Coordination of benefits

July 1, 2001
Coordination of benefits between standard insurance plans and managed-care plans is subject to whatever state regulations exist.

by Carol Tekavec, RDH

Coordination of benefits between standard insurance plans and managed-care plans is subject to whatever state regulations exist. Unfortunately, there are few definitive guidelines to follow. Each carrier must know about the existence of the other plan when reporting claims (Line 14, ADA Dental Claim Form, 1994 version; Line 31, ADA Dental Claim Form, 2000 version).

You also must review any office network-provider contracts for individual contract responsibilities. If a dentist signs on to be a provider for a particular plan, he or she is bound by the rules of that contract. Generally speaking:

1. The plan that covers the patient directly is in the first position. The patient is the employee of the business providing the plan. A spouse's plan is in the secondary position.

2. Some plans are "nonduplication of benefits plans. That means they will never pay when they are in the secondary position. "Maintenance of benefits" plans may pay in the secondary position if the primary plan does not cover the service.

3. Indemnity plans typically only pay toward the actual cost charged to the patient, regardless of the "regular" fee of the dentist. For example: Dr. Jones is a contract provider for XYZ Managed Care plan with a monthly capitation payment of $10 per person. An XYZ plan patient pays $200 for a porcelain-fused-to-high-noble metal crown (D2750), not $700. An indemnity plan in the secondary position normally will consider only the $200 fee actually charged to the patient as eligible for any additional benefits.

4. Coordination of benefits is generally not applicable if the insured person receives treatment from a nonparticipating dentist under a managed-care plan. For example: Dr. Jones is not a contract dentist for XYZ Managed Care. His patient, Mrs. Smith, belongs to XYZ Managed Care and has additional coverage under ABC Indemnity. No reduced fee can be required of Dr. Jones because he is not a contract dentist for XYZ, but a claim can be filed with ABC Indemnity on behalf of Mrs. Smith.

5. If a managed-care plan is secondary, the office should submit the claim to the standard indemnity plan first. If the primary, standard indemnity plan pays more than the contractual payment required by the managed-care plan, the dentist may waive that payment. For example: Dr. Jones is a contract dentist for XYZ Managed Care. His patient, Mrs. Smith, belongs to XYZ Managed Care in the secondary position, but has a standard indemnity plan, ABC Indemnity, in the primary position. Dr. Jones' normal fee for a D2750, Crown — Porcelain-Fused-to High-Noble-Metal, is $700. His fee under the XYZ Managed Care fee schedule is $200. ABC Indemnity will pay 50 percent of its fee schedule ($650), which is $325. XYZ Managed Care stipulates a fee of $200 to be paid by the patient for a D2750. In this case, Dr. Jones could conceivably waive the additional balance of $375. (This is something that most patients would want to have happen, but most dentists would not want to do. The dentist's contract should be consulted prior to treatment.)

If a balance will remain, patients must know in advance that they will be required to pay it. A written, patient-signed estimate of the total fee, emphasizing the patient's responsibility is a must. Dr. Jones also could ask patients to pay the $200 that they normally would have been responsible for under the XYZ Managed Care Plan. In this scenario, the patient would not be paying out of pocket more than the managed-care fee, but the dentist would only be "discounting" $175, rather than $375.

Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at

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