- How do I find out about Direct Deposit?
DDAZ has launched the direct deposit feature as a thank you to dentists who submit at least 75% of claims electronically. Click here to find out more. back to top
- Where can I get answers regarding the National Provider ID? (NPI)
View a listing of FAQs regarding the NPI. back to top
- Why does DDAZ require Premier Participating Dentist Agreements?
Delta Dental plans have retained a unique characteristic by providing service benefits, that is, actual dental services, to subscribers instead of merely a financial reimbursement for the cost of treatment. This difference is an important one, since it demonstrates the fact that dentists and Delta Dental have joined together to offer quality, affordable care to subscribers.
This uniqueness of Delta Dental plans is made possible by the willingness of dentists within a given state to participate in their plan’s program by agreeing to provide professional care to Delta Dental subscribers under rules developed by the Delta Dental plan.
This willingness, formalized through the plan “Premier Participating Dentist Agreement,” permits Delta Dental to provide the marketing and delivery system for its participating dentists’ services to subscriber groups seeking dental coverage. back to top
- What is the Premier Participating Dentist Agreement?
Under the terms of the signed agreement with Delta Dental of Arizona (DDAZ), participating dentists agree to the requirements established by the DDAZ’s board of directors. They agree to file a listing of their usual fees on a confidential basis. Thus, DDAZ is able to make payment directly to participating dentists for services provided on the basis of their own usual fees.
Participating Dentists submit attending dentist statements for their patients and agree to accept direct payment from Delta Dental on a “maximum plan allowance” fee basis. Furthermore, they agree that patients will not be charged more than their coinsurance amounts established by the dental program. back to top
- How does DDAZ determine the reimbursement level?
The usual fees of each Participating Dentist are filed on a confidential basis with the state Delta Dental plan. From the aggregate data, the customary fee for a given geographic area is established. For DDAZ, the state of Arizona is the geographic area used.
Delta Dental pays the appropriate coinsurance percentage of each participating dentist’s usual fees as long as those fees have been determined to be within the customary range of fees charged by other dentists of similar training in a given geographic area.
Therefore, it should be noted that:
• Payment is not based on the average fee for the area
• Payment is not based on the most frequently charged or prevailing fee for the area
• Payment is not limited based on an arbitrary percentage of each participating dentist’s filed fee
The maximum plan allowance fee approach was developed to pay the usual fees of the majority of dentists and so payment is determined by a formula directly related to the dentist. back to top
- What is the advantage of the maximum plan allowance fee concept?
The maximum plan allowance fee concept makes it possible for Delta Dental to base payments to participating dentists on their own fees. This approach differs from fee schedules which limit the program’s payment to a fixed dollar amount, without regard to the actual fee. Unlike these unchanging allowances, maximum plan allowance fees keep up to date as dentists’ fees change. back to top
- Why are nonparticipating dentists paid differently?
Nonparticipating dentists have no signed participating agreement or filed fees. Accordingly, Delta Dental may base its payment for treatment provided by the nonparticipating dentist on a basis other than the one that is followed for its participating dentists. As stated in the group’s contract, the payment must be issued directly to the patient.
The patient is responsible for any difference between the nonparticipating dentist’s charges and the payment made to the patient by Delta Dental. back to top
- Why does a participating dentist agree not to charge any difference to the patient?
Participating dentists are permitted to charge their patients’ copayments, deductibles or amounts in excess of annual or lifetime maximums. These amounts are the patient’s obligations under a particular group program.
However, if Delta Dental determines that a fee is not chargeable, the participating dentist agrees not to bill the eligible patient this amount. This feature of the participating agreement reflects the service benefit concept by allowing Delta Dental to guarantee the patient’s copayment. A patient who is covered by a Delta Dental program which provides, for example, an 80% program payment and a 20% patient copayment, can go to any Delta Dental participating dentist and know that his or her responsibility will be exactly 20% of the dentist’s fee as accepted by Delta Dental. This is different from commercial insurance where patients must pay their 20% plus any portion of the dentist’s fee which the insurance company finds to be above its maximum allowance. back to top
- What is the fee verification program?
Delta Dental has a responsibility to assure that the filed fee approach remains the best payment method and that it is not abused. In line with the Premier Participating Dentist Agreement, fee verifications conducted by visiting randomly selected participating dental offices and reviewing records for information. This procedure provides cost and quality assurance to purchasers by verifying that contracting dentists are adhering to the participating agreement. Other important areas checked during the review include that applicable copayment amounts have been billed to the patient, that proper reporting methods have been followed. In summary, the fee verification ascertains whether the filed fees of the participating dentists are his or her usual fees. back to top
- Why does Delta Dental require collection of the patient’s copayment?
Waiving a copayment is called “overbilling”. The most common form of overbilling occurs when a dentist accepts a third party carrier’s payment as payment in full and forgives all or part of the patient’s copayment portion. It is a practice that has an adverse effect on the maximum plan allowance fee concept, since it tends to drive up the customary range of fees as the dentist seeks to recoup the amount of copayment lost.
Another demonstrated effect of overbilling is the overutilization of services, here the dentist performs more, or more extensive, services, than would a dentist who collects the full patient payment. This, in turn, causes purchasers’ premiums to increase since rates are based in large part on utilization. As costs of employee benefits become prohibitive, purchasers may choose to limit benefits, select alternative delivery methods or terminate the dental program.
Because of the serious consequences of overbilling, Delta Dental has taken a firm stand against it. If evidence of overbilling is gathered, overbilling violations could lead to several actions such as reduction of submitted fees, recovery of funds, termination of participation and even legal action when necessary. back to top
- What is the value of predetermination?
Predetermination of benefits has become one of the most valued elements in the administration of the third party prepayment programs. To obtain a predetermination, the dentist submits a treatment plan and preoperative radiographs (where indicated) to Delta Dental before performing certain procedures.
Predetermination removes the guesswork in determining what the plan will pay for the services, and thereby eliminates possible confusion and misunderstanding between the dentist and the patient.
By submitting a treatment plan and predetermination of costs before initiating treatment, the dentist can be assured:
• That the patient is eligible at the time of predetermination of benefits;
• That the proposed dental services are covered;
• That the plan’s payment has been calculated for covered services;
• Of the copayment details, giving the dentist an opportunity to discuss with the patient proper financial arrangements before treatment is begun.
Program benefits are established through group contracts between purchasers and Delta Dental. The submitted treatment plan is examined by licenses dentists or professionally trained dental auditors to determine which proposed services are contract benefits.
Delta Dental’s determination need not change the plan of treatment, but establishes a cost allowance toward the service upon which the patient and dentist decide. back to top
- Why must diagnostic aids be submitted?
Delta Dental plans require, in some instances, the submission of appropriate diagnostic aids for two reasons:
• To assist the plan in identifying treatment which falls into the not-covered or optional category, as required by the group contract;
• And, to assist the plan in fulfilling its commitment to provide only procedures which are necessary and consistent with standards of accepted dental practice. back to top
- Why did Dental Societies form Dental Service Corporations?
Beginning in the mid-1950’s, state dental societies began forming separate, not-for-profit dental service corporations to meet the growing public demand for a way to finance, on a group basis, the cost of needed dental services.
At that time, such a financing mechanism was not available from the commercial insurance industry. The service plans emphasized the delivery of care to subscribers through benefit programs that offered coverage for actual services, rather than the indemnity dollar payments of the commercial insurance industry approach.
Aware of its responsibilities to the public, the profession pioneered the concept of dental prepayment. The objective of these service plans was to project the voice of organized dentistry into the marketplace for prepaid dental programs and thus assure the application of professional judgment in such critical matters as benefit design and the scope of treatment provided. As the oldest and largest dental plan system in the United States, Delta Dental has more experience in designing and managing group dental programs than anyone else. back to top
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