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CDBP helps solve MetLife claim issues

Dr. Bob Flath started noticing a pattern when he submitted claims to MetLife.

When an initial diagnostic image procedure was submitted on the same claim as an endodontic procedure, an auto adjudication system MetLife uses denied the claim. Other dentists reported that MetLife denied a first diagnostic radiograph for endodontic therapy when the claim was first filed and again on appeal.

But when the radiograph was filed on a separate claim form than the endodontic therapy, both claims were paid. The Code on Dental Procedures and Nomenclature states that the first diagnostic image for endodontic treatment is not included in the endodontic procedure; whether the procedures are reported on the same claim is irrelevant.

Dr. Flath and some other dentists contacted the American Dental Association, specifically the Council on Dental Benefit Programs, about the issue and asked for help. Staff members were able to work with MetLife on the problem, which was ultimately resolved.

MetLife determined that there was an issue with the computer software. No live person was reviewing the claims, so the auto adjudication system denied claims that had procedures performed on the same day that were submitted on the same form, said Dr. Jim Richeson, CDBP chair. The problem ended up being deeper than that, he said, because these claims were also being denied on appeal.

“This is one of the many examples of how CDBP and its staff are constantly responding to concerns from individual dentist members. Via our continuous communication with the top management executives at dental benefit companies, we are able to influence a change for the betterment of the entire profession and the patients we are privileged to serve,” Dr. Richeson said.

Dr. Richeson encourages members who have concerns or complaints about how a third-party has administered or adjudicated dental benefit claims to contact CDBP during business hours by calling the ADA member toll-free number on the back of their membership card. To receive an answer electronically, email dentalbenefits@ada.org.

The ability to call the ADA and have staff members investigate a problem was invaluable to Dr. Flath.

“They had established channels of communications with people who are decision makers in the insurance industry that I did not have access to as an individual,” Dr. Flath said. “I appreciate their help and it’s one of the reasons we pay dues.”