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ADA House acts on dental benefit policies, guidelines, standards

Honolulu—Here follows a summary of actions related to the Council on Dental Benefit Program and ADA Standards Committee on Dental Informatics passed by the 2009 ADA House of Delegates last month.

Resolution 1H-2009 reinforces the Council on Dental Benefit Programs goal of revising the policy, Guidelines on Coordination of Benefits for Group Dental Plans, by clarifying language.

The amended policy on Guidelines on Coordination of Benefits for Group Dental Plans says:

When a patient has coverage under two or more group dental plans the following rules should apply:

(a) The coverage from those plans should be coordinated so that the patient receives the maximum allowable benefit from each plan.

(b) 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 received. Also resolved,

  • that third-party payers, representing self-funded as well as insured plans, should be urged to adopt these guidelines as an industry-wide standard for coordination of benefits,
  • that constituent societies are encouraged to seek enactment of legislation that would require all policies and contracts that provide benefits for dental care to use these guidelines to determine coordination of benefits;
  • that all third parties providing or administering dental benefits should adopt a unified standardized formula for determining primary or secondary coverage and that the formula should be readily applied by dental providers based on information easily obtained from the patient;
  • that the ADA seek federal legislation requiring that third parties comply with a standardized formula for determining primary and secondary coverage;
  • that the ADA, through its appropriate agencies, urge the National Association of Insurance Commissioners to amend their model legislation to conform with ADA policy.

Res. 2H-2009 clarifies language in the second and third resolving clauses of the ADA policy on Reporting of Dental Procedures to Third Parties.

Changes include replacing the word "system" in the second resolving clause with "taxonomies," deleting "since third-party payers are voting participants in the Association's code revision process," and other editorial changes so that the second and third clauses of the policy resolve as follows:

  • that third-party payers should not require the reporting of dental treatment or filing fees by any other coding taxonomies;
  • that the Association formally contact commercial carriers, service corporations, any and all other third-party payers and their agents who process dental claims, and vendors of electronic claims processing, to request that the ADA Code on Dental Procedures and Nomenclature be used as the code taxonomy for their claims adjudication process.

Res. 78H-2009 directs the Council on Dental Benefit Programs to study the development of an aggressive national public relations program to educate human resource professionals on the value of dental coverage and the process of evaluating comprehensive dental insurance benefits and provide a report to the 2010 House of Delegates.

Res. 83H-2009 directs the ADA Standards Committee on Dental Informatics to develop a standard for the secure electronic transmission of digital radiographs and photographs and promote this standard for use by practitioners as well as third-party payers and provide a status report to the 2010 House of Delegates.