Chapter 14:
Patient Dental Benefits
Dental Benefit Plans
Communication rests at the core of any good
dentist/patient/third-party payer relationship and
is more effective when everyone understands
their roles. The dentist uses his or her clinical
judgment to determine the best treatment for
the patient and establishes a fee for each service
rendered. The patient is expected to be at the
office to receive services that are scheduled
according to the treatment plan, and has financial
responsibility for payment. Payments may be
made directly to the dentist, or with assistance
from the third-party payer, if any. The third-
party payer, when there is one, determines
The dentist-patient the payment it will make, based on the services
reported on a claim and the coverage provisions
relationship is most (e.g., limitations and exclusions) of the dental
benefit plan purchased by the patients employer.
important; the third-
The third-party payer does not, however,
party payer merely determine the treatment.
provides a source of If a dentist has signed a participating provider
agreement with a third-party payer, that contract
payment assistance.
may place a limit on the dentists fees for services
to patients with coverage from that third-party
payer. Additionally, this provider contract may
preclude balance billing of the patient for services.
In some cases, the participating provider agree-
ment may preclude billing the patient at all for
certain services in particular situations.
Dental benefit plans can be an asset to your
practice. Both your cash flow and level of patient
satisfaction may grow with good relations between
your patients and third-party payers.
Patient understanding
The dentist-patient relationship is most important;
the third-party payer merely provides a source of
payment assistance. Thus, the dentist is directly
responsible to the patient for professional services;
the patient is directly responsible to the dentist
for payment unless the benefits are directly
assigned to the dentist. All patients should be
treated impartially, receiving equivalent fee and
treatment consideration, regardless of their insur-
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ance status. This is not to suggest that dentists
must charge all patients the lowest fee set by a
participating provider agreement.
When discussing treatment plans and payment
practices with patients, share your experiences
regarding dental benefit plans in general that you
have experienced. Let your patient know that the
benefits may change over time. Summaries
should include: maximum annual and lifetime
benefits; deductibles; predetermination limits;
co-insurance factors; reimbursement amounts
available from the payer (sometimes termed
UCR, usual, customary and reasonable) per-
centages or scheduled benefits; toll-free telephone
numbers; persons to contact in the employers
and third party payers office; coverage of pre-
ventive services; and orthodontic coverage.
Your primary concern is the dental care needs of
the patient; that point is the one you should
emphasize. Stress that a third-party payer will pay
only an amount determined by appropriate mem-
bers of its staff, in accordance with the contract.
Paperwork
A common complaint in the dental profession
concerns the paperwork involved in processing
insurance forms. For ease of claim form comple-
tion, establish efficient office procedures to handle
benefit program paperwork.
Keep the dental benefit file separate from the
patient record files, so the status of any claim
can be readily determined. Check these files
frequently for claims requiring attention.
Mark patient files with a colored sticker if the
patients are covered by a dental benefit program.
This allows the paperwork to be initiated by
your staff in a timely fashion.
Summarize your policies about accepting assign-
ment in a written statement. Use it to guide
your discussion with patients; provide copies
during case presentations. One version of such
a policy statement that can be adapted to suit
your practice is found on page 86.
Predetermination
Depending on the benefit program, you may
need to file a predetermination form. Submission
of a treatment plan for procedures that will cost
$150-$250 or more is generally required. This
allows a predetermination of the amount of ben-
efits payable upon completion of the treatment.
Keep in mind that a predetermination of benefits
is not a guarantee of payment.
Many offices use the ADA-approved claim
form to file for predetermination. (See sample
on page 112.) Print your name, address and I.D.
license numbers on this form. Please note that
provider I.D.s may vary by payer until National
Provider Identifier (NPI) is in place. NPI is the
nationwide standard way to identify dentists and
other health care providers, whose use is required.
The ADA claim form is available in a variety
of ways (e.g. NCR, continuous form) to fit your
needs. All ADA claim forms are available through
the ADA Catalog, 800-947-4746 or online at
www.adacatalog.org
Submit the original to the carrier and keep
copies in both your insurance file and the patient
file. Advise the patient when determination of
benefits has been received from the carrier and
file patients insurance claim record under cases
in treatment. Keep a folder of pending insurance
pre-determinations for follow-up purposes.
Claim Submission
When treatment is complete, submit the claim
to the third-party payer. A copy of the claim
should also be kept in your payment pending
file. This duplicate should contain all pertinent
information so that, if the original is lost, the
facts are easily accessible.
At the end of this chapter you will find a number
of materials that will help you in handling dental
benefit claims, including sample letters to patients,
the ADA-approved claim form, and the
Associations Guidelines on the Use of Images
in Dental Care Programs.
For information regarding electronic submission
of claims, refer to Chapter 12 Bookkeeping,
Taxes and Computers.
Finally, if a dentist runs into a dispute with an
insurance company, one possible option available
to settle the dispute is to initiate peer review
through your state dental society, assuming that
this option is offered. There are several state
dental societies that provide peer reviews between
dentists and insurance carriers and this can be
an effective tool to help dental offices resolve
concerns with carriers. Please check with your
constituent dental society to determine is such
assistance is provided.
Your decision to join a
Third-party contracts: should you sign?
Your decision to join a third-party system third-party system is a
(DHMO, PPO, IPA, closed panel, etc.) is a
professional one that
professional one that can dramatically affect
your practice. The ADA does not encourage can dramatically
dentists to make any extended business decisions,
affect your practice.
including whether and how to participate in
such plans, without diligent investigation and
weighing the pros and cons.
As with any business decision, it is prudent to
begin with consideration of the effects the
proposal will have on the business aspects of the
practice and whether it can advance the practices
long-range goals. If the proposal is attractive
financially, the legal and financial aspects of the
proposal should be carefully considered to be
certain that there are adequate protections for
the dentist. At this point, your personal finan-
cial and/or legal counsel can provide valuable
professional advice and assist you in negotiating
terms that are important to you.
The ADA offers a contract analysis service that
analyzes legal aspects of proposed written contracts
between individual dentists and third-party
dental benefit organizations, and makes the
analysis available to members as a matter of the
highest priority.
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 This contract analysis service does not provide
individualized legal advice for members, and in
no way takes the place of the members own
attorney. Nor does it provide practice advice.
Contact your state dental society or the American
Dental Association contract analysis service for
more information.
For more information regarding specific plans,
please contact the National Committee on
Quality Assurance (NCQA) at www.ncqa.org.
Another good resource for dentists who sign up
for numerous plans is the Coalition for
Affordable Quality Healthcare (CAQH).
Contact them at www.CAQH.org.
Most indemnity plans
resulting in a total annual maximum benefit of
$1,500 per covered individual. The totals can
be individual or family maximums.
A DR plan may also permit employees to pay
their share of their dental expenses on a before-
tax basis by establishing dental flex accounts.
Flex accounts are funded by employees with
pre-tax paycheck withholding, and can be used
to pay dental expenses that are not covered by the
DR plan design. In addition to the employees
tax savings, the employer benefits because the
amounts withheld from the employees paychecks
are not subject to FICA taxes. Flex accounts
must comply with IRS regulations to insure that
the payments qualify for pre-tax treatment.

reimburse patients The ADA, as well as state dental societies, brokers

Types of Dental Benefit Plans
and benefits consultants can assist a company in
There are several different types of dental benefit
based on a Usual, estimating how different designs will affect costs.
plans in the market today. The seven most com-
To utilize this service, call the ADA at 800-621-
Customary and mon types of plans are discussed below.
8099 extension 2746.
Reasonable (UCR)
Direct Reimbursement
Indemnity
system. Direct Reimbursement (DR) is a self-funded
An indemnity plan is a fully insured or self-
dental benefits plan that reimburses patients
insured non-network dental plan that reimburses
according to dollars spent on dental care and not
the member or dentist at a certain percentage of
the type of treatment received. It allows the
charges for services rendered, often after a
patient complete freedom to choose any dentist.
deductible has been satisfied. Indemnity plans
Instead of paying monthly insurance premiums,
typically place no restrictions on which dentist a
even for employees who dont use the dentist,
member may visit. Indemnity plans are also
employers pay a percentage of actual treatments
referred to as fee-for-service plans.
received. Moreover, employers are removed from
the potential responsibility of influencing treat- Most indemnity plans reimburse patients based
ment decisions due to plan selection or sponsor- on a Usual, Customary and Reasonable (UCR)
ship. DR is the ADAs preferred method of system. In other words, UCR plans pay an estab-
financing dental treatment. lished percentage of the dentists fee or the plan
administrators reasonable or customary fee
The design of the DR plan is selected by the
limit, whichever is less. The limits are the result
employer to fit the employers budget, and can
of a contract between the plan purchaser and the
therefore vary widely among companies. For
third-party payer. Although these limits are
example, one plan may reimburse 100% of the
called customary, they may or may not accu-
first $200 of dental expenses, 80% of the next
rately reflect the fees that area dentists charge.
$250 and 50% of the next $2,200, resulting in a
There is wide fluctuation as to how plans deter-
total annual maximum benefit of $1,500 per cov-
mine the customary fee level. A UCR element
ered individual. Another company may reimburse
is not exclusive to indemnity plan types.
50% of the next $3,000 of dental expenses,

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Preferred Provider Organization Point of Service Options
Preferred Provider Organization (PPO) pro- Point of Service (POS) plans are health plans
grams are plans under which patients select a that allow the member to choose to receive a
dentist from a network or list of providers who service from a participating or nonparticipating
have agreed, by contract, to discount their fees. provider, with different benefit levels associated
In PPOs that allow patients to receive treatment with the use of participating providers.
from a non-participating dentist, patients who
choose a non-participating dentist are usually Table of Allowance
required to pay higher deductibles and/or co- Table of allowance (sometimes called schedule
payments. PPOs can be fully insured or self- of allowance) indemnity programs determine a
insured. PPOs are usually less expensive than list of covered services with an assigned dollar
comparable indemnity plans and are regulated amount. That dollar amount represents just how
under the appropriate insurance statutes in the much the plan will pay for those services that are
companys state of domicile and operation. covered. Most often, it does not represent the
dentists full charge for those services. The
Dental Health Maintenance patient usually pays the difference.
Organization/Capitation Plan
Dental Health Maintenance Organization
Code On Dental Procedures and
(DHMO) or capitation plans pay contracted
Nomenclature
dentists a fixed amount (usually on a monthly
The ADA Code on Dental Procedures and
basis) per enrolled family or individual, regard-
Nomenclature (CODE) is used to record the
less of utilization. In return, the dentists agree to
services you provide to a patient and to report
provide specific types of treatment to the patient.
dental treatment on claims submitted to third-
The patient may be required to pay a co-pay-
party payers. The current version of the Code is
ment. Theoretically, the DHMO rewards den-
effective January 1, 2007 through December 31,
tists who keep patients in good health, thereby
2008 and is published by the ADA in the manual
keeping costs low. DHMO models typically
titled CDT 2007/2008. This manual includes
offer the least expensive dental plans.
other information that can assist in preparing
claims. Copies of CDT 2007/2008 can be ordered
Discount/Referral Options
from the ADA Catalog at 1-800-947-4746 or
Discount (referral) plans are arrangements in
online at www.adacatalog.org. The Code lists
which employers direct employees to a limited
dental procedures by category of services (e.g.
number of providers who have agreed to discount
Diagnostic, Restorative). Each code number
their normal fees in exchange for the expectation
includes a definition (nomenclature) plus addi-
of a larger patient pool. Patients pay the dis-
tional explanatory information (description).
counted fee directly to the dentist. There is no
third party reimbursement to the patient or to
the provider. A third-party marketer will package
and sell a discount program for a fee, in order to
cover administrative costs and profits.

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 Sample Letter to the Patient (Where dentist has NO CONTRACT with the insurance company)

Dear Patient:

As a courtesy, I file insurance claims on behalf of my patients for dental services performed in my office. It is
important to remember that as your dentist I can only file claims on your behalf. The benefits belong to you,
and it is up to you to ensure that you are receiving appropriate reimbursement under the terms of your plan.

Employers purchase dental insurance for their employees to supplement the cost of care. Unlike medical insurance,
most dental benefits do not cover the full cost of care. In fact, according to recent statistics from the U.S.
Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS), private dental
insurance paid only 48% of the cost for dental care. You will be responsible for paying my office for any services
provided that are not covered by your insurance, and for any fees that are above the amount payable by your
benefits program.

There may be times when claims for what appear to be clearly covered procedures are denied. Should this happen,
the information outlined below may be helpful to you.

1. Since you are the insured individual and I do not have a contractual agreement with your insurance carrier,
you are responsible for appealing the claim and paying any outstanding amount that is not covered by your
dental benefits plan.

2. As your dentist, I will provide you with an accurate statement of services rendered or treatment proposed
and will work with you toward a resolution.

3. In cases where conflicts arise over reimbursement, denial of claims or proposed treatment, or other
administrative problems for a service that appears to be covered by your dental benefits plan I recommend
that you involve your employer (or other plan purchaser) in order to find an appropriate solution.

4. Exhaust all reasonable avenues for resolution with the insurer. This means using all levels of appeal.

Make sure that all supporting documentation is included with the claim.

File a complaint with your benefits manager. Since your employer purchases insurance on your behalf,
it will want to know if you are having problems obtaining the available coverage.

If the claim cannot be resolved through the appeals process, and if the plan is state regulated, contact
the State Insurance Commissioner and file a complaint that clearly outlines your case.

If the plan is self-funded, it is regulated by the U.S. Department of Labor. Complaints can be filed with the
U.S. Department of Labor, Pension and Welfare Benefits Administration, 200 Constitution Avenue, N.W.,
Washington, D.C., 20210.

You may also wish to contact the [Insert name and phone number of your State Dental Association].

I appreciate the opportunity to be your dentist. Please feel free to call me if I can be of assistance to you.

Very Truly Yours,

Dentists Name

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Sample Attachment (Where dentist has NO CONTRACT with the insurance company)

Please note the language set forth below can be combined with the language on the previous page,
or be used in a separate letter to the patient.

You may also find the following suggestions helpful in understanding your dental benefit plan and ensuring
appropriate coverage:

Plan Program. Read your dental plan benefits booklet carefully so you fully understand the extent of your dental
coverage. Dental insurance, unlike medical insurance, rarely covers the total cost of treatment. It is critical that
you understand the treatments or procedures your plan includes, excludes or restricts. If you are unsure of
any benefits to which you are entitled, consult your benefits manager or plan administrator.

Copayments/Deductibles. Ask your plan administrator or benefits manager what you are responsible for paying
when you use your dental benefits (e.g., deductibles, co-payments).

Preauthorization. Some dental benefit plans require that the treatment plan be reviewed to determine whether
the plan provides reimbursement for the procedures before treatment starts. This will help you determine
which services are your financial responsibility. Before using your dental benefits, determine which services,
if any, have to be preauthorized/pre-determined by the carrier.

Statement of Services. To assist in filing your own claims, obtain a complete statement of services from our
office which thoroughly explains the services provided.

Authorization of Benefits and Assignments of Benefits. If I am going to file claims on your behalf, please be
sure to sign the authorization of benefits statement on the ADA claim form. This allows me to receive reim-
bursement directly from the insurance carrier on your behalf. However, I do reserve the right not to accept
the assignment of benefits (i.e., payment directly from your insurance plan).

Sometimes the benefit plan provided by your employer only covers a portion of the cost of your treatment.
Under these circumstances, I may not be willing to accept any assignment of benefits that would preclude me
from receiving my full fee. If you are not entitled to any benefits under your insurance program, you are still
responsible for paying for any services rendered.

Treatment Plan. If you are uncertain about any of the procedures or costs associated with the procedures,
consult our office. It is better for us to discuss your concerns prior to rather than after the service has been
performed. We are accustomed to answering questions from patients and you should feel free to inquire
about any concerns you may have.

PLEASE NOTE: THE SAMPLE LETTER AND ATTACHMENT ARE OFFERED FOR YOUR INFORMATION AND
DO NOT CONSTITUTE LEGAL ADVICE. DENTISTS MUST CONSULT WITH THEIR PRIVATE ATTORNEYS
FOR SUCH ADVICE.

111
 Dental Claim Form

112
Dental Claim Form Completion Instructions

113
 Guidelines on the use of Images in Dental Benefit Programs
The American Dental Associations recommendations
on selection criteria for images state that diagnostic
imagery should be used only after clinical examina-
tion, review of the patients history, and considera-
tion of the dental and general health needs of the
patient. The type, frequency and extent of diagnostic
images necessary for each individual patient will be
provided in accordance with the
dentists professional judgment.
The Association believes that the following guidelines
should be applied in the use of images in dental
benefits plans:
1. Images should be taken only for clinical reasons
as determined by the patients dentist. Clinical images
may be used as part of a system for determining
those benefits to which the patient is entitled under
the terms of a contract. However, third-party payers
should not request that images be taken for adminis-
trative purposes and dentists should not comply with
such requests.
2. When a dentist determines that it is appropriate to
comply with a third-party payers request for images,
a duplicate set should be submitted and the originals
retained by the dentist.
3. There are many instances in which a determination
of benefits cannot be made solely on the basis of
images and it is improper for third-party payers to
deny benefits or make determinations about treatment
that could not ordinarily be made without proper
examination of the patient.
4. Third-party payers shall not use images to infringe
upon the professional judgment of the treating dentist,
or to interfere in any way with the dentist-patient
relationship. All questions of interpretation of images
must be reviewed by a dentist consultant.
Source: ADA Current Policies, Guidelines on the Use of Images in Dental Benefit Programs (1995:617).
114
5. Patients should be exposed to radiation only when
clinically necessary, as determined by the treating
dentist. Postoperative images should be required
only as part of dental treatment.
6. It is important that images be correctly mounted
and are of diagnostic quality.
7. Third-party payers should protect the confidentiality
of all records, including images, which are submitted
to them by dental offices. Al! mages submitted to
third-party payers should be returned to the treating
dentist within fifteen (15) working days.
8. Images held by parties, other than the treating
dentist should not be transmitted to any agency or
entity without written consent f the dentist or patient.
9. Where a claim or predetermination request indicates
that images are enclosed, he third-party payer should
immediately notify the submitting dentists office if
the images are missing.
10. A patients predetermination request or claim
should not be prejudiced by the third-party payers
loss or misplacement of images.
11. Images are an integral part of the dentists clinical
records and, as such, should be considered the
property of the dentist where consistent with state
law. Because it is necessary for a dentist to maintain
accurate and complete records, third-party payers
should accept copies of images in lieu of originals.
12. Any additional costs incurred by the dentist in
copying images and clinical records for claims deter-
mination should be reimbursed by the third-party
payer or the patient.