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Coordination of benefits guidelines available on Center for Professional Success

May 18, 2015

By Kelly Soderlund

The ADA Practice Institute has developed guidance on coordination of benefits — a scenario that's increasingly more common as more Americans register for coverage under the Affordable Care Act and medical plans offer embedded dental services.

Dental plans coordinate a patient's benefits if they are entitled to benefits from more than one dental plan. This eliminates over-insurance or duplicating benefits.

Because more people are able to purchase dental benefits within medical plans through the Affordable Care Act, questions have arisen on whether there are more administrative demands when it comes to coordination of benefits.

In response to these questions, the ADA House of Delegates in 2014 passed House Resolution 63RC, which calls for ADA agencies to develop guidance on coordination of benefits.

"Coordination of benefits can be confusing and frustrating for both dentists and their staff," said Dr. Charles Hoffman, chair of the ADA Council on Dental Benefit Programs.

"With the implementation of the ACA an increase in the number of patients with more than one dental plan is expected. CDBP, at the request of the House of Delegates, put together guidelines to assist our members with information that should be considered when filing claims."

The current ADA policy on coordination of benefits for group dental plans states that when a patient has coverage under two or more group dental plans, the following rules should apply:

  • The coverage from those plans should be coordinated so that the patient receives the maximum allowable benefit from each plan.
  • The aggregate benefit should be more than that offered by any of the plans individually, allowing duplication of benefits up to the full fee for the dental services rendered.

The ADA's guidelines are available as a members-only resource on the Center for Professional Success website at Success.ADA.org/COB.