New Delta Dental rule can affect dentists' fees

CDA Practice Support continues to receive calls from member dentists regarding Delta Dental of California’s recently implemented contractual change under Participating Dentist Rule 2, Basis of Fees.

In a letter mailed to participating providers last January, Delta Dental of California shared revisions to its provider participation documents. Specifically, 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 communication stated that the change would be in effect no sooner than Aug. 1, 2018; however, CDA Practice Support recently confirmed that Delta Dental’s implementation of this rule commenced on Sept. 15, 2018. Dentists who do not have a “Premier Contracted Fee” on file for a specific procedure they provide will now be paid at the applicable Delta Dental PPO fee.

Despite the advance notification, some dentists have now found themselves unprepared for the rule change and are experiencing a negative impact to their reimbursement levels on specific procedures. Dentists may be further impacted when the 2019 Code on Dental Procedures and Nomenclature (CDT) codes from the ADA go into effect in January 2019.

CDA Practice Support offers the following considerations and a case study to help ensure dentists are aware of the potential impact to their practices.


Time your fee updates strategically: 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.

In light of the recent rule change, Delta Dental has been allowing dentists to submit a fee proposal for the missing code(s) on the dentist “Premier Contracted Fee Schedule.” However, dentists are advised to evaluate the importance of adding any missing fees for 2018, while also taking into consideration upcoming CDT code changes effective January 2019.

Additionally, replacing one missing fee to avoid the PPO reimbursement level may reset a dentist’s fee filing anniversary date.

Monitor CDT code updates carefully: The ADA’s Code Maintenance Committee updates the CDT codes annually. Updated CDT codes are released in early fall for the following year and the codes may be purchased either in electronic or hard copy formats from the ADA. Additionally, dental teams are encouraged to update the CDT codes in their practice management software and review code changes prior to submitting fee revisions to Delta Dental or other dental plans. (Read “CDT 2019 dental code additions, revisions and deletions announced.”)

Implement dental plan document review process: Establish a system in the dental practice for reviewing dental plan correspondence to evaluate potential impacts to payment and processing policies, re-credentialing, etc. Under a law that took effect in January 2013, dental plans are required to notify contracted providers 45 days in advance of any changes to their agreements, rules and procedures. In addition to this advance notice that CDA negotiated for as part of Assembly Bill 2252, the specific terms of the Delta Dental settlement include that Delta Dental will provide Premier dentists with 120 days’ notice of material changes to participating dentist agreements. This new requirement for Delta Dental protects the dentist from being caught off guard by revisions to provider agreements by allowing the dentist time to review the proposed changes and assess the impact to their dental practice.

Case study

The following case study includes thoughtful consideration around this rule revision when evaluating filing fee updates. 

Dr. Smith’s dental office has diligently updated its annual fee proposal with Delta Dental on June 1 of each year. Dr. Smith’s office manager received and carefully read the communication sent by Delta Dental noting revisions to their participation documents earlier in the year. The office manager was not concerned with the previously mentioned rule change as they did not have any missing fee proposals on their schedule for services Dr. Smith performed with regularity.

On Oct. 1, Dr. Smith performed a surgical sialolithotomy, code D7980. The office manager received an Explanation of Benefits (EOB) from Delta Dental after the service was processed and the reimbursement was lower than anticipated. On Oct. 12, the office manager contacted Delta Dental requesting clarification on the reduced fee and the representative explained that on Sept. 15, 2018, Delta Dental implemented the previously mentioned rule change. The representative explained to the office manager that Dr. Smith had not proposed a fee for the D7980 during his last fee revision, so when Delta Dental implemented the new rule, the fee for the D7980 was paid at the PPO rate.  The office manager was told that nothing could be done to have the claim recalculated because the rule change had been communicated to the dentist well before the required advance notification time frame. 

The Delta Dental representative informed the office manager that the dentist could log in to the dentist’s account in their Delta Dental Provider Tool and add a fee for the D7980, but it would reset their fee revision anniversary date and Delta Dental would not make any considerations or revisions to codes that already had a fee on file. The representative said Dr. Smith would be allowed to add a fee proposal for any code without a previously proposed fee to his schedule. The representative then explained that should Dr. Smith opt to add a fee amount for the D7980, his fee filing anniversary date would change from June 1 to Oct. 12. 

Dr. Smith’s office manager contacted CDA Practice Support for assistance with this issue, explaining how infrequently Dr. Smith billed for D7980. Based on the information gathered, the analyst advised the office manager to consult with Dr. Smith and review the ADA CDT 2019 code book. The analyst advised they evaluate the code changes and the potential impact of being paid at the PPO fees for those procedures that Dr. Smith regularly provides. Given this information, Dr. Smith decided that since he rarely performs the D7980, he would not submit his fee proposal to Delta Dental until it adds the 2019 CDT codes to its fee revision template on Jan. 1, 2019. Had Dr. Smith added a proposed fee for the D7980 on Oct. 12 and had he not carefully thought through his fee proposal to Delta Dental by including the CDT 2019 code changes, he may not have been allowed by Delta Dental to propose fees for the newly added codes for 2019 until Oct. 12, potentially causing a negative financial impact on his practice.

For assistance with dental benefits, contact CDA Practice Support at 800.232.7645. Read more about CDT 2019 changes.

Related Items

Every year, CDA encourages all dentists to prepare for dental code additions, revisions and deletions. The ADA has released the CDT 2019 with 15 additions, five revisions and four deletions that will go into effect Jan. 1. It is recommended that all dental offices have a current copy of the CDT to assist with proper claim billing. Typically, plans will start sending updates about policy changes for the new year during the fourth quarter.

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I’ve heard from some dentists who signed on to a plan’s network only to discover afterward that the plan has certain policies and procedures that the dentist disagrees with. It appears, then, that the advice “buyer beware” also applies to one considering “buying” into a provider network. Many of the complaints CDA Practice Support hears from dentists are about plan payment policies that are often spelled out in the provider contract or handbook, so a thorough review of a plan’s provider contract prior to signing is strongly recommended.