Common questions dentists ask about the application of COB

The below questions and responses are based on the ADA Guidelines on the Coordination of Benefits for Group Dental Plans and have been reviewed by the National Association of Dental Plans as reflective of the National Association of Insurance Commissioners’ Coordination of Benefits model and contract law under which COB is applied, except as noted.

鈥?How do you coordinate between a capitated plan (dental health maintenance organization) and a dental preferred provider organization plan when contracted with both?

When the reduced-fee plan (DPPO) is primary and treatment is provided by a participating dentist, the reduced fee is that dentist’s full fee unless the dentist has contractually made another arrangement. The secondary plan should pay the lesser of its allowed benefit or the difference between the primary plan’s benefit and the reduced fee.

鈥?If you are only contracted with the primary payer, not the secondary payer, should you bill your contracted amount to the secondary payer or your full fee?

Dental offices should submit their usual fee, defined by ADA policy as “the fee which an individual dentist most frequently charges for a specific dental procedure,” to a dental benefit plan. The benefit plan will adjudicate the claim based on its allowed fee schedules.

鈥?When contracted with secondary payer only, can you bill the patient over the contracted amount when the primary has considered the entire amount? If the dentist is not contracted with the primary payer, doesn’t he or she have a right to the full fee?

When a full-fee plan is primary and a reduced-fee plan is secondary, the full-fee plan should provide its allowed amount for the service and the secondary plan should pay the lesser of: its allowed benefit for the service or the difference between the primary plan’s benefit and the allowable charge of the secondary plan.

NADP Viewpoint: The charge to the patient is governed by contract law. When a DPPO is secondary, there is a binding legal agreement that the allowable charges are the limits of the patient’s responsibility. In this instance, the maximum amount that can be charged to the patient are the DPPO deductible and co-payments if applicable. If the secondary carrier is state licensed, then COB applies and that carrier would be responsible for paying up to its maximum allowable benefit which may cover the co-payments that are the responsibility of the patient.

鈥?The secondary plan did not pay anything, due to non-duplication of benefits-what is nonduplication of benefits? If an employee is paying insurance premiums for two plans, why is it possible that there may not be benefits available from the secondary payer (after all, the secondary payer has accepted the premiums paid)?

Nonduplication of benefits is a term used to describe one of the ways the secondary group carrier may calculate its portion of the payment when that carrier is an “employer- sponsored” or collectively bargained plan. Employer-sponsored and collectively bargained plans operate under federal law not state COB law. (Note: Some 22 percent of the all dental benefits fall into this category.)

Where nonduplication provisions exist, the secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, the secondary carrier would pay up to 30 percent to meet the 80 percent coverage.

Nonduplication of benefit provisions are contrary to ADA policy on coordination of benefits and, according to NADP, to state insurance law regulating state-licensed carriers.

Both ADA policy and state COB laws provide that when an insurance company accepts premiums from an employer and it is the secondary carrier, it should coordinate benefits with the primary carrier and pay its appropriate amount as follows: (1) The coverage from those plans should be coordinated so that the patient receives the maximum allowable benefit from each plan; (2) The aggregate benefit should be more than that offered by any of the plans individually, but not such that the patient receives more that the total charges for the dental services received.

鈥?If an indemnity plan is primary and a capitated plan (DHMO) is secondary and the capitated plan says that the patient is only responsible for the DHMO co-pay amount, but the primary indemnity plan states the patient responsibility is the full amount owed, what is the patient responsibility?

Under ADA guidelines, when the indemnity plan is primary, and treatment is received from a capitation-participating dentist, the indemnity plan should pay its allowable benefit.

NADP Viewpoint: The charge to the patient is governed by contract law. Even where the DHMO is secondary, there is a binding legal agreement that the allowable charges are the capitation amount for a general dentist or the discounted fee of a specialist. In this instance, the maximum amount that can be charged to the patient are the DHMO co-payments. If the secondary carrier is state licensed, then that carrier would be responsible for paying up to its maximum allowable benefit which may cover the co-payments made by the patient.

鈥?The secondary carrier paid too much because there is no COB clause in the patient’s plan. Who gets the overpaid amount?

The secondary carrier should receive back the amount it overpaid.

鈥?If the dentist is contracted with the primary plan only and the procedure is not a covered benefit (denied) does the dentist bill the secondary payer the full fee or the contracted fee?

The dentist should bill the carrier his/her usual fee and the carrier will determine the allowed amount based on any applicable agreement.

鈥?If the dentist is contracted with primary and secondary (both DPPOs) and the allowed amounts are different, what is the write-off amount and what amount should the patient be billed?

When the reduced-fee plan is primary and treatment is provided by a participating dentist, the reduced fee is that dentist’s full fee unless the dentist has made other contractual arrangements. The secondary plan should pay the lesser of: its allowed benefit or the difference between the primary plan’s benefit and the reduced fee.