Understanding the ins-and-outs of patient’s dental insurance plans can be a complicated and frustrating task for many dental offices. Find out how to increase your chances of a successful claim submission, and what to do when you receive a claim rejection.
Do you have a dental insurance question or concern? If so, the ADA Third Party Payer Concierge is here to help! This is a free service for ADA members. You can reach the Concierge from 8:00 a.m. to 5:00 p.m. Central Time Monday through Friday.
Phone: 800-621-8099
Email: dentalbenefits@ada.org
In this webinar, you will get answers to your scaling and root planing claim submission questions.
Many concerns reported to the ADA by dental offices are claim denials and requests for additional information.
Browse our claims assistance tools and answers to commonly asked questions.
When a dentist signs a participating provider agreement, they agree to abide by the dental plan’s processing policies. Download the following documents to gain a better idea of common scenarios related to claim rejections from third-party payers.
Responding to Claim Rejections [PDF]
Making sense of claim rejections from third-party payers can be a little frustrating at times. With the onslaught of patients using new consumer-directed employee benefit plans, knowing how to correctly code procedures and responding to claim rejections has become even more important.
Navigate the sometimes complicated world of claim rejections with this special guide. The guide covers the following topics:
How to File an Appeal [PDF]
When a patient's claim is denied by a third party carrier, exhaust all reasonable avenues for resolution. This means using all levels of appeal and make sure that all supporting documentation is included with the claim. This document provides briefs tips to appropriately file an appeal.
Introduction to Dental Benefits [PDF]
Chances are, a fair amount of the time you spend at your practice each week has very little to do with your clinical training and everything to do with your patient's dental benefits plans. There are multiple types of dental plans such as PPOs, DHMOs, indemnity plans, and point of service plans. This document discusses the differences between various types of dental benefit plans.
In addition to other procedures that are frequently denied reimbursement by payers, dentists report concerns with the large number of denials, alternate benefits and requests for additional information from dental insurers as it relates to scaling and root planing claim submissions. Periodontal scaling and root planing (SRP) procedures (D4341 and D4342) tend to have a higher frequency for denial and/or requests for additional information from dental plans in comparison to many other procedures – and this can be for a variety of reasons. These documents have useful information to help dentists better understand what an SRP entails, including an overview of common concerns, information on recording attachment loss, periodontal charting, examples of SRP processing policies and examples of good and poor radiograph submissions for SRP Claims.
Claims Submission: Scaling and Root Planing - Long Version [PDF]
For your convenience, there is also a summary version of the above document.
Claims Submission: Scaling and Root Planing - Short Version [PDF]
Your patient may be covered under an emerging model of benefit plan, called an exclusive provider organization (EPO).
A preferred provider organization (PPO) is a managed care plan combined with a network of dentists under contract to the third party carrier to deliver specified services for set fees according to the provisions of the contract. Traditional PPOs pay a percentage of the maximum allowable fee to the contracted dentist. EPO plans are very similar to PPOs but require that patients use only participating dentists for services covered by the plan (these are also referred to as “closed panel plans”). In EPO plans the patient will need to bear all costs of care if they choose to go to an out-of-network dentist, whereas in a PPO the patient may incur greater out of pocket costs but would still receive a benefit. There is no benefit payable to an out-of-network dentist under an EPO plan. While such closed panel plans have typically been used by DHMOs they are now starting to gain popularity with PPOs as a mechanism to control costs.
Dentists should be prepared to talk to patients about the repercussions of these types of closed panel plans. For example, does the patient understand that they will not be able to receive a benefit from their dental insurance plan if the patient sees an out-of-network provider? Do they further understand that the patient is responsible to the dentist for the dentist’s full fee? It is always a good idea to have your patients discuss any kind of concerns about their dental plan with their human resources department, especially before the employer makes a decision to switch the type of dental plan offered to its employees. Dentists can refer patients to Types of Dental Plans for basic information on varying kinds of dental benefit plans.
Federal anti-trust laws prevent the ADA from negotiating fees on behalf of dentists; however, dentists are free to negotiate fees on an individual basis. The ADA legal division has information on anti-trust concerns available to members.
Staff has been working with state dental societies to pass assignment of benefits legislation aimed at preventing this exact scenario, and we are aware of 23 states that have passed such legislation. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance.
Many factors can determine what fee a doctor can charge in this situation, including but not limited to state insurance statutes, participating provider agreements and the carriers processing policies. It is recommended that you check with the carriers to determine what fee you are ultimately allowed to bill the patient. You should also check with your state dental society to determine if there is legislation in your state that addresses which fee should be allowed.
There is an important distinction between changing the submitted procedure code and paying for a different procedure code based on the plan’s design and processing policies. It is not uncommon for third-party payers to acknowledge the code submitted, but to then pay an alternate benefit. They are allowed to do this. What they cannot do is substitute a different code without acknowledging the original code submitted. You should submit the procedure code(s) that most accurately describes the procedure performed. Any pressure from a payer for you to submit a different code other than the one that most accurately describes the procedure you performed, in order to conform to their payment policies, should be aggressively resisted. Additionally, if you feel the claim was not properly adjudicated, you should appeal the decision.
If you signed a participating provider agreement with a dental plan that has this provision, and there are not state statutes in your state to prevent it, then you may be contractually bound to only charge the patient the carrier’s maximum allowable fee for the non-covered procedure(s). ADA staff has been continually working with state dental societies on non-covered services legislation and 40 states have passed legislation preventing third party carriers from capping what a dentist can charge a patient for a non-covered service. This means that the dentist could charge his or her full fee in the above scenario. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance.
You may encounter situations in which a payer will allow you to charge your patient for non-covered procedures if the patient is willing to sign a consent form. The ADA has created a sample form for third party payer payment (PDF) that you may customize to meet your particular needs.
If you have signed a participating provider agreement with the dental plan, you may have contractually agreed to this. Please check the provisions of your signed provider agreement. If you are not in-network with the plan, please check with your constituent dental society for information on how this may be handled in your state. The ADA is currently working with dental insurance plans to find an equitable solution.
Sample letters that dentists can use to send to dental insurance plans and employers regarding dental services that the carrier does not consider necessary are available for members to use. In addition, it is highly recommended that you appeal the decision in writing and be sure you supply any additional information that would help explain the rationale for providing the service and why it is in the patient’s best interest to have this procedure done. This type of response from a payer may be inappropriate based on the amount of information they have at their disposal. The ADA has more information on how to properly file an appeal.
Although the ADA has no authority over dental plans to increase annual maximums, for years it has advocated for annual maximums to keep pace with the cost of living and recent surveys are starting to show increases. In 2016, 89% of plans where patients saw a network dentist, had maximums ranging from $1,000 - $2,500 – up from 79% in 2011.
This happens for purely economic reasons and to lower the amount a carrier has to pay on a claim. This is usually based on the benefits purchased in a given plan to keep the cost of the plan down. If you are a non-participating dentist with the plan, you may bill up to your full fee. If you are a participating dentist, please check with the carrier for the amount you can bill the patient. If you feel the claim is not being adjudicated correctly, it is recommended you appeal the decision with the carrier.
If you participate with the plan, it is recommended you contact your provider relations representative for assistance. If you are a non-participating dentist, it is a good idea to call the carrier to find out what happened to the radiographs you sent. It is recommended that you send duplicate radiographs to the carriers and not your originals as some carriers may not return the radiographs to your office. It is ADA policy (Guidelines on the Use of Images in Dental Benefit Programs (Trans.1995:617; 2007:419) that all images submitted to third-party payers should be returned to the treating dentist within fifteen (15) working days, but unfortunately that is not binding on payers.
Potentially, yes. A dental practice risks a breach of patient confidentiality whenever it sends unsecured electronic protected health information over an open network. A dental practice must also consider the risks associated with storing ePHI on a device that can be lost or stolen.
Sending unsecured images and text over a cellular network is a violation of HIPAA Security Rule requirements for transmission security if the dental practice has not:
So the answer is "maybe." To avoid a breach a dental practice must be mindful of the following:
The dental practice must employ appropriate safeguards for data “in motion” where appropriate. Some examples of transmission methodologies that might work include, but are not limited to:
Another, far greater risk is the threat of loss or theft of the cell phone itself, especially if it stores images on its memory card that are not encrypted.
Lost or stolen unsecured devices are a major cause of large breaches affecting thousands of individuals. In turn these breaches result in complaints and expensive, highly publicized settlements and sometimes levied federal civil monetary penalties. No dental practice wants this.
Using personal phones without appropriate security features is extremely risky and could be ruinous if lost or stolen. As such, it is HIGHLY inadvisable to use a non-dedicated, unsecured cell phone or unsecured app that does not also encrypt images stored on the cell phone’s memory card or in the phone’s cloud-based storage. If a secured phone is lost or stolen, the encryption can still provide safe harbor against breach notification requirements, provided it conforms to methodologies named in the HITECH Breach Notification Rule’s Safe Harbor provisions.
If a secured, encrypted phone or app is used in your dental practice, make sure the encryption algorithm and strength have been independently tested and validated for conformance with HHS Guidance.