12/21/2015

The correct way to bill for associate dentists

By Denise Martinez, CDA Practice Support Manager

As the dental marketplace continues to change, hiring associates and having a multi-dentist practice is increasingly more common. CDA Practice Support receives frequent inquiries from members regarding the correct way to bill for associate dentists providing treatment in their practice.

Recent versions of the ADA claim form provides clearly identifiable areas to report billing entity and treating provider information. It is very important that dental offices report accurate treating provider information on the claim form, as it is considered unprofessional conduct and fraudulent billing to do otherwise.

It is not recommended to use older versions of claim forms as they do not provide adequate areas of reporting treating provider information. Using these older claim form versions does not dismiss an offices requirement to report accurate treating provider information. If you have multiple treating dentists in your practice then it is recommended to move to an updated form.

A sample claim form and complete claim form instructions are available at ada.org. Here are specific instructions for completing the ADA claim form based on the dental practice structure:

Billing for a Corporation or a Group
Box 48: Enter the billing entity, corporate or group name and address.
Box 49: Enter the type 2 NPI for corporation or group.
Box 50: Leave blank, unless this is for an individual.
Box 51: Enter the entity's tax ID number if this is a group practice.
Box 54: Enter the Type 1NPI of the individual treating dentist.
Box 56A: Enter specialty information (if applicable) of the treating dentist.

If the Provider is a Sole Proprietor
Box 48: Enter the name of the dental entity.
Box 49: Enter a Type 2 NPI when the claim is submitted by an incorporated individual - unincorporated practices may enter the individual practitioners Type 1 NPI.
Box 50: If the billing dentist is an individual, enter the dentist's license number.
Box 51: Enter the SSN or TIN if the billing dentist is unincorporated. Enter the corporation TIN if the practice is incorporated
Box 54: Enter the treating dentist's Type 1 NPI.
Box 56A: Enter the specialty information for the professional who delivered the treatment.

If the dentist is expecting the associate to become a contracted provider with those dental plans they are contracted with, there are a few things to consider. This detail should be addressed in the Associate Agreement between the practice owner and potential associate. There may be instances when the practice owner may be contracted with a particular plan but the associate is not contracted. Since the reimbursement rates differ for in-network providers vs. out-of-network providers based on whether the treating provider is contracted with the plan, this can cause confusion for both the practice-billing administrator and the patient. The claim can be processed and paid differently for out-of-network providers ultimately affecting the patient's financial responsibility. Generally, in-network/participating providers receive direct payment from the plan; however, some plans refuse to allow assignment of benefits to non-participating providers, resulting in the patient receiving reimbursement. It is best to check with the specific plans regarding this scenario and any other contracting rules.

It is important to notify the plans when an associate is hired. Most plans require notification an associate is working under a billing entity or corporation even if the associate will not be contracting with the plan and remain out of network. Plans will need to update their claims processing system and associate the treating dentist to the billing entity or corporation so that claims do not reject.

For more information on billing for associates, visit cda.org/practicesupport and review the resource titled Considerations When Billing for an Associate.



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