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Contract Analysis Service helps with national policy, billing and network list questions

The Council on Dental Benefit Programs often receives calls from ADA members who have questions about the contracts they signed with their network plans.

Image: Dr. May
Dr. May

“The ADA provides CDBP staff with the resources to resolve the issues, but dentists should also be reminded of a valuable service offered by the Association,” said Dr. David May, chair of CDBP’s Dental Benefit  Information Service Subcommittee.

The Contract Analysis Service provides a clear, plain language explanation of contract terms and is designed to allow dentists to make informed and independent decisions on the merits of participating dentist contracts. The service is free to members who request a review through their constituent dental society and costs $50 for members who contact the ADA directly.

To learn more about the Contract Analysis Service, visit www.ada.org/1308.aspx.

Below are some common scenarios dentists may face.

National processing policies possibly not in the contract

Some dentists have inquired with their carrier’s customer service representative about the way their claims were handled and were told it was because of company policy.

Many times, if a dentist has contracted with a third-party payer, he or she may have agreed to abide by the carrier’s national processing policies, which may or may not appear in the contract.

The processing policies of many carriers are published on their websites. Dentists may have to sift through dozens of pages of policies, including a breakdown of how every dental procedure code is adjudicated by the carrier.

For the average dentist who contracts with multiple carriers, it can be overwhelming and time consuming to try to grasp an understanding of their contractual obligations, Dr. May said. 

“CDBP recommends dentists request a face-to-face meeting so that a plan’s provider relations manager can visit the dental office to explain dental plan policies and procedures in detail,” Dr. May said. “This will give dentists the opportunity to ask where additional information and guidance can be obtained.”  

Billing for component and denied dental procedures

Sometimes, dentists and their patients will receive an explanation of benefits statement where a carrier denied a procedure claim because it was provided on the same date as another procedure. This scenario has left dentists and CDBP wondering whether that procedure would have been paid had it been provided on a different date, Dr. May said.

“The ADA receives many complaints from dentists regarding third-party payers not allowing them to bill patients for procedures the payers consider incidental to other procedures. Some carriers may even disallow these procedures, which means not only will the plan not cover the procedure it will not allow the dentist to charge the patient for the procedure,” Dr. May said.

“Dentists may feel like they are offering free services to the patient.”

Limitations in an employer’s group policy may result in noncovered procedures or denial of the procedures. Dentists should appeal the claim decision if they feel it was incorrectly denied, Dr. May said.

“It is extremely important for dentists to educate their patients that a denied claim does not mean the procedure wasn’t necessary,” Dr. May said. “It simply means that the procedure was not a covered benefit under the patient’s group dental plan.”

Removal from network lists

Terminating your participation with a network plan should guarantee that your name no longer appears as a participating provider on the carrier’s website but that is not always the case.

Dentists have reported receiving calls months after they have cut ties with a carrier from patients who are insured by that company and are looking to make an appointment.

“This can cause problems for new patients who have scheduled an appointment with the dentist simply because the patient thought that this dentist was still a participating provider with the payer,” Dr. May said. “Problems can occur as these new patients were expecting to be billed by the plan’s maximum allowable fees and instead are receiving the dentist’s full fees.”

CDBP recommends dentists submit a request in writing at the time of cancelation for the carriers to remove their names from any participating provider list.

There’s often a contractual waiting period, anywhere from 30 to 90 days, before terminations take effect. Dentists should follow up with carriers who fail to remove their name in a timely fashion, Dr. May said.

States interested in reprinting this series of articles can contact Karen London, londonk@ada.org, at the ADA for permission.