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Up, Up & Away With Dental Sales
Part III of Our Annual Dental Survey
Welcome to Part III of California Broker’s 2009 Dental Survey. We’ve asked the top dental providers in California to answer 28 crucial questions to help you, the agent, understand their benefits, features, and services. Read the responses and sell accordingly.
19. If covered, explain the process that allows the general dentist to refer to the specialist.
Aetna: For DMO plans, GPs can refer to a participating specialist directly based on published guidelines. DMO members have direct access to participating orthodontists and do not need a specialty referral. Indemnity and PPO plans have direct access to specialty services.
Ameritas PPO and the FDH Networks: Specialist referrals are allowed any time from our general dentists. There is no gatekeeper involved in this process.
Anthem Blue Cross: With PPO dental plans, there is no formal process for a general dentist to refer to a specialist, but Anthem Blue Cross PPO dental plans use pre-treatment and post-treatment professional review to monitor referral activity. In-house dental consultants (licensed dentists) perform all professional review. Under the Dental Blue PPO contract, pre-treatment review is recommended for procedures in over $350, but not required. Members can also self-refer to specialists with our PPO dental plans. For the Dental Net DHMO, referrals that do not include the high-risk procedures are reviewed post-treatment. Using the Direct Referral program, the participating general dentist can refer a patient to a specialist without prior authorization. Dentists’ practice patterns have been scrutinized to help ensure that they share in our commitment to providing access to effective healthcare. For the Dental Net DHMO products, the member’s assigned general dentist can call the customer service hotline in an emergency to get an immediate authorization for emergency services.
Blue Shield: The general dentist completes a specialty care referral form and provides a copy to the DHMO member who brings this to the participating specialist at the time of the appointment. DPPO members may self refer to a specialist.
CIGNA Dental: DPPO plans do not require referrals and general dentists are not required to act as gatekeepers. For DHMO plans, general dentists act as coordinators for all specialty services except pediatrics (up to age seven) and orthodontic network dentists. Referrals are not needed for orthodontia or for individuals under age seven to visit a network pediatric dentist. General dentists refer individuals to network specialty care providers as deemed necessary. CIGNA Dental works directly with the specialists for preauthorization and direct payment when appropriate.
Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO patients, the general dentist must submit documentation for review and approval. Approvals are returned to the dentist, who directs the enrollee to the appropriate specialist.
Dental Health Services: The general dental office sends Dental Health Services a specialist referral authorization. Upon approval, the authorization is sent back to the general dentist who informs the patient that they are now eligible to get appropriate care from a specialist.
Golden West: Using our direct referral process, the participating general dentist can refer a patient to a specialist without prior authorization. For PPO plans the member would self refer.
GroupLink: The general dentist can refer to any specialist.
Guardian: Under our dental PPO plans, we do not require referrals to specialists. For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a Participating Specialist Dentist upon written approval. When the General Dentist identifies the need for a referral, a Specialty Referral Form is completed and submitted to us for review. After review, the General Dentist, Specialist, and Member are notified of the determination.
Health Net Dental: For DHMO plans that require pre-authorization, the contracting Primary Care dentist completes a specialty referral form and submits to Health Net Dental. Approvals are returned to the Primary Care dentist, member and specialist. Upon receiving the approval, the member contacts the specialty office to schedule an appointment for completion of treatment. Our PPO dental plans allow self-referrals to participating or non-participating specialists as needed.
HumanaDental: General dentists are encouraged to refer members to participating specialists to provide the highest level of benefit to the member. The general dentist can refer out-of-network if there are no specialists within a reasonable distance.
MetLife: Our Dental PPO product does not require referrals for specialist care. For Dental HMO, the SafeGuard SGX series of Dental benefit plans, available in Calif., allow participating general dentists the flexibility to refer members to participating specialists without prior approval from SafeGuard, except for orthodontic and pedodontic specialty services in Calif. where the member’s selected general dentists will contact SafeGuard for pre-approval.
MWG Dental Plans: Our national PPO network has Endodontists, Orthodontists, Pediodontists, Prosthosdontists and Oral Surgeons.
Principal Financial Group: Patients can choose any provider in the network; referrals are not required.
Securian Dental: No referral is required.
United Concordia: Although DHMO plan members must coordinate all care through their primary dental office, including referrals to specialists, no preauthorization or referral review is required, allowing the referral process for all specialty services to be completed immediately.
Western Dental: Once the general dentist determines that the necessary procedure is out of their scope of practice, the office will submit a written referral request to our plan. Western Dental’s dental director then determines whether the referral is medically necessary and whether the procedure is covered under the benefit plan.20. Are any of your specialists board eligible/certified?
Aetna: Yes.
Ameritas PPO: Yes, all are board eligible or certified and are monitored
during the PPO credentialing process.
Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible.
Blue Shield: Yes, this varies by specialist.
CIGNA Dental: Yes, all network dentists contracted to provide specialty care have completed post-graduate dental specialty programs in their fields. The CIGNA Dental networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry, and oral surgery. It is important to note that in dentistry, board certification is not the norm. As a result, we do not require this item for credentialing. We accept dentists who are recognized specialists, including those who are board certified or board eligible.
Delta Dental: Yes, under state law, all specialists must be board certified or eligible.
Dental Health Services: Almost all of our participating specialists
are board eligible/certified.
Golden West: Yes, all contracted specialists must be board-eligible/certified.
GroupLink: Yes, but leased.
Guardian: Yes, many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible.
Health Net Dental: Yes, our provider network includes board-certified dentists. While we do not require our contracting providers to be board certified, if a provider indicates that he or she is board certified, Health Net Dental verifies this information during the credentialing process.
HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates.
MetLife: In order to participate with the Dental PPO or HMO, specialists must submit and keep current any certifications and/or other factors necessary to maintain their specialty.
MWG Dental Plans: All specialists are required to be board certified, the same as our general dentists.
Principal Financial Group: Yes, all specialists are required to be board eligible, board certified or be a designated specialist by the ADA.
Securian Dental: 100% of the specialists in our network are board
certified or board eligible.
United Concordia: Specialists agree to accept an amount per procedure as payment in full. If the member’s co-payment is less than the guaranteed amount, the plan will reimburse the specialist the difference between the negotiated fee and the member co-payment.
Western Dental: All contracted specialists are board eligible/certified.21. How do you fund your specialty care?
Aetna: Specialty services are paid on a fee-for-service basis.
Ameritas PPO and the FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the group’s general dentist claims. If employers are fully insured, all are funded out of the premium charged to each group. If employers are self-funded, the specialist claims would be included in the claim-funding bill provided to the employer.
Anthem Blue Cross: The PPO and DHMO specialty care is paid through claims processed according to the provider’s fee schedule.
Blue Shield: Specialty care is paid on a fee-for-service basis for both DHMO and DPPO plan designs. Member and plan co-payments vary depending on the plan design.
CIGNA Dental: DHMO and PPO specialists are compensated similarly through discounted fee-for-service, which is paid from a portion of the overall collected premiums.
Delta Dental: Specialty care is built into the premium. Specialists are reimbursed by a combination of maximum plan allowances by procedure (pre-contracted fees between Delta Dental and dentists) and co-payments paid by the covered enrollee.
Dental Health Services: Specialty care and treatment is paid for on a contracted basis and payment varies by procedure. These costs are built into each plan’s monthly premium rate.
Golden West: A percentage of sold premium is allocated for specialty care.
Guardian: Our PPO specialists are paid on a fee-for-service basis. For our DHMO plans, specialty care is funded through a portion of premium.
Health Net Dental: For both our DHMO and PPO plans, we underwrite and rate dental plans based on an assumed specialty care claims liability and build an allowance into our dental premiums.
HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit.
MetLife: For Dental HMO, specialists are reimbursed based on a pre-determined fixed fee schedule. The SafeGuard SGX series of dental plans, available in CA, have co-payments for specialty services — listed on the Schedule of Benefits for the plan. These plans also provide a 25% fee reduction off the participating dentist’s usual and customary fee for non-listed services, unless specifically excluded from coverage.
Principal Financial Group: Through normal plan provisions.
Securian Dental: Network dentists (general and specialty dentists) are reimbursed on the basis of a discounted fixed fee schedule. Network dentists agree to accept the fee schedule amount as full consideration, less applicable deductibles, coinsurance and amounts exceeding the benefit maximums and will not balance bill the member.
Western Dental: We incorporate into our premiums what we expect specialty care claims to be. We then pay the claims based on dental necessity and plan guidelines.22. Does the member have to be referred by the primary dentist to the orthodontist or can he or she self-refer?
Aetna: No.
Ameritas PPO and the FDH Networks: No, every member can self-refer.
Anthem Blue Cross: Members enrolled in the Anthem Blue Cross Dental Blue PPO program can self-refer. Members can seek services from a network specialist to realize the full cost savings advantage of their benefits. There is no paperwork involved since the member goes directly to the specialist. Once the specialist has performed an evaluation, they can submit a pre-treatment estimate, or on consent of the member, can perform the needed procedures without submitting a pre-treatment estimate. The same is true for our traditional Prudent Buyer dental PPO plans. Members enrolled in the Anthem Blue Cross Dental Net DHMO program must be referred by their primary dentist to an orthodontist. Using our Direct Referral program, the participating general dentist can refer the patient directly to the specialist without prior authorization.
Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member who brings this to the participating specialist at the time of the appointment. PPO plan members may self refer.
CIGNA Dental: DPPO/DEPO and dental indemnity plans do not require referrals to visit a specialist. Our DHMO plans do not require a referral to see a network orthodontist.
Delta Dental: Enrollees can self-refer. For DHMO plans, the enrollee can self-refer only to a contracted DHMO orthodontist.
Dental Health Services: Members must get a referral from one of our network dentists before visiting a participating orthodontist.
Golden West: The member can self refer to the panel orthodontist office.
GroupLink: Members can self refer.
Guardian: PPO members can self-refer to all types of specialty care, including orthodontia. General Dentists in our DHMO network will refer the member to a Participating Orthodontist. The referral does not require Plan authorization.
Health Net Dental: Our PPO product does not require referrals for specialty or orthodontic care, so participants can self-refer. For DHMO, there are three types of specialty referral processes based on the member’s schedule of benefits. For plans that require pre-authorization, the Primary Care dentist must submit a specialty referral form. For plans that have direct referral, the primary care dentist may directly refer the member to a participating orthodontist by visiting our website or by contacting our customer service. For plans that allow self-referral, the member may go directly to a contracted specialist by visiting our website or by contacting our customer service.
HumanaDental: In our PPO, the member can self-refer to an orthodontist.
MetLife: Our Dental PPO product does not require referrals for specialty or orthodontic care, so participants can self-refer. For Dental HMO in Calif., orthodontic specialty services require pre-approval. The member’s general dentist will contact SafeGuard for pre-approval, and once approved will contact the member with the name of a participating orthodontist.
MWG Dental Plans: No referrals required. They can self-refer.
Principal Financial Group: A member can choose to seek services from any provider.
Securian Dental: The member can self-refer.
United Concordia: Our PPO plans allow members to self-refer. Under our DHMO plans, the primary dentist determines if a specialty referral is required, regardless of the specialty.
Western Dental: The member has to be referred by the primary dentist to the orthodontist for our IPA Dental Plan. Our Western Centers-only plan allows the member to self-refer.23. What is the time frame for processing a referral in terms of member notification and payment to the specialist?
Ameritas: Since this is a self-referring process, this question is not applicable.
Aetna: DMO GP’s usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim.
Anthem Blue Cross: With Anthem Blue Cross PPO plans, the member can self-refer, so there is no timeframe. Our PPO plans do not require referrals to specialists. Members can go directly to any PPO specialist without any referrals. With Anthem Blue Cross Dental Net DHMO plans, referrals are usually processed within 48 hours through the use of our Direct Referral program. Referrals for emergency reasons are usually processed within the same day.
Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member who brings this to the participating specialist at the time of the appointment. Our average turnaround time for claims payment to the specialist after receipt of the claim is approximately six days.
CIGNA Dental: Typical turnaround time for specialty referrals is five days for preauthorization and five days for payments on our DHMO.
Delta Dental: For fee-for-service patients, specialty care referrals are not required and payments to specialists are processed the same as for general dentists. In 2008, the average time for processing all claims was five days. For DHMO enrollees, 2008 specialty care referrals were processed within an average of seven business days and specialists were paid within an average six business days.
Dental Health Services: Emergency referrals are processed immediately. In a non-emergency situation, referrals are processed within one to two weeks. Claims are paid within two to three weeks.
Golden West: The general dentist provides a real-time referral to
the specialist. Plan approval is not required.
Health Net Dental: The average turnaround time in processing a non-emergency referral is 48 hours and then 7 to 10 business days for the EOB to be received by the member. Once the specialist submits the claim, our average turnaround time in processing is 10 business days from receipt and then 7 to 10 business days for the specialist to receive payment in the mail. If claim was sent electronically, it will be sooner.
HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. The member gets a higher benefit when seeing a participating dentist and specialist. In 2008, 85% of claims and 97.4% referrals were processed within 14 calendar days.
MetLife: For Dental HMO, standard referrals are processed in an average of five business days for member notification and 14 business days for payment to the provider.
MWG Dental Plans: No referrals required.
Principal Financial Group: N/A
Securian Dental: No referral is required.
United Concordia: All referrals are immediately effective. The member is instructed to provide the referral to the specialist at the time of service and the specialist files the referral with the claim. All claims, including specialist claims, mailed to United Concordia are usually processed within 14 days. Claims filed electronically through Speed eClaim are processed for payment immediately unless a review of an x-ray or other document is required.
Western Dental: Emergency referrals are handled within 24-hours. Turnaround for non-emergency referrals is three business days. Specialists can expect payment in 10 business days for clean claims.
24. If you limit services with an annual or lifetime maximum, what does the maximum dollar amount allowed refer to?Aetna: The total amount Aetna will pay for covered benefits.
Ameritas: The maximum is the total amount of dollars payable to a member under their policy during the specified plan year.
Anthem Blue Cross: With Anthem Blue Cross PPO plans, the maximum dollar amount allowed refers to the amount allowed by the plan. With Anthem Blue Cross Dental Net and Dental Select DHMO plans, there are no annual or lifetime maximums.
Blue Shield: DPPO annual plan maximums range from $1,000 to $2,000 and are based on the amount paid by the plan. DPPO orthodontic calendar maximums are $1,000. We do not have lifetime orthodontic maximums. DHMO has no annual maximum.
CIGNA Dental: For DHMO: There is no annual or lifetime maximum; for DPPO/DEPO/Dental indemnity. The maximum dollar amount refers to the maximum amount payable by CIGNA for covered services rendered.
Delta Dental: The maximum dollar amount refers to the amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums, except for the accidental injury provision.
Dental Health Services: The majority of our prepaid plan offerings have no annual dollar maximums, although this option is available by client request. PPO plan annual maximums range from $500 to $2,000.
Golden West: The maximum amount is the total amount paid by
the plan.
GroupLink: It is the maximum out-of-pocket benefit a patient would get.
Guardian: The maximum refers to the total of benefit dollars actually paid for covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia.
Participating PPO dentists may charge no more than the fee schedule amount for services on the fee schedule, even when members have been reimbursed up to the plan annual or lifetime maximum. With Preventive Advantage, only Basic and Major services count toward the annual maximum. We also offer an option to cover cleaning after the maximum is reached.
Health Net Dental: The maximum dollar amount is the total amount the plan will pay for covered benefits. For PPO, orthodontic lifetime maximums typically range between $1,000 and $2,000 per member. For DHMO, there are no orthodontic lifetime maximums.
HumanaDental: Annual maximum refers to the maximum amount paid annually for services, excluding orthodontia. Orthodontic treatment has a lifetime maximum.
MetLife: For Dental PPO, maximums affect only the total annual eimbursement amount available under a plan to an individual or family. It does not limit access to our negotiated fees for services after the maximum is exceeded. For Dental HMO, there are no calendar or lifetime maximums as part of the SafeGuard plans.
MWG Dental Plans: Annual maximum is the annual amount the plan will pay for the member. For example, a plan has $1000 annual maximum. Once the plan has paid out $1000 the member no longer has coverage under the plan for the rest of that year.
Principal Financial Group: The maximum dollar amount refers to benefits paid.
Securian Dental: The annual and lifetime maximum refer to the maximum dollar amounts we will pay for covered services in a calendar year (annual maximum) or over the coverage lifetime (lifetime maximum). Our plans generally include an annual maximum for non-orthodontic covered services and a separate lifetime maximum for orthodontia.
United Concordia: DHMO plans do not have annual or lifetime maximums. PPO plan annual and lifetime maximums vary by benefit plan and refer to the total amount paid in benefits by United Concordia annually or over the member’s lifetime.
Western Dental: The Series 7 DMO plans do not have an annual
or lifetime maximum.25. How & when do you provide eligibility information to your dental offices? How can you ensure that your offices will provide services to a member if they are not on the eligibility listing and it is after regular plan hours?
Aetna: ID cards are issued to our DMO, PPO and Vital Savings by Aetna members. There is a monthly roster the first week of the month to our DMO providers.
Ameritas: They will want to verify eligibility through our real-time system. Our plans do not require preauthorization or mandated PPO network usage.
Anthem Blue Cross: Our customer service representatives are available Monday through Friday from 5:00 a.m. to 7:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and mediating member complaints for resolution. An interactive voice response (IVR) system is also available to answer calls 24 hours a day, seven days a week. Through the IVR, members and providers can get eligibility and benefit information (voiced or faxed), and claim status information, hours of operation, and web site addresses. Members can also request ID cards through the IVR.
Blue Shield: Eligibility lists for DHMO plans are distributed to the DHMO dental center during the first week of each month. Providers are responsible for contacting our Customer Service Department to verify eligibility, if a member is not on their list. Our Interactive Voice Response (IVR) is available 24 hours, seven days a week and has the capability to verify eligibility and assign members.
CIGNA Dental: Dentists can view eligibility information in real time by visiting our secure website for healthcare professionals (24/7). In addition, we send eligibility information to our DHMO general dentists on a monthly basis. The general dentist can also call the plan for automated verification for an individual who is assigned to a particular office, but is not on the eligibility list. This automated system will fax the dentist a written confirmation of eligibility. There is no eligibility listing given to DPPO providers; people can seek treatment from any DPPO network dentist at any time. If a DPPO dentist wants to verify an individual’s participation in the plan, they can check the secure website or call our toll-free number.
Delta Dental: Eligibility and benefit information is available through secure online services. Delta Dental also provides an automated toll-free telephone and facsimile services for dentists and enrollees, which provide information on benefit levels, co-payments, deductibles, and maximums. In rare instances, a patient who is not shown as eligible may be asked to pay the entire bill up front, and Delta Dental will reimburse the patient (less applicable co-payment).
Dental Health Services: Participating dental offices get eligibility rosters twice a month. If immediate eligibility is needed at any time, the dental office can call our 24-hour automated eligibility verification system or check eligibility online through our website.
Golden West: Eligibility is provided on the first week of the month to the DHMO providers. Eligibility lists are available in electronic format if the dental office selects this method of notification. A customer service representative can also phone, email or fax in member eligibility. The plan maintains a 24/7 emergency phone number for after-hour emergencies.
GroupLink: Automated eligibility is available. A fax-back system is accessible 24 hours a day, seven days a week via an 800 number.
Guardian: We do not provide eligibility lists for the PPO plan. Dentists can call our toll-free line and receive a faxed verification of benefits from 3:00 a.m. to 8:00 p.m., Monday through Friday and from 3:00 a.m. to 1:00 p.m. on Saturday, Pacific Time. Eligibility Rosters for the DHMO plan are provided to the offices twice a month, at the first of the month and the 10th of the month. Dental Offices may also call our Member Services Department from 8:00 a.m. to 5:00 p.m. Monday through Friday.
Health Net Dental: Our DHMO dentists receive a monthly updated eligibility list that includes member name, member status (active, dropped, suspended or transferred), member ID number, dependent names and eligibility status, fee schedule code, group number and capitation amount, if applicable. PPO dentists do not receive an eligibility roster since members are not required to select a primary care general dentist. Members would simply choose any network dentist (or non-participating dentist, if they desire) and schedule an appointment. PPO and DHMO dentists can verify eligibility information via our interactive voice response system and Web site, which are both accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7 eligibility can be verified anytime of the day regardless of whether the need occurs during business hours.
HumanaDental: Participating offices are encouraged to check eligibility before providing treatment. They can verify members and benefits by calling our toll-free customer service line or through our automated information line to get 24 hour-a-day, seven-day-a week eligibility verification.
MetLife: For Dental PPO and Dental HMO, MetLife has developed a multi-channel technology platform for customer service inquiries including Web, fax, or phone. Through dedicated, real-time channels (except when the systems are undergoing scheduled or unscheduled maintenance or interruption), dentists have access to the same plan information provided to employees at the time of service. Dental offices do have access to dedicated online and automated phone system benefit information services to verify eligibility and plan details at any time. Additionally, Dental HMO, eligibility data is forwarded once a month to each participating dentist.
MWG Dental Plans: Through the VRU system eligibility is real time. Our plans have a palliative emergency benefit feature, which will get them temporary relief until they can get an appointment with their dentist.
Principal Financial Group: N/A
Securian Dental: Dental offices can use a toll free number to call customer service to verify eligibility and benefits. Dental offices can also access www.securiandental.com to verify eligibility.
United Concordia: Dentists can access member eligibility and benefit information online, or toll-free using United Concordia’s IVR system. DHMO providers also receive printed eligibility rosters once per month.
Western Dental: Western Dental provides eligibility listings to our Staff Model Offices electronically and printed eligibility listings to our IPA Providers. This information is updated on the 1st and 15th of each month. For members who are not on the eligibility listing, we offer guaranteed capitation to our network of providers.26. How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment?
Aetna: Quarterly claim payments cease on the member termination.
Ameritas PPO: PPO provider discounts are determined using the treatment start date. Our PPO providers are contractually obligated to honor those discounts for any ongoing covered treatment under their plan.
Anthem Blue Cross: Anthem Blue Cross’ contract with Dental Blue PPO participating dentists includes a provision that requires the dentist to complete work-in-progress in the event of contract termination.
Blue Shield: Once the member’s coverage is terminated, the cost of treatment is the responsibility of the member.
CIGNA Dental: Individuals whose plans are ending are covered for services through the end of the month of their termination.
Delta Dental: The enrollee’s coverage ends when the contract terminates. Payments for fee-for-service orthodontic services will be pro-rated based on the remaining treatments. A DHMO enrollee is responsible for the balance due up to a maximum amount defined in the benefit level. The contract orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment, and the enrollee will make payments based on an arrangement with the contract orthodontist.
Dental Health Services: If a member’s coverage is terminated in the middle of orthodontic treatment, we encourage the member to participate in a COBRA individual plan that will allow the member to retain orthodontic benefits. If the member chooses not to maintain their coverage, the dental office can prorate any additional treatment fees. The member would then be responsible for only the prorated amount for completing their treatment.
Golden West: Coverage terminates at the end of the month in which a member is no longer eligible unless the member chooses to continue or maintain coverage.
GroupLink: Benefits end on the day coverage is terminated.
Guardian: When an orthodontic appliance is inserted prior to the PPO member’s effective date, we will cover a portion of treatment. Based on the original treatment plan, we determine the portion of charges incurred by the member prior to being covered by our plan, and deduct them from the total charges. What we pay is based on the remaining charges. We limit what we consider the shorter of the proposed length of treatment, or two years from the date the orthodontic treatment started. Also, we enforce the plan’s orthodontic benefit maximum by reducing the total benefit that Guardian would pay by the amount paid by the prior carrier, if applicable. If a member is undergoing orthodontic treatment and their Guardian coverage terminates, we pro-rate the benefit to cover only the period during which coverage was in-force. We do not extend benefits.
Health Net Dental: Upon termination of coverage, we will pay for orthodontic cases in progress on a prorated basis up to the last effective date of coverage. Benefits are no longer payable after the member terminates and are the responsibility of the member and/or the new dental carrier.
HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.
MetLife: Benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant gets continuation of coverage, in which case, benefits would continue as long as coverage remains in effect.
Principal Financial Group: On individual terminations, some of our plans allow for extended benefits that provide one month of additional coverage.
Securian Dental: Benefits are paid based on the services received while the member was covered by Securian Dental.
United Concordia: The extension of orthodontic coverage for DHMO and PPO plans is 60 days if payments are being made monthly. However, if payments are being made on a quarterly basis, coverage will be extended to the end of the quarter in progress or 60 days, whichever is later.
Western Dental: Western Dental has designed a termination clause to protect the member. The member does not incur any additional fees for the early termination of a provider.
HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.
MetLife: Benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant obtains continuation of coverage, in which case benefits would continue as long as coverage remains in effect.
MWG Dental Plans: We do not provide any additional claim payments
beyond the termination date.
Principal Financial Group: On individual terminations, some of our plans allow for extended benefits that provide one month of additional coverage.
Securian Dental: Benefits are paid based on the services received
while the member was covered by Securian Dental.
United Concordia: The extension of orthodontic coverage for DHMO and PPO plans is 60 days if payments are being made monthly. However, if payments are being made on a quarterly basis, coverage will be extended to the end of the quarter in progress or 60 days, whichever is later.
Western Dental: Western Dental has designed a termination clause to protect the member. The member does not incur any additional fees for the early termination of a provider.27. How do you handle the additional cost of OSHA required infection control in your participating offices?
Aetna: We consider these costs to be of doing business.
Ameritas: All paid procedures are based on CDT codes. Infection control is a cost that is already anticipated in the provider’s procedure fees.
Anthem Blue Cross: Our relationship with network providers is an independent contractor relationship. We are not, directly or in any manner, involved with how participating dentists operates and runs their offices. On our Dental HMO plans, our contracted providers cannot charge members for the additional cost of OSHA requirements. It is the responsibility of the participating offices to absorb the additional cost of these requirements.
Blue Shield: Our DHMO plans include a $5 sterilization fee, which is paid by the member.
CIGNA Dental: Typically, dentists include these costs into their over head and we do not allow dentists to charge for this separately. For our DHMO plans, we pay an encounter fee to the dentist to help offset their added cost for OSHA-required infection control. Each time an enrollee visits the general dentist, the office submits an encounter form, telling us which patient they saw and which procedures were performed. For each encounter form received, we pay the dentist a fixed dollar amount, which they can apply towards OSHA-required infection control or any other overhead costs as they see fit.
Delta Dental: The cost is included in regular dental office overhead The dentist cannot charge back to the enrollee or to the plan for this.
Dental Health Services: The combination of member co-payments, supplemental co-payments, and capitation is designed to help cover costs associated with operating a dental office including necessary additional costs such as OSHA required infection control measures.
Golden West: OSHA costs are the responsibility of the provider.
GroupLink: N/A
Guardian: Most dentists have incorporated the cost of OSHA requirements into the fees for services and do not charge separately. If it is the office policy to charge separately for OSHA, we do not restrict or limit the fee as long as all patients, not just the PPO patients, are charged. Since there is no CDT/ADA code for OSHA, Guardian plans do not cover such charges. Also we do not allow participating DHMO dental offices to charge additional fees for this.
Health Net Dental: OSHA-require infection control procedures are not eligible for payment. It is industry standard to implement OSHA-compliant infection control standards for all equipment, facilities and staff without a standalone fee and/or reimbursement. For those dentists who do charge a separate fee, payment is the responsibility of the patient, although a Maximum Allowable Charge (MAC) is established.
HumanaDental: Most offices have incorporated the cost of OSHA required infection control in their overall service charges. These costs would be reflected in the data used to compile fee schedules. It’s not usually a separate billable expense.
MetLife: Most dentists include these charges as part of their general overhead expenses, which, in turn, are part of the fees submitted to MetLife and SafeGuard. MetLife and SafeGuard use these fees as the basis for reasonable and customary data and/or for determining Dental PPO or Dental HMO provider fee schedules, as appropriate.
MWG Dental Plans: These costs are all included in our negotiated contracted rates.
Principal Financial Group: N/A
Securian Dental: The dentist must be in compliance with OSHA required standards including:
1. Meeting OSHA guidelines for hazardous material disposal
including sharps.
2. Meeting all state and local requirements for safety and health. The participating office would absorb any costs associated with fulfilling this requirement.
United Concordia: Participating dentist offices include sterilization costs in their service fees. In turn, United Concordia uses these fees to determine our maximum allowable charge (MAC) and fee schedules.
Western Dental: Western Dental handles the additional cost of infection control in its rates and does not charge a co-payment.28. Do you provide utilization data to your clients and brokers?
Aetna: Yes.
Ameritas: Depending on the type of plan funding and the level of information, utilization data is available in conjunction with HIPAA requirements.
Blue Shield: Yes. This is available upon request for employer groups of 300 or more employees at renewal.
Anthem Blue Cross: Yes, for groups of 51+ employees, Anthem Blue Cross provides a complete standard utilization, reporting package for dental plans. The packages are also adapted to accommodate the reporting of a client’s dental experience.
Delta Dental: Yes, Delta Dental provides utilization data to client groups and brokers in accordance with state laws; the plan does not disclose any personally identifiable information.
Dental Health Services: We provide a wide range of utilization reporting, including treatment access, specialty claims activity, and member service call activity on client or broker request.
CIGNA Dental: Yes, we can report group utilization data to our clients on an annual basis at no charge. For more frequent reporting, additional charges may apply.
Golden West: Yes, utilization data is available to groups and brokers upon request.
GroupLink: Yes, at renewal if requested. It is only provided in summary formats based on new HIPAA standards. Individual private health information would not be provided on a routine basis unless we got a specific release from the employee to do so.
Guardian: Yes, our standard reports are available monthly, quarterly or annually, and detail: (a) paid vs. submitted charges showing 13 components of savings; (b) PPO savings; (c) PPO usage In network vs. out-of-network; (d) monthly summary report; (e) dental charges and payments by category; and (f) dental claim turnaround time.
Health Net Dental: Yes, we will provide utilization upon request for large groups.
HumanaDental: Yes, on requests and within the boundaries permitted by HIPAA.
MetLife: Brokers are provided utilization data, if requested, as part of a proposal situation.
Clients have online access to their utilization data or can be provided upon request.
MWG Dental Plans: Yes, most requests for itemization data that
have validity are for groups over 200 lives.
Principal Financial Group: Yes, based upon the request of the client
and/or broker.
Securian Dental: Yes, we can provide this information to individually
rated employer groups upon request.
United Concordia: Yes, utilization reporting is available to cients and
brokers.
Western Dental: Yes, utilization data can be provided on request to clients and brokers for large accounts.29. Please provide contact information for your company:
Blue Shield of California Dental Plan
Producer Services 888-559-5905
Specialty Benefit Group Sales (888) 800-2742Guardian Life Insurance Company
Joe Stefano, Director, All of Southern
Central California & Phoenix
jstefano@glic.com
Main Phone: 800-662-6464 •Direct Line: 949-885-1720
Fax: 949-453.9919
Arthur Stern, Regional Manager, Los Angeles District Office
astern@glic.com
Main Phone: 800-225-3399 •Direct Line: 310-765-2201
Fax: 310-312.3371
Gregg Holdgrafer, Regional Manager, San Diego District Office
gholdgra@glic.com
Main Phone: 800-769-6759 •Direct Line: 619-881-3502
Fax: 619-296-3912
James Hill, Regional Manager, San Francisco District Office
jhill@glic.com
Main Phone: 800-832-9555 • Direct Line: 415-490-4413
Fax: 415-788-4412
Chris Anderson, Regional Manager, Sacramento District Office
canderso@glic.com
Main Phone: 800-438-5853 • Direct Line: 916-403-2326
Fax: 916-638-0288MetLife
David Heil
Regional Director, Northern California
1333 North California Blvd, Ste. 170
Walnut Creek, CA 94596
925-658-1102
dheil@metlife.com
Jason Ackermann
Regional Director, Southern California
1 Park Plaza, Suite 1100
Irvine, CA 92614
949-471-2312
jackermann@metlife.comThe Principal Financial Group
711 High Street
Des Moines, IA 50392
www.principal.com
Theresa McConeghey, Dental Product Director
mcconeghey.theresa@principal.com