Do you know the difference between a Processing Policy and a Dental Plan Contract

Many dentists become fed-up fighting with PPO insurance to get paid for what they feel are legitimate claims of warranted services.  When it comes to money being paid to dentists it really boils down to their processing policy not whether the dentistry is deemed professionally necessary for the patient.  Many if not most dentists sign a PPO contract without carefully reading the PPO Processing Policy Manual.  Understanding the intended language of the dental plan contract and the processing manual should be required of all employees that are dealing with processing the procedures and the claims in dental practices.

Claims for dental procedures are processed based on the limitations and exclusions established by the plan document and upheld by the processing policy manual.   Most of the time dentists get summaries of the dental plan but patients can get the entire document from their HR or from the payer and pass it on to the dental practice.  The processing policy manual can be obtained from the provider relation department or sometimes on the plan website.  As in any contract, reading the “fine print” is important, for instance, if a radiograph is determined to be not diagnostic quality or medically necessary the payer may request a refund.

EAssist workers are faced with the processing policies in every appeal that they mount to get the claims paid.  Doing battle daily to get claims paid is what eAssisters do and do it well!