The Cat and Mouse Game of Insurance Processing Policy Manuals

Just when you thought you had it all figured out about what is covered and what is not on a dental insurance policy, along comes the fine print in a new policy provision to shut the door on payment.

As any PPO claim is adjudicated it will be done so in line with the current policy provisions that are provided in the PPO processing policy manual for that individual insurance company group.

When the dentist joins a PPO organization, he/she will have signed an agreement to abide by the payer’s processing manual.

It is said that the only way to keep ahead of the game is to get ahold of these elusive policy manuals.  When the patient phones the dental office to make an appointment, all the office gets is the name, date of birth, subscriber name, date of birth, employer group or an employer ID number/insurance company.  From there benefit information must be obtained on the insurance company website portal or by a tedious phone call. Getting this accurate information is only the first step to getting the claim paid.

Take for example, Delta Dental National Policy Manual for 2018 and its rules regarding billing scaling and root planing.  When you obtain benefits for a patient, scaling and root planing maybe listed as a covered expense with stated frequency limitations.  It does not tell you what the clinical evidence should be and that on this policy four quadrants of scaling and root planing done on the same appointment will not be covered.  That is where the policy manual comes in. The policy manual states that only two quadrants that fit the criteria are to be paid in a single appointment. The other two will be denied even if the procedure meets the clinical criteria.  Can you appeal this. Yes, but you must have a medical necessity in the clinical notes and backed by supporting clinical evidence and the patient’s health history. Whereas if you had just known about that policy provision before treatment you would have saved yourself a big headache.

Documentation requirements vary by plan and or PPO contract.  Often it is required (and sometimes just wise) for some services to get a predetermination.  To be the cat and not the mouse in this story, make sure to review the policy processing manual for all PPO contracts.



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