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Dental Plan Questions are Attempt to Ascertain Primary Payer

July 01, 2019 7219

A claim submitted for treatment we provided to a child was denied. The plan won’t pay the claim until our office provides information about who the child lives with, which parent has custody, whether the parent with custody is remarried, and any court orders that may affect responsibility for the child’s treatment. Why is our office being asked for this information, how are we to know the answers to all of this, and is it even legal for a dental plan to impose this requirement upon us?

As onerous as this request may seem, the questions the dental plan is asking regarding the minor patient’s living situation — who they’re living with after a divorce, which parent has custody, whether the parent is remarried, and so forth — are simply means of determining which dental plan is primary in a dual coverage situation. And the questions being asked are those situations specifically listed in law for determining the primary payer.

Coordination of benefits when a patient has dual insurance (or, even coverage from three separate plans, and yes, we’ve heard such examples before), can be one of the most difficult tasks related to filing claims for treatment. There’s a stair step approach, codified in state regulations, for determining the primary payer in a given situation: If the first situation doesn’t apply, you go to the next one. Admittedly, the further one goes in trying to determine the applicable coordination of benefit rule for determining which plan is primary, the more daunting it becomes.

There’s the “birthday rule” — For a child covered by both parents’ dental plans, which parent has the earliest birth date in the calendar year?

Then there’s the “custody rule” — If the parents are divorced, which parent has custody of the child?

Then there’s the “stepparent rule” — A stepmom or stepdad’s coverage will be come into play after the coverage of the parent with custody, but before the coverage of the non-custodial parent.

Then there’s any modification to any of the rules that a court may have made (the “court-order rule”) — This rule comes into effect if a judge has determined that the parent who doesn’t have custody of the children is nevertheless responsible for the children’s health care.

Then there’s the “employment rule” — Does the patient have coverage through both their current employer and their former employer? The current employer’s coverage is primary.

Finally, if none of the above scenarios apply to the patient’s coordination of benefits situation, there’s the “length-of-time rule” — Under which benefit plan has the patient been covered the longest?

So, when a dental plan seeks answers from a dental office to a number of questions in order to determine a patient’s primary carrier, the plan is only trying to determine the primary payer given the myriad situations listed in state law. It’s confusing. So confusing that, admittedly, a dental plan has no way of sorting out the situation. That is why the plan relies upon the dental office to determine primary coverage. And let’s be practical: The dental office has direct contact with the patient; the plan usually does not. This is why a dental plan will throw the responsibility to the dental office.

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