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ADA prompts EOB language changes

The ADA's efforts with insurers on behalf of members are resulting in more accurate explanation of benefits language, dentists say.

"We meet with insurers on a regular basis about dental benefit issues," said Dr. Bert Oettmeier, incoming chair of the Council on Dental Benefit Programs. "CDBP welcomes the opportunity to hear members' concerns about EOB language that in members' opinions may be inaccurate, defamatory or interferes with the dentist-patient relationship."

The council provided information this year where ADA members were in effect told they were submitting incorrect codes. United Healthcare and Shasta Administrative Services questioned the codes for procedures that some dentists were reporting.

The option that the insurers believed appropriate was problematic because according to the current Code on Dental Procedures and Nomenclature, it could have resulted in reporting procedures which the dentists did not perform. After considering information provided by CDBP, the payers determined to use EOB language based on their processing policies when they apply an alternate benefit, but accepted the dentists' coding submissions as reported.

UHC initially denied a D1110 (adult prophylaxis and topical fluoride), stating in its EOB, "Member's age not within plan guidelines," due to processing policies based on age instead of state of dentition, per the code descriptor. After receiving information from CDBP staff, UHC determined it would accept the claim with the code for a 12-year-old patient with no primary dentition as reported and applied an appropriate alternate benefit for reimbursement.

"We are also in the process of re-examining our overall approach to reimbursement for this procedure and would be happy to keep you updated on our progress," said Dr. Michael Weitzner, in a February e-mail to the council. The vice president of Clinical Product Development, United Healthcare Specialty Benefits/United Healthcare Dental in Rockville, Md., Dr. Weitzner is the current president of the American Association of Dental Consultants.

Shasta Administrative Services, Redmond Ore., reported to the council in April that it would not ask dentists to resubmit a D4342 code when a D4341 for periodontal scaling and root planing was performed.

Early this year a dentist complained to CDBP that instead of applying an alternate benefit for a D4342 and noting it on the EOB, Shasta told the dentist: "D4341 may be better represented by another code; D4342 does warrant." CDBP provided information to Shasta indicating such EOB language was inaccurate, as Shasta's requirement that at least four teeth in the quadrant must display 4 mm or more pocket depth with loss of attachment and some bone loss in order to meet the requirements for reporting D4341 differs from the code descriptor for D4341, which does not mention bone loss or pocket depth.

"We want dentists to submit accurately for the procedures they performed, according to the current Code," said Dr. Oettmeier. "We're happy when insurers understand where discrepancies exist," he said about the success with Shasta.

Dr. Jerry Zackin called Blue Cross Blue Shield of Georgia's commitment to discontinue the EOB statement—Your dental plan does not allow benefits for services on a tooth that has an unfavorable five-year prognosis—"a step in the right direction." The insurer told CDBP staff that as of May 2009, such EOB language would no longer be used.

Dr. Zackin, a retired periodontist and insurance consultant for the American Academy of Periodontology, said, "All the science shows such prognosis is very difficult to determine even by the best trained experts."

Dr. Oettmeier advises dentists to continue to contact the council about EOB issues important to them, adding, "ADA successes often have broader implications on the entire profession."

ADA members interested in contacting CDBP about EOB language should contact the ADA at the toll-free number or via e-mail at