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Participating in a Plan

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After fully reading and understanding the contracts and your practice dynamics, you may decide to participate in a payer’s network. Once you sign, successfully navigating the third-party payer world requires a strong office team with an office manager who understands coding and dental benefits issues.

Always remember that even though you have agreed to participate in the payer’s network and offer discounts to plan enrollees, the benefit ultimately belongs to the patient. Concerns regarding benefit reductions to the patient are best addressed through the plan’s purchaser (the patient or the patient’s employer). Here are some resources to help you navigate this field.

Office Financial Policy

Patients may believe that all recommended treatment should be a covered benefit, but it’s important to point out that dental benefits are not intended to pay for all care. Proactively establishing an office financial policy is a “must-do” to support a successful practice. Visit Managing Patients | Policies: Financial: Payment Options, Insurance Handling and check out the sample financial policy statement.

Coordination of Benefits and Managing Write-offs

Some patients may have multiple plans and it is an onerous task to make sense of what needs to be collected and from whom. Check out the ADA’s Guide to Coordination of Benefits.

Explanation of Benefits (EOB) and Denial Language

Consider sending your payer representative information on the ADA’s model Explanation of Benefits. If you encounter language on an EOB you feel is important or unwarranted, contact us at dentalbenefits@ada.org.

Getting Paid: CDT Code

The ADA supports maintenance of the CDT Code through a transparent, multi-stakeholder process. It’s important to note that just because there is a code for a recommended treatment, it does not guarantee the procedure is covered under the patient’s plan. However, knowing how to code appropriately for the services rendered can help ensure timely payment and may limit audit requests from a payer. Review some frequent general questions about dental procedure codes, the CDT Companion and the claim form completion instructions. Remember: always report your full fee on the claim form!

Communicating to Carriers and Employers

Visit our section of sample letters you can use to send to third-party carriers and employers regarding dental services that the plan does not consider necessary. 

Appealing a denial – Do you need to appeal a denial? Review the Tips for a Successful Appeal.

Maintaining Good Patient Records

Regardless of whether you participate with a dental plan, it is always important to maintain accurate and complete dental records. The claims for treatment submitted to a payer should match the information in the patient’s record. All claims should be signed and dated. For more information on keeping good records, check out Managing Patients | Treatment Recommendations Documentation/Patient Records and Managing Finances | Risk Management and Fraud Prevention.

Patient Education

Patients may think of dental benefits in the same way they do medical insurance. Medical care can be very expensive and insurance is necessary for most patients to afford even routine care. However, routine preventive dental care is not as expensive and insurance is not required. Instead, patients receive a benefit that helps them pay for the care they need. Help your patients understand what dental “insurance” means through the Why doesn’t my insurance pay for this? brochure, and feel free to provide them with the ADA’s free patient resource: Your Guide to Finding and Paying for Dental Care.

An unwanted contract?

At some point you may wish to re-negotiate a contract. Use Strategies for an Unwanted Contract from the ADA to help you with this situation. Contracts can be terminated. Your contract will usually stipulate a specific process to terminate a relationship with the payer you are contracted with. The carrier may require a specific notice period along with other requirements. Be sure to read and comply with all requirements when terminating your contracted participating status.

More questions? Try our frequently asked questions on dental benefits and our Third Party Issues Checker.

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