The ADA Council on Dental Benefit Programs continually receives and addresses a variety of dental claim submission and adjudication questions from member dentists and practice staff. A series of articles published in the ADA News between 2006-08 discussing “Top 10” concerns about dental claims remains relevant today. The articles included perspectives from ADA members, National Association of Dental Plan members and the Council on Dental Benefit Programs.
Many complaints concerning the denial of core buildups were brought to the attention of the ADA Council on Dental Benefit Programs. Dentists perform this procedure when it is necessary prior to restoring a tooth with a crown. Complaints centered on the lack of a benefit for this procedure. Some dentists complained that this procedure is bundled with a crown procedure.
Bundling of separate procedures to limit a benefit is against ADA policy. If a plan chooses to bundle these procedures, the plan should allow the sum of the fees for the crown and the crown buildup as the total fee for the procedure and provide the appropriate benefit. Dentists do not always understand the parameters for payment by plan. Patients should be clearly informed as to benefit limitations and it should be made clear in the benefit booklet and explanation of benefits that plan limitations and not clinical necessity determine payments.
CDBP notes that many patients do not understand how their dental benefits really function. They do not understand that dentists who attempt to deliver ideal care may find that the constraints of a given policy do not align with the treatment plan. It is incumbent on us to give appropriate care notwithstanding a patient's insurance coverage. This is an example of just such a situation. We cannot interpret the meaning of any code beyond what it actually states.
The payers who choose not to fund for core buildups do so for many reasons. Having patients who understand the limitations of their plan prior to treatment can avoid problems.
Regarding explanation of benefit language, CDBP works very hard to help insurance companies find language which is not only succinct but which does not infer bad faith on the part of the dentist. We have had some success in this regard by direct correspondence with individual companies.
It is incumbent upon the dentist to help the patient understand the clinical basis for treatment, in spite of contractual limitations by the plan. In doing so, the rationale for the core buildup to improve retention form and improve the clinical outcome is clearly explained for the benefit of the patient. In cases of denial, it may be appropriate to submit an appeal outlining the reasons for the procedure, leading to improved prognosis.
Dental benefits industry perspective
Both this code and D6973 core buildup for retainer, including any pins, creates problems for payers. Some of the problems result from limitations in an employer's group policy and some result from lack of documentation to support use of this procedure in addition to a crown.
The change in the descriptor in CDT-4 clarified the procedure, however all claims submissions are not consistent with the descriptor. In the description it states the procedure, "Refers to building up of anatomical crown when restorative crown will be placed, whether or not pins are used. A material is placed in the tooth preparation for a crown when there is insufficient tooth strength and retention for the crown procedure. This should not be reported when the procedure only involves a filler to eliminate any undercut, box form or concave irregularity in the preparation."
Some payers find that buildups are reported in addition to a crown procedure when there is a base placed only to restore undercuts and tooth structure that is removed during the crown preparation. This is contrary to the descriptor for this code. Under this definition, a dental consultant acting on behalf of the payer may decide, based on the documentation submitted, that the reported crown buildup did not meet the definition and is a part of the crown procedure. Thus, only the crown procedure will be reimbursed.
Benefit limitations are required, under state law or in the case of Taft-Hartley contracts under negotiated labor agreements, to be disclosed in plan documents that are provided to insured patients. These documents must meet readability standards which are most often at the grade school reading level and sometimes are required in foreign languages as well. While these plan documents are made available to insured patients, they may be lost or misplaced and thus not referenced by the patient when seeking treatment.
EOB* language is intended to be succinct yet descriptive of the payers' action relating to the patient's claim. Payers are often limited in the space provided for explanations and use shortened descriptions to convey information. When such language results in misunderstandings between the patient and the dentist, payers are open to suggestions for changes in language.
Tip to minimize claim denials for core buildup:
In the initial claim submission, documentation of the condition that resulted in the buildup should be provided, if applicable.
*The National Association of Dental Plans has recently distributed to its members the ADA Council on Dental Benefit Programs' summary, "ADA Position on Content of Explanation of Benefits (EOB) Statements."