There is an ongoing trend within health care toward integration and consolidation of health care delivery systems. This trend is reflected in provisions of the federal Affordable Care Act, such as the envisioned coordination of care provided under a single entity, the "Accountable Care Organization." The objective of such integration and consolidation is to provide better management of care, create greater efficiencies in the provision of care and improve patient outcomes.

CDA Practice Support occasionally hears a complaint from dental offices that a plan granted a preauthorization for treatment and then denied payment when the claim was submitted. Digging a little deeper into these complaints, there may be some confusion between what constitutes a “preauthorization” and what is a “predetermination” or pre-estimate of benefits.

Beginning in the New Year, and with the forthcoming issue of the CDA Update, the dental benefits column will host a semiregular series discussing basic dental benefit issues. The topics covered address questions that CDA Practice Support receives from dental offices and from local dental components. This first installment addresses proper billing for treatment provided by an associate and waiving of co-payments.

CDA has learned that due to a Delta Dental of California system error, crown procedure claims were erroneously processed and paid for, affecting approximately 350 self-funded employer groups between Oct. 13, 2018 and Jan. 10, 2019. Statements were sent to approximately 1,000 California dentists beginning the week of Oct. 21 seeking recoupment for procedure codes D2750-D2752 and D279-D2792.

Do you have a question about a dental benefit issue? You can receive timely assistance from a CDA Practice Support expert. Simply submit your question online using the dental submission form available within your cda.org account. 

Congratulations — the dental plan paid the claim! Or did they? Confirmation that your claim has been processed comes in two forms: payment and/or an explanation of benefits. An EOB is sent to the patient and/or dental office as a receipt of services provided. Unfortunately, dental plans do not have standardized formats for these documents, which is why it’s necessary for an office to read the EOB completely.