Buyer Beware of Clauses in the Dental Insurance Processing Manual

Some clauses that may be found in Processing Policy Manuals (can be found on the insurance company’s website or the patient should have one issued at the time of signing the contract) These policies restrict payments on claims and that affects the patient and the practice:

1.       You may have taken x-rays of a patient who made it difficult to get a great exposure because of movement, gagging or complaining but if it is not of diagnostic quality determined by the insurance company consultant you won’t be paid or if you were paid now have to refund the insurance company.  The x-rays can also be denied if there isn’t provided “medical necessity” documentation.
2.       When the insurance company asks for a refund within a certain time period and you don’t comply they can subtract that amount from a patient’s benefits in the same group or from the same family.
3.       There are policy provisions in some plans that state that you cannot perform four quadrants of root planing in the same appointment.  They can deny the entire visit and you cannot bill the patient.
4.       If the claim was paid and it was later found that the patient was ineligible, the practice has to refund the money but can bill the patient since they weren’t covered at the time of service.
5.       Some policies require a predetermination or preauthorization and if you treat the patient without one there will be zero benefits.
6.       Payments from the insurance company can be issued in any form they see fit without your approval such as virtual credit card payments and some require EFT to your bank account.  Some will work with you on this and some won’t.
7.       Each plan determines its “incurred liability date” and that could be the date of preparation or the date of seat.   If the plan pays on the seat date the procedure must be billed on or after that date.
8.       Each Policy has a claim filing statute of limitation.  Some are 90 days and some up to a year.  A claim filed after the date will not be paid unless there were circumstances that affected the office operations such as a tornado, flood or earthquake.
9.       Some policies have restrictions and will not pay and also will not allow you to bill the patient.  Among those are pulp caps on the same date as the filling, core build-ups or the same day as the crown prep, x-rays without evaluations, one restoration on each tooth per 24 month interval, every 24 months periodontal assessment or a decline for a D4910 and the list can vary from one plan to another.
10.   Some plans  and this varies from state to state will not allow you to bill the patient for a non-covered service or will direct you in what you can charge for the service if it is not a covered benefit.
11.   Benefits may say implants are covered but if there is a “missing tooth clause” on the contract and the tooth was extracted prior to coverage there will be no benefit at all.

These exclusions are often not found in the benefit description but will be in the Certificate of Insurance issued to the patient at the time the policy is purchased.