Questions about coordination of benefits? CDA Practice Support has answers

November 19, 2019

CDA Practice Support receives hundreds of calls each year concerning the coordination of benefits when a patient has more than one dental plan for coverage.

Standard COB allows secondary dental plans to pay up to 100% of the covered service, i.e., the primary plan pays the service at 80%, and the secondary could pick up the remaining 20%. Plans apply COB to prevent overpayment for the dental treatment rendered while ensuring the patient can utilize their dual coverage to minimize their out of pocket expense.

In this month’s column, I cover the COB basics and answer common questions members have about COB, such as what to charge the patient once all plans have paid and what to do when the plans disagree on which of them is the primary payer.

Before you submit a claim

It is important that dental practices submit the correct fees on the claim form. As a best practice, dentists should always bill their full practice fee (actual fee charged) on all dental claims and take the necessary write-offs (if applicable due to plan contracts) only after all claims have been paid.

Do not submit negotiated fees, such as PPO fees or any other reduced-fee schedule fees on any claim form, as doing so skews the data collected by the plans and deflates the value of treatment. Additionally, if you are out of network with any of the plans billed, you are not required to write off any part of your submitted fee.

COB basics

Federal and state COB laws are in place to help determine the order that dental plans process claims for patients covered by multiple policies.

Once a policy is determined to be the primary policy, the office submits the claim first to that primary plan, and the primary plan processes the claim according its policies, benefits and limitations. After payment or denial by the primary plan, the office sends the claim and the primary plan’s explanation of benefits to the secondary plan. If the secondary plan utilizes a standard coordinating policy, the secondary plan then coordinates the benefits/payments based on the information supplied on the primary EOB.

A patient can have an unlimited number of polices. In fact, it’s becoming more common in California for patients to have more than two dental policies. If the patient is covered by more than two plans, the dental office would continue to submit claims and EOBs from the plans previously billed to the next policy until all the patient’s policies have either paid or denied the services rendered.

Keep in mind that not all policies follow the same rules. Some policies follow state laws, while a self-funded policy, which is not subject to state regulation, can create a different set of coordination policies as long as the policy adheres to federal laws.

Below are answers to the most common questions we receive from our members and our members’ staff regarding coordination of benefits:

Q. I called the plan and the plan says the secondary policy has a non-duplication of benefits clause. What does that mean?

A. Non-duplication of benefits means that the secondary plan will not pay any benefit if the primary plan paid the same or more than what the secondary plan allows. For example, if the primary carrier paid 80% of the cost of treatment and the secondary carrier also covers the service at 80%, the secondary carrier will not make a payment.

Q. How do I determine what to charge the patient after all plans have paid?

A. If you are contracted with one or more of the plans billed, the patient should receive the benefit of the lowest contracted fee schedule, according to California Health and Safety Code §1374.19.

To determine if an adjustment should be made in the patient’s account, start by determining the lowest contracted fee between the contracted plans. Total all the payments made to the plans; if the total equals the lowest contracted fee, then the patient owes nothing, and the difference between the submitted fee and the amount received would be the write-off in the patient’s account. However, if the total of the insurance payments is less than the lowest contracted fee, the patient owes the difference between the amount received and the lowest contracted fee. This only applies if you are contracted with one or more of the plans.

If you are out of network with all the plans, you are not required to write off any part of your submitted fee.

Q. If an overpayment is identified, does the overpayment belong to the practice, patient or plan?

A. First, determine if the claim was overpaid by totaling the amount paid by all the plans.

  • For an out of network dentist, if the amount received exceeds the total submitted fee reported on the claim form, then there is an overpayment.
  • For an in-network dentist, if the amount received exceeds the lowest contracted rate, then there is an overpayment.

Do not issue a credit for an overpayment to the patient until you have contacted the last plan to pay, informing the plan that you believe the claim may have been overpaid. The plan should offer guidance on whether the refund is due to them and/or the patient and provide direction for returning the funds to the appropriate party.

Q. What do I do when the plans disagree on which plan is the primary payer for coordination of benefits?

A. Remember, not all policies follow standard COB rules. For example, fully insured plans would follow state COB laws, while self-funded and federal plans may not. It is best practice to check with each plan to determine its COB rules prior to submitting the claim to avoid payment delays and overpayments.

Q. What are the rules for determining the COB order when a child is covered under an Affordable Care Act embedded policy?

A. The embedded policy is the primary policy.

Q. Both plans paid as the primary. When I contacted the plan, the plan said that any credit is due to the patient, not the plan. Is this correct?

A. Individually purchased dental policies are becoming more common in the marketplace. You will find at times that these polices will not coordinate benefits. If the payments from all plans exceed the total submitted fee on the claim, do not assume that the credit belongs to plan, as it may belong to the patient. Contact should be made with the plan to determine who receives the credit.

Q. What is the responsibility of the secondary carrier?

A. According to California Health and Safety Code §1374.19, a secondary dental plan will pay the lesser of the amount it would have paid if it were the only coverage, or the enrollee’s out-of-pocket expense for services covered by the secondary plan.

Q. Does dual coverage mean the patient’s benefits are doubled?

A. No. Coordination of benefits is a coordination of reimbursement only between policies; it does not duplicate benefits or double the benefit frequency. Example: a patient has two policies, and each one covers two cleanings a year. If the secondary policy is a standard coordinating policy, it will either pay the lesser of the amount it would have paid if it were the only coverage, or it will pay the total patient copayment under the primary policy for benefits.

CDA Practice Support offers individual member assistance with dental benefits questions. Simply submit your questions online using the dental benefit submission form accessible through your account. Practice Support will analyze the issue, evaluate it for possible resolution and communicate clear next steps. Just visit My Account, click the link for Dental Benefits Issue Submission and follow the prompts.

For more help understanding COB, visit the Practice Support resource library and look for the Dental Benefit Plan Handbook, Chapter 4 – Understanding Coordination of Benefits.


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