Eligibility Verification | American Dental Association

Eligibility Verification

With higher rates of unemployment, patients reporting for dental appointments may have experienced recent changes in their employment situation.

Often dental offices face recoupment situations because of retroactive changes to eligibility. Dental plans are able to reflect eligibility changes retroactively and clauses within the participating provider contracts allow them to recoup funds from the participating dentist when treating a patient who has lost benefit coverage or has had a claim paid incorrectly. Out-of-network dentists are not contractually obligated to return payments received in this situation. However, payers have withheld funds from future payments to these dentists.

It is essential that dental offices verify eligibility on the date of service to avoid recoupment requests in the future.

Usually, eligibility and coverage is verified by office staff through the payer’s online portal or by calling the toll-free number on the patient’s identification card. However, a patient’s dental plan may not have received timely notification from the employer informing the plan that the patient’s employment and/or corresponding benefits have been terminated. This means that information verified through the payers’ portals or call centers may not be up-to-date or otherwise accurate.

Documenting the interactions (including screenshots of the portals with a date-and-time stamp showing when eligibility information was accessed or by recording the date and time when the customer service representative was contacted along with the name of the representative) with the payer may assist in any future dispute resolution. Although payers generally place the burden on the provider by refusing to reimburse or by clawing back reimbursement already paid.

Patients can be asked to provide some information during the visit to screen for potential eligibility changes. Sample questions to ask may include the following.

Since we last saw you, has your dental coverage changed?

  • If yes, do you have a new dental plan? (Office staff should request a copy of the new card. Also, note that some payers have moved to digital cards available on patients’ smartphones). Document the name of the dental benefits carrier, group number, and individual/member identification number.

Since we last saw you, have there been any recent employment changes for yourself and/or the policyholder?

  • (Office staff should listen for these key words from the patient: “laid off from job,” “no longer at that employer,” “shifted to part-time work,” “leave of absence,” “furlough,” or “loss of job.”)
  • If yes, did the employer provide you and/or the policyholder with paperwork stating how long the dental plan coverage will remain in effect, or how it might affect your coverage due to this change? (Office staff should request a copy of the paperwork if the patient received any documentation from the employer. It may be a good idea to keep on file.)

The patient is ultimately responsible for payment to the dentist regardless of plan coverage and dentists may attempt to use any preferred collections methods in situations where the patient does not pay.

Additional information on complex dental insurance issues along with other valuable, educational ready-to-use resources on innovative solutions for dentists are available at ADA.org/dentalinsurance.