Preferred Provider Administrative Guide

Preferred Provider Administrative Guide
Welcome to the Dental Select Network ............................................................................................................................................................................
Updating Your Manual
Confidentiality
1
Contacts ...........................................................................................................................................................................................................................
Provider Relations
Member Services
2
Advantages of Participation ............................................................................................................................................................................................
3
Preferred Provider Agreement .......................................................................................................................................................................................
4
Claim Guidelines ..............................................................................................................................................................................................................
Required Fields on All Claim Forms
Common Claim Filing Errors
Waiting Periods
Alternate Benefit
Coordination of Benefits (COB)
X-rays
Orthodontic Claim Guidelines
Predetermination Estimates
Electronic Data Interchange (EDI)
Administrative Guidelines
Submission of Claims
Offices with Multiple Dentists / Providers with Multiple Locations
Claims Questions or Corrections
Your Right to Appeal
4
Reimbursement ................................................................................................................................................................................................................
Explanation of Payment (EOP)
Adjustments, Refunds and Overpayments
Payment Options
8
Discount Plan ....................................................................................................................................................................................................................
Payment Procedures
Specialist Referral
Plan Identification Card
9
Co-Pay Plans ..................................................................................................................................................................................................................... 10
Individual Plans
Group Plans
Claim Submittal
Co-Payment Procedures
Specialist Referral
Plan Identification Card
Co-Insurance Plans ......................................................................................................................................................................................................... 12
Individual Plans
Group Plans
Claim Submittal
Co-Insurance Procedures
Max Plan Options
Specialists
Specialist’s Benefit Payment Guide
Plan Identification Card
Helpful Hints ...................................................................................................................................................................................................................... 14
Definition of Terms ............................................................................................................................................................................................................ 15
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Welcome to the Dental Select Network
This Provider Administrative Guide is a supplement to your Preferred Provider Agreement and is designed to explain the policies
and procedures of Dental Select Benefit Plans. While your office may not have elected to be a Preferred Provider on all Dental
Select plans, we have included information on all of our plans for your convenience. For specific questions or additional
information not addressed here, please contact the appropriate department or representative listed on our contact page.
Updating Your Manual
The most current version of this guide is available on our provider web portal as well as on our website at www.dentalselect.com in our Provider Services
section. Click on the “Provider Administrative Guide” link available on the Forms and FAQs section of the Provider Services page to view and print pages
directly from the website. If you do not have Internet access, you may request updated pages or a complete guide by calling our Provider Relations
Department at (800) 999-9789.
Confidentiality
Dental Select is committed to assuring the highest level of confidentiality regarding the dental and personal information of our members. Our employees
are held to strict standards and internal guidelines to ensure complete compliance with the Health Insurance Portability and Accountability Act (HIPAA).
The member’s signature on their enrollment card allows Dental Select to obtain information from dental providers necessary to provide dental services and
process claims. All information is reviewed within the guidelines of our corporate confidentiality policy and patient identifiable information is never shared
without the member’s consent.
Corporate Headquarters
5373 S. Green Street, 4th Floor
Salt Lake City, UT 84123
Tel (801) 495-3000 or (800) 999-9789
Fax (801) 495-3368 or (888) 673-5328
www.dentalselect.com
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Dental Select Contacts
Member Services Provider Relations
Toll Free (800) 999-9789
Utah (801) 495-3000
*Prompt #2 for customer service
Provider Relations
Sharon Smith - Utah Provider Relations Representative
Phone (801) 641-6250
Fax (801) 290-5118
[email protected]
Corporate Office
SLC (801) 495-3000
Toll Free (800) 999-9789
Fax (888) 998-8708
[email protected]
Call Member Services to verify:
• Patient eligibility, coverage effective dates and specific patient benefits
• Claims status
• Questions regarding payment amounts, adjustments, COB or other claims questions
• Claims filing procedures
Please ensure you have the following information available when you call:
• Provider’s Tax Identification Number
• Subscriber ID number from the member’s identification card
• Patient’s name and birth date
• Type of visit or procedure to be done
It is important to understand that benefits obtained by telephone are not a guarantee of payment before a claim is submitted. Our Member Services
Representatives will provide you with the most current, accurate information that is available at the time of your call, but due to circumstances beyond
our control benefits and/or eligibility may change.
All Preferred Providers have a Provider Relations Representative assigned to assist you in person, by phone or by email. Your representative is a
knowledgeable dental industry professional and can assist you with questions regarding your Provider Agreement, Dental Select Plans, administrative
or other issues.
For updates to your address, Tax ID number, NPI Number, Fee Schedule requests or other administrative questions or functions, please contact Provider
Relations in our corporate office.
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Advantages of Participation
Fast and Accurate Claims Payment
Dental Select is known for its claims payment speed and accuracy. Your patients’ claims will be processed efficiently and your office will be paid
promptly.
• Electronic claims capabilities (see page 7 for complete listing of clearing houses)
• Prompt payments for services rendered to members
• Average turnaround time of 7 to 10 days for clean claims. Our audit score with ACE American (our underwriters) is 99% for timeliness and
accuracy.
• Claims payments are issued weekly, ensuring prompt turnaround on claims
Members Pay at the Time of Service
Members are asked to pay at time of service, unless prior arrangements have been made with your office. This means more cash on hand and less time
spent trying to collect payments. (see page 11 & 13 for more information)
Consistent Patient Referrals
Your office is now advertised in the Dental Select provider directory. This directory is available in print and on our website (www.dentalselect.com) to all
Dental Select members, resulting in increased business for your office.
Fee Schedules
It is the standard practice of Dental Select to review all Fee Schedules regularly.
Prompt Customer Service
We understand that your office staff’s time is valuable. Our representatives are personable and knowledgeable. Excellence in customer service is our
reputation.
• Calls to Member Services typically answered in less than one minute
• Prompt eligibility and benefit information available
• Claims inquiries handled immediately
Dedicated Provider Relations Department
Dental Select believes it is our outstanding provider panel that allows us to offer excellent dental benefits to our members. It is for this reason that
our Providers’ concerns and issues are of utmost importance to us. We have an established Provider Relations Department, dedicated to servicing our
Providers and their needs.
At the head of the department is our Chief Operations & Strategy Officer - COO/CSO, Suzette Musgrove. With 29 years experience in the dental industry,
including 16 years working within a dental office environment, Suzette has a deep understanding of the dental industry and a unique perspective of
our Network Providers. Suzette is a National Association of Dental Plans (NADP) member, serving on the Professional Relations committee and working
directly with the ADA to promote excellence. Suzette is also a member of the National Dental Electronic Data Interchange Council (NDEDIC) and has
also been a lecturer for the Utah Dental Association (UDA). Suzette proudly sits on multiple boards for non-profit dental related organizations serving
under-served children and indigent citizens.
Your Provider Relations Representative for Utah is Sharon Smith. Sharon has more than 23 years experience in the dental industry, including 12 years
as a dental office manager and 11 years with Dental Select. She has a solid understanding of the daily operations of a dental office as well as Dental
Select’s policies and procedures. Sharon’s extensive knowledge will assist you and your staff with any questions that may arise.
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Preferred Provider Agreement
As a Preferred Provider with Dental Select, you agree to:
• Accept Dental Select’s maximum allowable amounts as designated in Dental Select’s Fee Schedules as payment in full for covered services. Your
patient is responsible only for copayments, co-insurance portions, deductibles, and for services not covered by their plan.
• Apply the appropriate Fee Schedule and/or discount for the member’s particular plan, regardless of whether a waiting period or annual
maximum has been met or applies.
• Maintain appropriate license and credentials to provide dental services and provide copies to Dental Select upon request.
• Maintain policies of malpractice and other insurance in the amounts outlined in your Provider Agreement to insure that you and your employees
are covered against any claims for damages. Proof of coverage must be provided to Dental Select upon request.
• Submit proper claims information to Dental Select on standard American Dental Association (ADA) approved forms using the appropriate
procedure and diagnostic codes as presented in the most recent editions of the Current Dental Terminology (CDT) as provided by the ADA.
• Make every attempt, when a referral is necessary, to refer members to dentists or dental specialists who are part of Dental Select’s Preferred
Provider Panel.
• Provide ninety (90) days written notice to Dental Select if you should decide to terminate a specific plan or plans. It is also your responsibility to
provide ninety (90) days written notice to those patients who may be affected by a plan termination.
• Meet and maintain industry standards of professional care.
Claim Guidelines
Dental Select prides itself with an average 7-10 day turnaround time for processing clean claims (when complete and correct information is supplied).
In order to ensure accurate and efficient claims processing, please note the guidelines and requirements listed below.
• Claims must be submitted using the current American Dental Association (ADA) standard claim form, unless submitting electronically. The
required J400 form is available on our website.
• Please submit your office’s customary fee for each procedure, not the allowed or contracted amount. This assists us in monitoring trends in fees
billed, enabling us in establishing equitable pricing for our allowed amounts.
• Always use black or dark blue ink and, if highlighting is necessary, only use yellow. All claims are electronically scanned for processing and
dark colored highlighting will not scan correctly and will delay the processing of your claim.
Required Fields on All Claim Forms
• Provider’s Tax ID number (TIN) and/or Social Security number, and signature of treating provider
• Treating address
• Patient’s name and date of birth
• Insured’s Subscriber/Member Number or Social Security Number
• Correct CDT Code, date of service, tooth number or quadrant, surfaces and charge amount
NPI Numbers
National Provider Identifier (NPI) numbers are required for all electronic claims submissions. However, the NPI number does not replace the Tax ID
number (TIN) on your claim form. Your current TIN is still required on all claims submitted to Dental Select.
Periodontal Claim Requirements
• Periodontal charting and full mouth x-rays must be included with claims for periodontal scaling and surgery
Restorative / Prosthodontics Claim Requirements
• Indicate the initial placement of crowns, bridges and dentures
• Indicate the extraction dates for bridges and dentures
• Submit x-rays with claim for inlays, onlays, multiple surface composites (D2335), bridges, partials, crowns, implants, core build-ups.
Additional information regarding documentation can be found in the Helpful Hints on page 14.
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Claim Guidelines - (continued)
Common Claim Filing Errors (Causing Claims Denial)
Simple errors and oversights may cause delays in the processing of your claim or may even cause your claim to be denied.
• Billing with an incorrect Tax ID number
• Improper, incomplete or missing subscriber information
• Improper, incomplete or missing patient information, such as birthdates or ID numbers
• Illegible information due to worn printer cartridges or poor handwriting
• Missing tooth number, quadrant or surfaces
• Improper or outdated CDT codes
• CDT Code, date of service, tooth number or quadrant, surfaces and charge amount not in correct field
• No primary EOB submitted with secondary claim
• Physical treating address not supplied
Time Limitations
Claims must be submitted within 365 days (1 year) from the date of service. Claims submitted after that time will not be paid—no exceptions.
Balance Billing
As a Contracted Provider, you have agreed to accept the Contracted Fee Schedule as payment in full; balance billing beyond the contracted fee amount
is strictly prohibited for covered services. Contracted fees apply to all active members on the plan, regardless of whether a waiting period or annual
maximum has been met or applies.
Non-Covered Services
Any procedure that is not listed on the fee schedule is available on a fee for service basis for which your office may charge your customary fee.
Additional information regarding covered services can be found in the Helpful Hints on page 16.
Waiting Periods
During any applicable waiting periods, the patient is responsible for the full contracted fee for each service. To determine if your patient’s treatment is
subject to waiting periods, please contact Member Services at (800) 999-9789.
Alternate Benefit
• If – a less expensive, alternate procedure, service or course of treatment can be performed in place of the proposed treatment to correct a dental
condition and the alternate treatment will produce professionally satisfactory results,
• Then – the maximum benefit allowed for covered services will be the charge for the less expensive treatment.
NOTE: Alternate Benefit will be applied on specific plans. Please verify benefits with member services.
Coordination of Benefits (COB)
If the patient has other dental coverage in addition to Dental Select, submitted claims will be adjudicated as follows:
• If Dental Select is the Primary Carrier: The benefit will be paid according to the allowable expense without regard to the secondary carrier.
• If Dental Select is the Secondary Carrier: The patient or provider must submit the explanation of benefits of the primary carrier with the claim.
Dental Select will combine our normal benefit with the primary carrier’s payment so that the total benefits paid by both plans do not exceed the
highest contracted allowable expense of either plan.
File claims with the primary plan first for processing. When payment from the primary plan is received, submit an itemized claim along with the
primary plan’s Explanation of Payment (EOP) to the secondary plan. Secondary claims will be denied without the primary plan’s EOP.
• If your patient is covered by two Dental Select plans: You only need to file one claim. Be sure to list the ID numbers for both plans on the claim,
using the appropriate primary/secondary positions. The claim will be processed under the primary plan first and any remaining benefit will be
considered under the secondary plan. See Definition of Terms for an explanation of the Birthday Rule for determining coordination of primary and
secondary policies for dependent children.
Please Note - Dental benefit companies are regulated by state law on how to coordinate benefits when more than one entity is involved – this is not a
carrier choice.
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Claim Guidelines - (continued)
X-rays should only be submitted with claims for the following procedures:
• All crowns
• Multiple surface anterior composites
• Bridges (initial placement only)
• Partials
• Inlays/ Onlays
• Periodontal scaling and surgery
• Impacted wisdom teeth
• Implants (where coverage is applicable)
X-rays should be of diagnostic quality and enclosed in an envelope clearly labeled with the x-ray date, tooth number, patient’s name and dentist’s
name and address. We strongly recommend only duplicate x-rays be submitted. NEA Fast Attach is recommended to submit X-rays electronically.
PLEASE NOTE: Per law, do not submit original x-rays. Unless specifically requested, x-rays will not be returned. Also, x-rays that are not clearly
labeled with the required information, including your return address, will not be returned.
Orthodontic Claim Guidelines
• Bill initial banding with the correct ADA codes
• Monthly charges should be billed according to the CDT code book
• Adjustments will be billed monthly or quarterly
• Initial banding must be included when patient changes carriers during treatment. The total amount paid out by the previous carrier must also be
included and will be applied to Dental Select’s maximum
• When coordinating benefits with another carrier, a primary explanation of benefits is always required whether or not benefits were paid out
• Once a maximum has been reached by the primary carrier, you must attach a copy of the final EOB with every claim
• Per CDT code 8660 is to be used for diagnostic records (cepholametric film, panoramic or full mouth x-rays, diagnostic casts, diagnostic
photographs)
• 20% discount does not apply to Invisalign
Pre-determination Estimates
We recommend that all services over $300 be submitted for pre-determination. Dental Select will provide your office with a pre-determination estimate
to assist you and your patient in making informed decisions about the treatment program you have prescribed. Pre-determination estimates are
provided as a courtesy and are not a guarantee of payment. Pre-determinations are subject to the benefits, eligibility and limitations that are in
effect on the actual date of service.
Electronic Data Interchange (EDI)
Electronic Claim Submission is the preferred method of submitting claims and has many advantages:
• Improved cash flow
• Reduction in paperwork
• Expedited claims processing
• Savings in time and postage
• Reduction in potential for human error
The Clearinghouses currently working with Dental Select are:
• DentalXChange – 800-576-6412, ext 455
• ANS (Secure EDI) – 800-417-6693, ext 234 / [email protected]
• APEXedi – 800-840-9152 / [email protected]
• Emdeon – 888-255-7293 / [email protected]
• TesiaPCI – contact representative at [email protected]
• UHIN – 877-693-3071 / www.uhin.org
• Others as requested – contact Member Services to refer your clearinghouse if not listed
We recommend using NEA Fast Attach for electronic claims requiring X-ray attachments.
For more information please visit their website www.nea-fast.com.
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Claim Guidelines - (continued)
Adminstrative Guidelines
• Recoupment - The time frame for recoupment is 12 months from the date of service. A Provider may contact Dental Select with a specific
reason(s) for any recoupment outside of this timeframe. Corrected claims will be reviewed and responded to after receipt by Dental Select.
• Member Retroactive changes - Retroactive changes must be sent to Dental Select by a Group for Member changes within 30 days if claims
have been paid or 60 days if no claims have been paid. Exceptions include group terminations for non-payment of premiums and extenuating
circumstances to be reviewed and determined by Dental Select. By law, Dental Select reserves the right to recoup funds up to 12 months after
service.
Submission of Claims
You may submit your claims via mail or electronically.
Mail Claims To:
Dental Select
5373 South Green St, 4th Floor
Salt Lake City, UT 84123
Submit electronic claims through your preferred clearing house.
Offices with Multiple Dentists / Providers with Multiple Locations
For clinics or practices with multiple dentists:
• Please submit claims with the name and signature of the treating dentist in addition to the name of the clinic or owner of the practice.
• Associates of Participating Providers must have a Participating Provider Agreement on file in order to see patients as a Dental Select Preferred
Provider.
For Preferred Providers that practice at multiple locations:
• You need to have a Participating Provider Agreement on file for each location. If you need assistance with obtaining an application or agreement
for an associate or an additional office, please contact your Provider Relations Representative, Sharon Smith, at (801) 641-6250 or the Provider
Relations Department in our corporate office at (800) 999-9789, and we will be happy to assist you.
Claims Questions or Corrections
Should you have any questions on your claims, please call our Member Services Department at [(800) 999-9789] and we will be happy to assist you.
Most inquiries can be handled with a phone call.
Your Right to Appeal
If you disagree with a claim determination made by Dental Select, you may request a reconsideration of our decision through our appeal process.
All appeals must be submitted to Dental Select within 60 days of receiving payment or notification of Dental Select’s claim determination. The
appeal must be in writing, must include the disputed determination and must state the basis for the appeal. Also, please include any supporting
documentation or narratives to be reviewed. Dental Select will respond within 60 days of receipt of your appeal.
If you should continue to disagree with the decision on the appeal, you may request a second level review with Dental Select’s Review Board. This
appeal must be in writing and must include any additional supporting documentation pertinent to the determination in dispute. If your claim is
approved, you will receive an EOP outlining your claim payment. If your claim is denied, you will be provided a written notification detailing the basis of
the decision.
Appeals should be submitted to:
Claims Supervisor
Dental Select
5373 South Green Street, 4th Floor
Salt Lake City, UT 84123
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Reimbursement
As a Preferred Provider, you have agreed to accept our maximum allowable amount as payment in full for covered services on the plans you have
elected to participate in when providing treatment for a Dental Select member. You may only charge your patient for deductibles, co-payments,
co-insurance and non-covered services. You must write-off any balances exceeding the maximum allowable.
Explanation of Payment (EOP)
You will receive an Explanation of Payment (EOP) for all claims filed with Dental Select. The EOP will contain:
• Date of Service
• Procedure Code & Description
• Tooth Number/Surface
• Billed Amount
• Approved Amount
• Plan Allowable
• Deductible
• COB Adjustments
• Co-Pay/Co-Insurance
• Contract Adjustment (write-off)
• Amount Paid for Each Patient
Your EOP will also list any previous payments or amounts recovered by Dental Select.
Adjustments, Refunds and Overpayments
In the event that an adjustment is made to a previously processed claim, an additional EOP will be generated outlining the reason for the adjustment.
If the adjustment results in additional compensation owed to you:
• A check will be issued with the EOP.
If the adjustment results in a negative dollar amount (monies owed to Dental Select):
• You will receive a notification letter advising you of the overpayment. You will have 60 days to respond in which you may send Dental Select a
check for the overpayment amount or may request that funds be withheld from future claims payments until the negative balance is recovered.
No additional notification will be sent.
• If we do not receive a response from you within 60 days, funds from future claims payments will automatically be withheld until the negative
balance is recovered.
Negative adjustments must be posted to the patient’s account whose claim was the cause for the overpayment.
Payment Options
Dental Select offers three payment options for providers:
1.Paper check sent in mail after claim is processed.
2.Virtual credit card (Credit card will be issued to provider in exact payment amount and entered into point of service terminal. Standard merchant
fees apply).
3.Electronic Funds Transfer (EFT). Electronic deposit of claim to providers bank, instead of receiving paper check.
Call Emdeon to change payment option at anytime (866) 506-2830.
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Discount Plan
The Discount Plan utilizes the Silver Fee Schedule and is one of the easiest and most cost-effective plans for your office to administer. You save staff
time and billing expenditures, for there are no claims to file. This plan also brings instant profit to your office, as payment is due at the time of service.
The Silver Plan is a fee-for-service discount plan. It is not an insured product.
Discount Plan Guidelines – Silver Fee Schedule
No Claims to File
Simply charge the patient the “Patient Fee” as listed on the Fee Schedule at the time of service. There is no payment from Dental Select. If you have
additional questions, please call our Member Services Department at (800) 999-9789.
Payment Procedures
Patients are expected to pay their Patient Fee in full at the time of service unless they have made prior arrangements with your office. If patient is not
willing to pay their responsibility on day of service, you may bill your regular fees.
Specialist Referral
For procedures requiring a specialist, please refer Dental Select Members to a Dental Select Preferred Specialist. Members will receive a 20% discount
from the specialist’s customary fees, saving the patient out-of-pocket costs (no benefit is paid).
Procedures Not On the Fee Schedule
You may charge your customary fee for any procedure that is not listed on the Fee Schedule.
Plan Identification Card
To assist you in determining a member’s benefits, member’s ID cards will display the plan type and network (Fee Schedule). The ID card is not a
guarantee of benefits; plans and eligibility are subject to change. We always recommend you call our Member Services Department to verify eligibility
and benefits.
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Co-Pay Plans
Individual Plans (IDP) – Gold & Platinum Fee Schedules
• $25 annual deductible applies to all services
• No annual maximum
• 6 months waiting period for basic services
• 12 month waiting period for major services
• No waiting periods on preventive care
Group Plans – Gold & Platinum Fee Schedules
• A deductible may apply - please call Member Services at (800) 999-9789 for benefit information
• No annual maximum
• No waiting periods
Please Note – Frequency limitations apply. Call Member Services at (800) 999-9789 to determine whether your patient has individual or group coverage, and to verify benefit specifications.
Co-Pay Plan Guidelines – Gold & Platinum Fee Schedules
Claim Submittal
Submit claims to Dental Select with your total fee for each service. Please refer to pages 4 – 8 for claim
guidelines and submittal procedures.
Co-Payment Procedures
• Patients are expected to pay their co-payment in full at the time of service unless they have made prior arrangements with your office.
• After 30 days, if the patient’s co-payment has not been paid in full and prior arrangements have not been made, you may charge your customary
fees for the services rendered.
Specialist Referral
For procedures requiring a specialist, please refer Dental Select Members to a Dental Select Preferred Specialist. Members will receive a 20% discount
from the specialist’s customary fees; saving the patient out-of-pocket costs (no benefit is paid).
PEDODONTISTS – For Co-Pay Plan Members, please refer to the Pediatric Co-Pay Fee Schedule for benefit information.
Procedures Not On the Fee Schedule
You may charge your customary fee for any procedure that is not listed on the Fee Schedule. There is no claim payment from Dental Select for these
procedures.
*Specialists in Utah are contracted to a 20% discount on all procedures.
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Co-Pay Plans - (continued)
Plan Identification Card
To assist you in determining a member’s benefits, member’s ID cards will display the plan type and network (Fee Schedule). The ID card is not a
guarantee of benefits; plans and eligibility are subject to change. We always recommend you call our Member Services Department at (800) 999-9789
to verify eligibility and benefits.
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Co-Insurance Plans
Individual Plans (IDP) – Gold & Platinum Fee Schedules
There are two individual plan options. Please call Member Services at (800) 999-9789 to determine which option your patient is enrolled on, and to
verify eligibility.
Option One
Option Two
100%
No waiting periods
100%
No waiting periods
Basic
70%
6 month waiting periods
80%
6 month waiting periods
Major
50%
18 month waiting periods
50%
15 month waiting periods
$75/$225
Applies to all services
$50/$150
Applies to all services
20% Discount
(In-Network)
Adults - 20% discount (In-Network)
Children under 18 and under 50% Insured after
20% discount (In-Network)
Preventive
Deductible
Orthodontics
Group Plans – Gold, Platinum & Signature Fee Schedules
The Co-Insurance Plan is a highly flexible plan that is customized for each group. The Plan Guidelines listed below still apply; however, we recommend
that your office call Member Services at (800) 999-9789 to determine benefit specifications before beginning treatment.
Co-Insurance Plan Guidelines – Gold, Platinum & Signature Fee Schedules
Claim Submittal
Submit claims to Dental Select with your total fee for each service. Please refer to pages 4 – 8 for claim guidelines and submittal procedures.
Co-Insurance Procedures
• Patients are expected to pay their portion in full at the time of service unless they have made prior arrangements with your office.
• For Co-Insurance Plans - After 90 days, if the patient’s portion has not been paid in full and prior arrangements have not been made, you may
charge your customary fees for the services rendered.
Max Plan Options
All Groups benefit from the Max Plan which increases the member’s annual maximum on a yearly basis, based on the subscriber’s effective date, up to
a maximum of $2,000. If this feature has been selected, the member’s ID card will state “Max Plan”. Please call Member Services at (800) 999-9789
for further information regarding a member’s annual maximum.
Specialists
• Referrals - For procedures requiring a specialist, please refer Dental Select Members to a Dental Select Preferred Specialist when possible, where
they will receive a discount from the specialist’s customary fees, saving the patient out-of-pocket costs.
• Benefit Information – Dental Select Co-Insurance Plan participants receive the contracted discount from the Preferred Specialist’s usual fee. A
benefit may be paid according to plan guidelines, based on R&C or the General Dentist Fee Schedule. The patient is responsible for remaining
charges up to the discounted fee after the plan payment.
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Co-Insurance Plans - (continued)
Specialist’s Benefit Payment Guide –You have the option of filing a claim with Dental Select for reimbursement or providing the patient with a
walk-out statement to file their own claim – the choice is yours. If you should choose to file for benefits, the following information will assist you in
determining the amount Dental Select will pay on a claim and how much the patient will owe you for covered services:
1.Deduct contracted discount of 20% from your customary fees for each service provided.
2.Determine the patient’s benefit percentage and plan guidelines for the service. You may obtain this information from your patient or by calling
Dental Select’s Member Services at (800) 999-9789.
3.Determine the total allowable fee, which may be based on Reasonable and Customary (R&C) or the General Dentist Fee Schedule, and apply the
benefit percentage to determine what Dental Select will pay.
4.Subtract the Dental Select payment amount from the discounted fee. This difference is the member’s responsibility.
Specialist’s Benefit Payment Guide Example
1. Specialist’s fee is $100. Take 20% from $100
$100 – 20% discount = $80
2. Patient’s covered benefit percentage is 80% of allowable fee
3. Total allowable fee is $75. Determine benefit amount at 80%
$75 X 80% = $60
4. Discounted Amount
$80
–
Benefit Amount Patient Owes Dentist
$60
=
$20
Please note that deductibles and maximums apply
Procedures Not On the Fee Schedule
You may charge your customary fee for any procedure that is not listed on the Fee Schedule. There is no claim payment from Dental Select for these
procedures.
*Specialists in Utah are contracted to a 20% discount on all procedures on all plans.
Plan Identification Card
To assist you in determining a member’s benefits, member’s ID cards will display the plan type and level, deductibles (if any) and network (Fee
Schedule). The ID card is not a guarantee of benefits; plans and eligibility are subject to change. We always recommend you call our Member Services
Department at (800) 999-9789 to verify eligibility and benefits.
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Helpful Hints
Toll Free Phone: 800-999-9789
Toll Free Fax: 888-673-5328
DentalSelect.com
Below is the standard list of covered services.
This list may vary depending on the group’s plan design. Coverage is subject to the patient’s eligibility at the time of service.
Preventive Service
Frequencies / Limitations
Exams of any kind; prophys (child prophy age 14 & under; adult prophy age 15 & over); fluoride (age 14 & under)
Twice per year
Bitewing x-rays age 11 & over
8 Per Year
Bitewing x-rays 10 & under, code D0270 or DO272 only
8 Per Year
Occlusal x-rays (1 upper & 1 lower)
Once every 24 months
Panoramic (age 6 & over) or full mouth series x-rays (age 11 & over)
Once every 36 months
Basic Service
Frequencies / Limitations
Fillings on the same tooth on the same surface, other than gold fillings (composite fillings on primary posterior teeth will be reduced to an amalgam benefit)
Once every 24 months
Space maintainers, per tooth per area (age 14 & under)
Once per lifetime
Sealants (age 14 & under. Sealants are not covered on anterior teeth, previously restored teeth or if applied within 3 years of last sealant)
Once every 36 months
Major Service
Frequencies / Limitations
Inlays & onlays, crowns, bridges, complete or partial dentures and gold fillings, per surface per tooth (age 14 & over) (see Documentation below)
Once every 5 years
Occlusal guards for bruxism only (age 14 & over)
Once every 24 months
Full mouth debridement (with no history of prior cleaning; no other services except x-rays, exams D120 or D150 may be performed on the same day)
Once every 60 months
General anesthesia – age 7 & under, in conjunction with any service; age 8 & over, only in conjunction with extractions of permanent impacted teeth.
$150 maximum per year
Endodontics* - root canal therapy, pulpotomy, apicoectomy, apexification, retrograde fillings, retreat, pulpal therapy. Age restrictions may apply.
Once per lifetime,
per tooth, per procedure
Periodontics* – root scaling /planing per quad (age 14 & over)
Once every 24 months
Periodontal maintenance* (in lieu of preventive cleaning)
Twice per year
Periodontal surgery*
Frequencies may vary. Please call for
verification.
*Periodontics and/or Endodontics may be covered under Basic, depending on group specific plan design.
Orthodontic Service
Frequencies / Limitations
Diagnostic records (cepholametric film, panoramic or full mouth x-rays, diagnostic casts, diagnostic photographs); Bill as code D8660 for diagnostic records
Removable, fixed or cemented appliance for orthodontic treatment including impressions, installations, & all adjustments while covered under the plan
Children 18 and under, paid up to
lifetime maximum.
Bill quarterly or monthly
No coverage or limited coverage for orthodontic treatment that began prior to the effective date of coverage.
Documentation
Frequencies / Limitations
Inlays & onlays; multiple surface composites (D2335); bridges; partials; crowns; core build-ups; pontics, implants
Submit x-rays with claim (narratives
required on some procedures)
Scaling and root planing; periodontal maintenance; periodontal surgery; gingivectomy, osseous surgery; clinical crown lengthening and guided tissue regeneration
Submit periodontal charting and
full mouth x-rays with claim (Photos
required on some procedures)
Wisdom teeth, impacted; implants (if covered by Employer)
Submit x-rays with claim
No Coverage
Nitrous Oxide
Inlays & onlays or crowns on teeth that can be restored by direct placement materials
All Plans
Missing Tooth Clause – Replacement of teeth that were missing (extracted or congenitally) prior to the effective date of coverage are not eligible for 3 years from
effective date of continuous coverage.
Replacement of full or partial dentures, bridges, inlays & onlays or crowns within 5 years of placement.
Self Funded Plans
Groups that are self-funded govern their own unique fee schedules & benefits, which may vary from Dental Select’s standard plan design. Please contact Member Services for any questions regarding self-funded
groups or their plan benefits.
ALTERNATE BENEFIT: If: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental
condition; and 2) the alternative treatment will produce a professionally satisfactory result; then We will allow the charge for the less expensive treatment.
Current Dental Terminology © American Dental Association
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Definition of Terms
Allowable Fee/Charge – The amount Dental Select has established as full payment to a Participating Provider in accordance with the terms of the
Provider Agreement.
Alternate Benefit – A provision in a dental plan contract that allows Dental Select to determine the benefit based on an alternative procedure that is
generally less expensive than the one provided or proposed.
Approved Payment Amount – The amount that Dental Select has approved as full payment for a covered service.
Assignment of Benefits – A procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for a covered
procedure directly to the treating dentist.
Balance Billing – Billing a patient for the difference between the dentist’s customary charge and the allowable amount under the patient’s plan. This
is expressly prohibited.
Benefit – Payment provided by Dental Select for covered services.
Benefit Plan Summary – The description or synopsis of employee benefits that is distributed to the employees/members.
Birthday Rule – Coordination of benefits regulation stipulating that the primary payer of benefits for dependent children is determined by the parent
who has the earlier date of birth by month and day, without regard to the year of birth. This rule may be overridden by an official divorce decree ruling
or stipulation.
By Report – A narrative description used to describe a service that does not have a procedure code or is specified in a code as “by report”, may be
requested by Dental Select to provide additional information for claims processing.
Calendar Year –January 1 through December 31.
CDT (Current Dental Terminology) – American Dental Association (ADA) approved dental coding system.
Claim – A request for payment for services provided.
Co-insurance – Dental benefit program in which the member shares in the cost of covered services on a percentage basis.
Contractual or Contract Adjustment – The dollar amount that exceeds Dental Select’s maximum allowable or contracted amount, also referred to as a
write-off.
Coordination of Benefits (COB) – A method of integrating benefits payable for the same patient under more than one plan. The total benefits paid by
both plans are not to exceed the highest contracted allowable expense of either plan.
Co-payment (co-pay) – Fixed dollar amount of covered services under the Dental Select Fee Schedule associated with the member’s plan.
Coverage – Benefits available to a member covered under a dental benefit plan.
Covered Charges – Charges for services rendered by a dentist that qualify as covered services and are paid for in part or whole by Dental Select. May
be subject to co-pays, deductibles, maximums and limitations as specified by the member’s plan.
Covered Services – Services for which payment is provided under the terms of the dental benefit plan.
Deductible – An out-of-pocket expense that the member must pay before payment from the dental plan for covered services will begin.
Dependent – Generally spouse and children of covered individuals, as defined by the terms of the dental benefit contract.
Dual Coverage – Coverage under two different dental benefit plans.
EDI – Electronic Data Interchange; submission of claims using an electronic clearing house.
EFT – Electronic Funds Transfer; electronic deposit of claims payment to provider’s bank.
Eligibility or Effective Date – The date an individual and/or dependents become eligible for benefits under a dental benefit contract.
Excluded Service – A service not covered by the member’s benefit plan regardless of necessity.
Exclusive Provider Organization (EPO) – A dental benefit plan that provides benefits only if care is rendered by Dental Select Preferred Providers.
Explanation of Benefits (EOB) – Statement provided to the member by Dental Select, indicating the benefit/charges covered or not covered by the
dental benefit plan.
Explanation of Payment (EOP) – Statement provided to the Provider by Dental Select, indication the benefit/charges covered or not covered by the
dental benefit plan.
Fee Schedule – The list of allowable codes and charges established by Dental Select.
Group – The employer, association, union or other organization that provides dental benefits for a member.
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Definition of Terms - (continued)
Group ID – The number used to identify the employer or group that provides dental benefits for a member.
Health Insurance Portability & Accountability Act of 1996 (HIPAA) – A federal law that requires all health plans, dental professionals and associated
entities who transmit health information electronically, to follow stringent security standards as outlined in the Act.
Limitations – Restrictive conditions stated in the dental benefit contract, such as age, frequencies, conditions or waiting periods, which affect a
member’s coverage.
Maximum Allowable Amount – The amount Dental Select has established as full payment to a Participating Provider in accordance with the terms of
the Provider Agreement. The maximum may be reached through a combination of payments from Dental Select and the member.
Member – A person eligible to receive benefits under a member contract.
National Provider Identification (NPI) – The NPI is a component of HIPAA and is used to uniquely identify a health care provider in standard
transactions, such as claims. The NPI does not replace the TIN for tax or other identification purposes.
Network – A specific Fee Schedule associated with Dental Select’s established panel of Preferred Providers.
Participating Provider – A dentist who has signed a Preferred Provider Agreement with Dental Select to render services to Dental Select Members. Also
referred to as a Preferred Provider.
Plan Type – Describes the benefit level and design of a specific Dental Select plan.
Predetermination of Benefits – An estimate provided upon request to assist in establishing benefits and eligibility for a prescribed treatment program
for a Dental Select member. Estimates are not a guarantee of payment and are subject to changes and limitations.
Pre-existing Condition – Condition of a member which existed before his/her enrollment in their dental benefit plan.
Preferred Provider – A dentist who has signed a Preferred Provider Agreement with Dental Select to render services to Dental Select Members. Also
referred to as a Participating Provider.
Preferred Provider Organization (PPO) – A dental benefit plan designed to offer both in and out of network benefits to patients, but offers patients
lower out-of-pocket costs when receiving services from a Dental Select Preferred Provider.
Primary Plan – The dental plan which has the primary, or first, responsibility to pay benefits when a member is covered by more than one dental plan.
Reimbursement – Payment made by Dental Select to a dentist or member for payment of expenses incurred for services covered by the dental benefit
plan.
Secondary Plan – An additional dental plan that may cover dental expenses after the Primary Plan has paid on a claim.
Subscriber – A person who receives dental benefits on behalf of him/herself and his/her dependents.
Tax Identification Number (TIN) – Number issued through the Internal Revenue Service (IRS) and used for reporting earnings.
Termination Date – The date on which the member’s plan is no longer effective and the individual is no longer eligible for benefits under the
terminated plan.
Total Contracted Fee – The amount Dental Select has established as full payment to a Participating Provider in accordance with the terms of the
Provider Agreement.
Waiting Period – A period of time as determined by the dental benefit plan in which a member is not eligible for certain services or paid benefits.
Write-off – The dollar amount that exceeds Dental Select’s maximum allowable or contracted amount, also referred to as a Contractual Adjustment.
Virtual Credit Card (POS) – Instead of a check, receiving a virtual credit card which, when entered into your point-of-service (POS) terminal will
transfer an EOP’s payment directly into your account.
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