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Is the third-party payer bundling procedure codes, or is it something else?

August 09, 2012

The Council on Dental Benefit Programs receives phone calls and emails from many members concerning procedure code bundling and possible misuse of the CDT Code. A Letter to the Editor ran in the March 19 ADA News on this same topic. The council wants to clarify bundling and CDT Code misuse and has issued the following guidance.

An explanation of benefits that shows reimbursement for fewer services or for different procedure codes than reported on the claim raises eyebrows and prompts dentists to call the ADA and ask, “How can this happen? Isn’t the third-party payer doing something wrong or illegal? It looks like the CDT Code is being misused.”

The first step in answering these questions and concerns is to look at what guidance is in place concerning CDT Code use.

• A CDT Code license, which a third-party payer must sign in order to legally use this ADA intellectual property, clearly states that a procedure code entry cannot be changed—meaning a code’s nomenclature and descriptor are fixed and cannot be redefined. An example of redefinition and possible violation of the license is when a claim that reports delivery of D0120 (periodic oral evaluation), D1120 (prophylaxis - child) and D1203 (topical fluoride-child) is returned with the payer stating that all three services are part of D0120. Here the third-party payer is redefining D0120.

• The ADA defines procedure code bundling as “the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.” Procedure code bundling is frowned upon by the ADA. However, dentists who have signed participating provider agreements with third-party payers may be bound to plan provisions that limit or exclude coverage for concurrent procedures.

• The Health Insurance Portability and Accountability Act requires that the procedure code reported on a claim be from the CDT Code version that is effective on the date of service. Yet neither HIPAA, ADA policy nor the CDT Code itself require that a third-party payer cover every listed dental procedure. Covered dental procedures are identified in the contract between the plan purchaser and the third-party payer.

Many patients do not understand how dental benefit programs work and that coverage limitations and exclusions may limit reimbursement for necessary care. Such a misunderstanding is compounded when EOB language suggests that the dentist is at fault. Ensuring patients understand the limitations of their dental plan prior to treatment may help avoid problems and maintain a strong dentist-patient relationship.

Some dental claim adjudication practices are appropriate when based on plan design and should be clearly explained on the EOB to prevent misunderstandings. Other situations, where the EOB message suggests the dentist is in error, may pose problems. Each of these conditions is illustrated in the following examples:

• Probably correct: A claim for full mouth debridement and two-surface restoration is adjudicated and only the D4355 is reimbursed. The EOB message states that the benefit plan has limitations and exclusions, one of which is that the plan does not cover any restorative procedure delivered on the same day as a D4355 (full mouth debridement). Since the nomenclature for D4355 clearly states “to enable comprehensive evaluation and diagnosis,” it does not seem reasonable that restorative services could be performed without first providing an evaluation and diagnosis.

• Probably incorrect: The dentist reports a D1110 on the claim because the patient is 13 years old with predominantly adult dentition, but the EOB lists D1120 with a message that this is the correct code for a patient under the age of 15. The payer is wrong, as the message may imply that the dentist reported the incorrect prophylaxis procedure code. What the payer should do, if the benefit plan specifies an age-based benefit limitation, is accept the claim as submitted and note that payment is based on a D1120 as a result of benefit plan design.

The last example illustrates why it is important that the dental office help the patient understand the clinical basis for treatment. In this case the type of prophylaxis is determined by the state of the patient’s dentition, not age, even though the patient’s benefit may be determined by age.

How to appeal an adverse claim determination

It is appropriate to appeal the benefit decision if you think the claim has not been properly adjudicated. When appealing a claim, it is important to follow the specific instructions provided by the particular carrier including the submittal of the appeal in writing within the time allowed by the carrier. It is important to send it to the specified department of the carrier and it must be in the required format. The word “appeal” should prominently appear in the title and text of the document, as well as in any cover letter that accompanies the appeal document. Remember, the dentist consultant representing the carrier may only be looking at a dental claim form and you will want to provide the consultant as much information as possible so that he or she will agree with your treatment plan and approve the appropriate benefits for your patient.

A proper appeal involves sending the carrier a written request to reconsider the claim. Additional documentation should be included to give the carrier a clearer picture of why you recommended the treatment. For example, the following claim attachments may assist in getting consideration for core buildup claims—radiographic evidence of the need for a buildup, and a narrative description providing as much explanatory information as possible (even if this appears obvious to you). If you have further questions, it is best to give that carrier a call. Remember, you are trying to have the dentist consultant understand the rationale for your recommended treatment plan so that your patient can receive the appropriate benefit from his or her plan. It may help to ask the dentist consultant to call you if the claim is going to be denied. This way you can discuss the case with the dentist consultant on a professional level. You may want to leave a time and date when you will be available so that the consultant does not call while you are seeing patients.

Help the ADA help you

Arbitrary payer action is an ongoing ADA concern and we ask that dentists report such actions so that staff can address recurring issues with the third-party payer involved. Also, it is appropriate to appeal the benefit decision if you think the claim has not been properly adjudicated, and ADA staff are prepared to assist in your understanding of the appeal process.

Staff from the Council on Dental Benefit Programs’ Dental Benefit Information Service are here to help you with your insurance related problems, questions and concerns. Staff can be reached at 1-800-621-8099. If you wish to simply alert the ADA to a concern, you can complete the downloadable form on titled, “third-party payer complaint form” which gives dental offices the opportunity to provide ADA with information on the problems experienced with third-party payers. This form was developed by the ADA’s CDBP to track industry trends and facilitate discussions with individual insurance carriers and benefit plan providers.

Attention: dentists without a participating provider contract

The ADA is also currently looking for your help if you are a non-participating dentist and have encountered either of the following two scenarios. If you have encountered either or both please contact: Mike Kendall,, or Cathryn Albrecht,

1. Recoupment of alleged overpayments from a nonparticipating dentist

• You treated a patient covered by a large dental plan and submitted a claim under an assignment of benefits and were directly reimbursed for the treatment you provided to that patient.
• At a later time you received notification from the payer alleging that it overpaid you in connection with that patient, and that the payer is entitled to recoup the (alleged) overpayment.
• Either as part of the same notification, or afterward, the payer informs you that it is lowering reimbursement amounts for another patient, or patients, in order to recoup the (alleged) overpayment.

2. Underpayment to nonparticipating dentists

• You treated a patient covered by a large dental plan and submitted a claim under an assignment of benefits and received an EOB reflecting a reimbursement amount that falls below what you should have been paid, based on what you believe would be indicated by the unbiased applicable geographic and other relevant data.
• You properly appealed to the payer its reimbursement decision, which generally means:

a) You submitted your appeal within the time allowed by the payer
b) Your challenge is documented in letters, emails, etc. or is recited on an appeal form available from the payer
c) The term “appeal” is explicitly used (best practice), or any word is used that, to a reasonable person, would signify that you were appealing the reimbursement decision made by the payer, such as: “challenge,” “dispute,” “contest,” “object to,” and the like
d) The appeal is coupled with a demand that the amount of the reimbursement be increased or reviewed for the purpose of determining the correct amount

• The payer responded by rejecting your appeal.