Dental plan guidelines key to accurate claims processing and payment

By Ann Milar, CDA dental benefits analyst

As a Dental Benefits analyst with CDA, I get questions about claims payments at least a few times per day (on average) from member dentists and their staff as it relates to dental benefit plans. Obviously, the answer will vary based on each individual situation. Below I address one common scenario our members encounter in their practices on a day-to-day basis – what some of our members like to a call a “bait and switch.”

Dr. Smith’s dental practice verifies eligibility and benefits for a new patient. After the exam, X-rays and further evaluation the dentist determines that the patient needs a posterior implant. Based on the information provided by the patient’s dental plan, it appears that implants are a covered benefit under the patient’s plan. Upon completion of treatment, the claim is submitted to the dental plan for payment. The Explanation of Benefits arrives from the dental plan, along with payment, which is significantly less than what the dental office and patient expected the plan to pay toward the implant. Upon contacting the dental plan, dental plan representatives explain to Dr. Smith’s staff that posterior implants are not a covered benefit and an allowance was paid toward the implant. Pursuant to the patient’s coverage, this allowance was based on the fee of a removable partial denture.

Upon receiving this explanation, Dr. Smith’s staff contacts me to find out if this is permissible.

The answer … (drumroll please)

Yes, a plan can do this and bear with me as I explain why.

When an employer or individual enters into a contractual relationship with a dental plan, they select that plan based on the actual benefits that will be provided for the enrollee (preventive care, restorations, etc.) and the cost of the premiums. Within each dental plan selected there are processing and payment guidelines that clearly state what benefits are payable procedures that are not covered, as well as those procedures that will be paid as an alternative benefit. Upon enrollment in the dental plan, the patient/enrollee is provided with a Summary of Benefits that usually includes the plan’s exclusions and limitations. While these materials have been simplified over time, between the volume of materials and/or the lack of interest on the patient/enrollee’s part, there are not a lot of patients out there who read the plan documents from front to back.

If you are a contracted, participating provider for a dental plan, you should have a provider handbook or manual that outlines the plan’s payment and processing guidelines. Most dental plan provider contracts require that the provider understand these guidelines. However, it is important to remember that these are general guidelines, so it is important to verify benefits for each patient since the benefits may vary; and, when appropriate, obtain a preauthorization for treatment to obtain the most accurate information on the patient’s benefits.

If you are not a participating provider with the patient’s dental plan, obtaining the plan’s payment and processing guidelines becomes more difficult due to the lack of contractual relationship between the dentist and plan. The plan may be helpful to the patient/enrollee in clarifying the eligible benefits, and for the dentist submitting a preauthorization remains an option as well.

Whether a dentist is a contracted provider or not for the patient’s plan, there are several dental benefit plan and practice management resources available on cda.org/practicesupport that a dental office can utilize to ensure the patient is educated about the possible dental plan limitations and the practice’s expectations for payment. These include the Sample Patient Financial Agreement and Consent form, Patient Financial Protocols and the Dental Benefit Plan Handbook.

As we revisit the scenario with Dr. Smith’s office above, the patient was required to pay the dentist the difference between the implant fee and the amount paid by his dental plan. While the patient was not thrilled about this greater out-of-pocket expense, he understood his financial responsibility and, more importantly, was pleased with his implant.

For more dental benefits and practice support information, visit cda.org/practicesupport.