ADA Q&A: Dental Benefits

Over time, fees reported to the plan on claim forms are used to monitor trends and serve as the basis for the payer setting allowable amounts for the area. These analysis will not reflect the true market trends if the dentists in that area aren’t submitting their full fee. Coordination of benefits is also dependent upon the fee reported on the claim form. 

Dentists should always report their full fee for the procedure code on the claim form, regardless of what the benefit amount is. The full fee represents the costs of providing the service and the value of the dentist’s professional judgment in providing the service.  As dentists determine their fees for services rendered, the full fee could be any amount, beginning with zero dollars (i.e., $0.00). A $0.00 report on a claim form is a valid entry.

A dental plan administers a “benefit” to the patient and is not intended to cover all charges. If you bill your full fee the patient will receive the maximum benefit from their plan.

CDT Code and claim submission assistance is available from the ADA.  Please call 800-621-8099 or send an email to dentalcode@ada.org. Assistance is also available when there are issues with a third-party payer.  Please call the toll free number or send an email to dentalbenefits@ada.org

It is not uncommon today for dental benefit carriers and third party administrators (TPAs) to pay dental offices with a credit/debit card instead of the traditional paper check. In fact, this trend seems to be more popular with TPAs than it is with traditional dental plan carriers and has created concerns for dental offices.

You do not have to accept the stored-value card as payment if you do not wish to do so. You can request to opt out of using the stored-value card and instead receive a check as payment for services rendered. If that is your choice, you should call the toll-free number provided on the explanation of benefits (EOB) statement which accompanies the stored-value card and inform VPay or the issuing company that a check is preferred and that you are not interested in utilizing the stored-value card for claim payments.

The ADA has received reports from some dentists indicating that some of these companies’ customer service representatives are reluctant to waive the stored-value card as payment; thus, you may have to escalate your request to a supervisor or manager with the company.

The ADA’s Council on Dental Benefit Programs (CDBP) recommends dentists carefully read the fine print accompanying EOB statements and suggests that members call CDBP staff at 800-621-8099 for additional assistance.