of California shared revisions it made to its provider participation documents.
Appendix A – California Participating Dentist Rule 2 — was revised and now states:
Basis of Fees. A participating dentist will accept the lesser of his/her “Contracted Fees”* with Delta Dental, or the fee submitted on his/her Attending Dentist’s Statement, as full payment for services provided to any eligible patient.* If the participating dentist does not have a Contracted Fee for a Premier program (“Premier Contracted Fee”) with Delta Dental for a particular procedure submitted on an Attending Dentist’s Statement, payment will be based on the applicable Delta Dental PPO fee schedule(s).
The letter stated that the change would be in effect no sooner than Aug. 1, 2018. As noted above, Delta Dental implemented the rule on Sept. 15, 2018.
How does a rule change that became effective nearly three years ago continue to impact dental practices today?
The American Dental Association adds, deletes and revises codes in the Code on Dental Procedures and Nomenclature on an annual basis. Due to this process, dental practices can be impacted when the annual additions and deletions of the CDT codes take effect Jan. 1 of every year.
Here is one example of how the Delta rule change can continue to have a negative impact on a dental practice if the practice does not carefully consider and take action annually.
Earlier this year, a dentist performed and billed Delta Dental for a frenectomy using one of the new 2021 CDT codes. The office received payment for the service and found that it was lower than the Premier fee they once had for the now deleted code frenectomy D7960. During the analysis of the issue, it was found that the office did not propose a fee for the two new 2021 CDT codes for frenectomy, so the claim was paid at the applicable Delta Dental PPO fee.
Time fee updates strategically based on CDT code updates and Delta Dental’s fee submission policy.
Under Delta Dental’s current compensation policy, contracted providers submit separate Delta Dental Premier fee update requests for each practice location, specialty and taxpayer identification number every 12 months from the last submission. While Delta Dental allows dentists to submit a fee proposal for missing code(s) on the dentist “Premier Contracted Fee Schedule,” doing so outside of the fee-filing anniversary date, can reset the dentist’s fee-filing anniversary date.
CDA Practice Support is here to answer your dental benefit questions and offer individual member assistance. Submit your questions online using the dental benefit submission form accessible through your cda.org account. Once received, Practice Support will analyze the issue, evaluate it for possible resolution and communicate clear next steps. To get started, visit My Account, click the link for Dental Benefits Issue Submission and follow the prompts.
Find resources on dental benefit plans in the CDA Practice Support resource library.