A dentist's rights in a dental benefit plan dispute

By Greg Alterton, CDA Dental Benefit Plan Specialist

CDA receives numerous calls daily about various disputes dentists have with patients' dental benefit carriers. While CDA will consider how these disputes might be informally resolved, ultimately, the dentist has the right to appeal the dispute back to the plan, and eventually with the plan's regulator. 

The August 2015 CDA Update included an article about claim denials – why they tend to happen, how to avoid them and what to do in resubmitting claims with additional documentation and treatment narratives. But it's common that denials will stay denials even after reconsideration of additional documentation. 

California law requires every health plan, including dental plans, to have a formal procedure that providers, whether innetwork or out, can use to challenge adverse payment practices or specific payment decisions. Whenever a plan changes or denies a claimed procedure, the plan is required to notify providers of its dispute resolution process and the procedures for obtaining forms and instructions for filing a challenge. Failure to provide such notification is a violation of California Code of Regulations Section 1300.71.38(b).

Plans are required to acknowledge receipt of a provider's dispute within two working days of receiving a provider's formal challenge if submitted electronically, and within 15 working days if submitted by mail.

The regulations define a "provider dispute" as a written notice to the plan "challenging, appealing or asking reconsideration of" a claim that has been denied, adjusted or contested, or disputing a request from the plan for reimbursement of a reputed overpayment.

A plan must make a determination after reviewing a provider's dispute within 45 working days of receiving the dispute. A plan must resolve disputes without any charge to the provider; however, a plan shall not be responsible for reimbursing a provider for any costs incurred in connection with utilizing the provider dispute mechanism, such as the cost of an attorney or arbitration.

Dental benefit plans are required by law to notify providers of its dispute resolution process and the procedures for obtaining forms and instructions for filing a challenge. Failure to provide such notification is a violation of California Code of Regulations Section 1300.71.38(b).

The "prompt pay" laws and rules also define what is termed an "unjust" or "unfair payment pattern." If such payment patterns or policies persist, they should be communicated to the relevant state agency for possible investigation and enforcement action.

The Department of Insurance also has regulations governing "fair claims settlements." Information about filing a request for assistance with the California Department of Insurance is available on its website.

Examples of the types of problems that can be submitted include:

  • Improper denial or delay in payment of a claim.
  • Other claims handling issues.
  • Dispute resolution mechanism difficulties.
  • Misconduct of the health insurer.

Steps to Appealing Claim Denials

If a dental office is experiencing a claim that hasn't been paid in months, a perceived unfair or unannounced down-coding or re-coding of a claimed procedure, a denial of claimed procedures after a dental plan confirmed the patient's eligibility for coverage, or has received a refund demand on a claim that was previously paid, there are key steps an office may take to seek resolution for payment issues or disputes.

1. Contact the dental plan to make an informal inquiry into the reason for the payment decision or policy.
Most dental plans encourage dental offices to call the plan's customer service department to raise questions about a payment denial or adjustment on a payment that is contrary to what was claimed. Often, the customer service representative will transfer the call to claims adjudication, a dental consultant or the plan's dental director to explain the reason for the payment decision. Based on this information, a dental office can resubmit a claim if additional documentation is needed and quickly get it paid. On the other hand, it may be that the plan does not cover the procedure, but will pay for a less costly alternative.

However, it may be that the patient has exceeded his or her maximum. Any of these reasons for nonpayment should have been explained on the explanation of benefits (EOB), but a call to the plan's customer service department can clarify the reason for nonpayment.

2. Contact CDA Practice Support.
After speaking informally with the plan, if the question was not answered, or was not answered satisfactorily, and the claim denial is still unresolved, CDA can help. CDA, in cooperation with the major dental plans in California, has established a network of liaisons who review issues brought by member dentists, referring them to a higher level within the dental plan for review, and oftentimes leading to a resolution. The only request the plans make of CDA is that it is verified with the dental office that they have spoken with a plan representative on their own and that the contact was not able to address the issue or answer their question. To bring an unresolved issue to CDA, contact CDA Practice Support at 800.232.7645.

3. File a formal challenge to the payment decision through the dental plan's dispute resolution process.
If the informal routes through a plan's customer service department and through CDA's efforts do not bring a satisfactory resolution to a payment dispute, the next step is to formally file the dispute with the plan through its provider dispute resolution process. Notice of the option to file a dispute with a plan's dispute resolution process is required on each plan's EOB.

Providers must submit appeals through the plan dispute resolution process prior to filing formal complaints with the DMHC or DOI. Neither department will take up such a dispute unless the provider has first gone through the plan's internal dispute resolution process.

4. Filing a formal dispute.
If the plan rejects a provider's appeal, a second level of appeal is available through the appropriate state agency. The Department of Insurance is responsible for preferred provider organizations (PPO) and indemnity insurance. A form for appealing to the Department of Insurance is located on its website at insurance.ca.gov. Click the link at the top left of the page to "File a Complaint." The Department of Managed Health Care regulates health maintenance organizations (HMO) and all lines of business for Delta Dental of California. Go to the department's website at dmhc.ca.gov and click the link at the top left to "File a Complaint," then follow the link on that page specifically for filing provider grievances.

For more information about the formal dispute resolution process and links to the dispute forms of the larger dental plans in the state, visit cda.org/practicesupport.

Related Items

The ADA has released a resource that provides updated information to dentists on all of the latest dental code changes that will go into effect on Jan. 1. CDT 2016 provides accurate and up-to-date ADA dental procedure codes. Dentists who rely on old information may experience unexpected claim denials or reimbursement delays. Code changes for 2016 include 19 new codes, 12 revised codes and eight deleted codes.

The Centers for Medicare and Medicaid Services (CMS) has set the implementation date of the International Classification of Diseases version 10 Clinical Modification (ICD-10 CM) for Oct. 1. While the implementation of ICD-10 CM affects a limited number of dentists in California, such as oral surgeons, anesthesiologists, pathologists, etc., it is important to note that all dentists should be aware that diagnostic coding could become a requirement in the future.

What to expect during a dental plan utilization review
By Denise Martinez, CDA Sr. Dental Benefit Analyst
As part of a contractual commitment the dental benefit plans have with their consumers (employer groups and their employees), they are required to have a utilization review process. Recently, CDA has received an increase in calls about these types of reviews by the dental plans. Utilization review is a post-claims review process that can affect dentists who treat patients covered by a dental benefit company.