Preferred Provider Admin Guide

Transcription

Preferred Provider Administrative Guide
Welcome to the Dental Select Network ................................................................................................... 1
Updating Your Manual ........................................................................................................................ 1
Confidentiality...................................................................................................................................... 1
Contacts ..................................................................................................................................................... 2
Provider Relations ............................................................................................................................... 2
Member Services ................................................................................................................................ 2
Advantages of Participation ..................................................................................................................... 3
Preferred Provider Agreement ................................................................................................................. 4
Claim Guidelines ....................................................................................................................................... 4
Required Fields on All Claim Forms ................................................................................................... 5
Common Claim Filing Errors ............................................................................................................... 5
Waiting Periods ................................................................................................................................... 6
Alternate Benefit ................................................................................................................................. 6
Coordination of Benefits (COB) .......................................................................................................... 6
X-rays .................................................................................................................................................. 6
Orthodontic Claim Guidelines ............................................................................................................. 7
Predetermination Estimates ................................................................................................................ 7
Electronic Data Interchange (EDI) ...................................................................................................... 7
Submission of Claims ......................................................................................................................... 8
Offices with Multiple Dentists / Providers with Multiple Locations ...................................................... 8
Claims Questions or Corrections ........................................................................................................ 8
Your Right to Appeal ........................................................................................................................... 8
Reimbursement ......................................................................................................................................... 9
Explanation of Payment (EOP) ........................................................................................................... 9
Adjustments, Refunds and Overpayments ......................................................................................... 9
Discount Plan ........................................................................................................................................... 10
Payment Procedures ........................................................................................................................ 10
Specialist Referral ............................................................................................................................. 10
Plan Identification Card ..................................................................................................................... 10
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TX2012 Prov Admin 02/12 A
Co-Pay Plans ............................................................................................................................................ 11
Individual Plans ................................................................................................................................ 11
Group Plans ...................................................................................................................................... 11
Claim Submittal ................................................................................................................................. 11
Co-Payment Procedures ................................................................................................................... 11
Specialist Referral ............................................................................................................................. 11
Co-Insurance Plans ................................................................................................................................. 13
Individual Plans ................................................................................................................................. 13
Group Plans ...................................................................................................................................... 13
Claim Submittal ................................................................................................................................. 13
Co-Insurance Procedures ................................................................................................................. 13
Max Plan Options .............................................................................................................................. 13
Specialists ......................................................................................................................................... 14
Specialist’s Benefit Payment Guide .................................................................................................. 14
Helpful Hints............................................................................................................................................. 16
Definition of Terms .................................................................................................................................. 17
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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
Helen Andrews Mims
Corporate Office
Toll Free (800) 999-9789
Texas Provider Relations Representative
Utah (801) 495-3000
Phone (866) 746-0393
Toll Free (800) 999-9789
Fax (800) 945-9193
Fax (888) 998-8708
[email protected]
[email protected]
SLC (801) 495-3000
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 this department is our COO, Suzette Musgrove. With over 28 years experience in the
dental industry, including 16 years working within dental offices, Suzette has a deep understanding of
the dental industry and a unique perspective of our network Providers. She is a National Association of
Dental Plans (NADP) member, serving on the Professional Relations committee and working directly
with the ADA to promote excellence. She is 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 Professional Relations Representative for Texas is Helen Mims. Helen has been with Dental
Select since 2002 and has over 30 years experience in the dental insurance industry. She has a solid
knowledge and understanding of all aspects of the insurance process and of Dental Select’s policies and
procedures. Helen has the extensive knowledge and experience to assist you and your staff with any
questions or issues 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.
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.
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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, anterior crowns or two or more posterior crowns with no history of build-up
Additional information regarding documentation can be found in the Helpful Hints on page 16.
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.
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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.
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
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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: 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 only be paid every 30 days upon receipt of claim
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)
Specialist discount does not apply to Invisalign – no need to submit a claim
Predetermination Estimates
We recommend that all services over $300 be submitted for predetermination. Dental Select will provide
your office with a predetermination estimate to assist you and your patient in making informed decisions
about the treatment program you have prescribed. Predetermination estimates are provided as a
courtesy and are not a guarantee of payment. Predeterminations 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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Submission of Claims
You may submit your claims via mail or electronically.
Mail Claims To:
Dental Select
th
5373 South Green St, 4 Floor
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, Helen Mims, at (866) 746-0393 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 90 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 30
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
th
5373 South Green Street, 4 Floor
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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.
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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.
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 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
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).
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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.
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.
Preventive
Basic
Major
Deductible
Option One
Option Two
100%
No waiting period
100%
No waiting period
70%
6 month waiting period
50%
$75/ $225
Applies to all services
80%
50%
$50/ $150
Applies to all services
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.
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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.
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
$60
Patient Owes
Dentist
=
$20
Please note that deductibles and maximums may apply.
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.
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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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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 which 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.
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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
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.
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.
18
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.
19

Preferred Provider Admin Guide

Transcription

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