Welcome to California Broker’s 2014 Dental Survey. We’ve asked the top dental providers in California to answer 28 crucial questions to better help you, the agent, understand their benefits, features, and services.
California’s top dental providers answer crucial questions about their benefits, features and services.
1. What types of plans do you offer?
Aetna: We offer the following dental plans:
• Aetna Dental Maintenance DMO plan, PPO, PPO Max. •Freedom-of-Choice Plan Design (offering members their choice of two dental plans). •Aetna Dental Preventive Care, Aetna DMO Access, Aetna Dental Care Reward, Aetna •DentalFund (our consumer-directed dental plan), indemnity, Vital Savings by Aetna, a dental discount program. •Aetna ValuePass Card.
Aflac: Aflac Dental – voluntary insurance policy – has the simplicity of a Voluntary Individual Table of Allowances plan that pays a fixed benefit amount for each procedure, regardless of what the dentist charges.
Ameritas: We have the following types of dental plans available nationwide: PPO, indemnity, voluntary, non-voluntary, groups from two lives and up, individual, consumer driven and cost containment plans.
Anthem Blue Cross: Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company offer a comprehensive line-up of dental plans and products that include: PPOs and DHMOs for individuals, small groups, large groups and national accounts. We offer voluntary dental plans for small and large groups.
BEN-E-LECT: BEN-E-LECT offers fully insured PPO, EPO, high deductible, pre-paid and self-insured dental plans for the group market. Employer-paid and voluntary plans with multiple network and out-of-network options down to the employee level are available to groups with as few as two lives.
BEST Life: In California, we offer employer-contributory PPO, and indemnity dental plans to groups with two or more employees enrolling. Voluntary PPO/indemnity dental plans are available to groups with five or more employees enrolling. Custom dental plans can be offered for groups with 100 or more employees enrolling. Group term life and vision coverage.
Blue Shield: Blue Shield provides a wide range of affordable and comprehensive dental products to meet our clients’ needs. From dental PPOs, to in-network only (INO) and HMO plans, our plans offer members a wide variety of plan designs and networks that fit their budget. For individuals/families, we offer a unique dental PPO plan that provides member copayments instead of the usual coinsurance percentages. Our dental HMO plan offers comprehensive benefits with pre-determined member copayments. Finally, our Duo plan offers members dental and vision coverage at a single price. Our plans can be sold with medical plans or on a standalone basis.. For senior members, we offer two comprehensive dental PPO plans for Medicare supplement plan members. There is also a dental plus vision plan package option for Medicare supplement plan members. For groups, our dental PPO, INO and HMO plans are available on a contributory or voluntary basis, can be sold with or without Blue Shield medical plans and are UCR- or MAC-based.
BRIGHTER: Brighter offers two unique dental solutions: 1) An administrative services only (ASO) solution that utilizes revolutionary technology to reduce costs for self-funded employers; and 2) a savings-only plan for employees not wishing to purchase traditional coverage.
Cigna: We offer a full spectrum of dental solutions, including the Cigna Dental Care® (DHMO) plan, Cigna DPPO plan, Cigna DEPO plan, Cigna Traditional indemnity plan, and Cigna Dental Shared Administration. We also offer product features like Cigna Dental WellnessPlus®, Cigna Dental Waiver Saver®, and CignaFlex Advantage® that enhance our plans. We also offer CignaPlus Savings®, a discount dental program for retirees, part-time or seasonal employees, or anyone else not eligible for insurance coverage. All plans are available on a stand-alone basis. All plans except the discount card are also available alongside medical and/or vision plans. Cigna also has three WellnessPlus features, which can be paired with DPPO, DEPO, or dental indemnity products. Individuals who get any preventive care in one plan year qualify for increased benefits in the following plan year. All plans are available on a contributory or voluntary basis. In addition to WellnessPlus, Cigna offers Cigna Dental Waiver Saver, where customers Class 1 (preventive) services can be waived for maximums and deductibles, providing an incentive for customers to seek preventive care.
Delta Dental: Managed fee-for-service, PPO, and DHMO group dental plans; individual DHMO dental plans and group HMO vision plans. Also, in response to the Affordable Care Act, Delta Dental of California and its affiliated companies now offer pediatric and adult dental benefit plans in 27 health exchanges around the country, covering more than 300,000 new enrollees since the inception of the ACA. This required us to design pediatric and family dental plans based on different sets of rules for the federal and state exchanges, for stand-alone versus bundled scenarios, and for differing market conditions.
Dental Health Services: Dental Health Services offers high-quality, affordable prepaid (D-HMO) dental benefit solutions for large & small employer groups and individuals. Other plans are also available, including PPO, EPO, indemnity (reimbursement) products for groups of all sizes, and ASO services for self-funded groups.
Guardian: Dental PPO (active or passive), Prepaid/DHMO, and Indemnity plans are available on a voluntary or employer-sponsored basis. Dual and Triple Choice, Monthly Switch (between a DHMO and PPO), and Administrative Services Only plans are also available. Guardian specializes in customized plans based on the needs and price points of the employers and employees.
Health Net Dental: Health Net Dental HMO (DHMO) plans and dental PPO plans offer robust benefits covering most dental procedures. Dental plans may be purchased with a Health Net medical plan or on a stand-alone basis. In addition, the dental plans may be purchased as dual choice. Contributory and voluntary plans are also available.
HumanaDental: PPO, prepaid/DHMO, traditional preferred, and preventive plus plans are available on a voluntary or employer-sponsored basis. Humana also has a robust ASO dental plan available in California.
Principal Financial Group: We offer both employer paid and voluntary plans, including PPO, EPO and POS. We also offer a choice between our plans and dental HMO plans through marketing alliances.
Securian Dental: Group Dental PPO and indemnity
United Concordia: United Concordia offers flexible fully insured preferred provider organizations (PPOs) and dental health maintenance organizations (DHMOs) plans, as well as an individual product, iDental. ASO funding arrangements are available based on client size. Most plans are offered on an employer-sponsored or voluntary basis.
Western Dental: Western Dental offers DHMO mixed-model provider panel comprised of (a) contracted independent, general dentist and specialists, along with (b) Western Dental employee dentist and specialists, who work in the company-owned Western Dental Centers. Western Dental currently operates general dentistry and orthodontic offices throughout Calif., Ariz., and Nevada.
2. How do plans you offer for the individual and/or small group compare in rates and benefits to the large-group plans?
Aetna: The key difference between Aetna small group plans and larger group plans is that small group plans are pre-packaged plan designs. While larger groups can select from an array of benefits, the packaged small group plans are comprehensive, yet price sensitive and make it easy for our customers to choose from plans that are competitive in the market. Aflac Dental rates and benefits do not vary based upon the size of the account.
Ameritas: Ameritas’ small group and one-life group plans are rated by industry and are pooled in full or in part. Large groups’ experience is rated and includes lower rates in most cases. Ameritas offers a wide variety of plan designs, regardless of group size, to meet the needs of our customers. The pricing of our nongroup individual plans will be higher than group individual because of the nature of the risk.
Anthem Blue Cross: There are different underwriting considerations for each business segment depending on the product offered. With our Dental Prime and Dental Complete plans, both small and large groups can customize benefits to fit their employees’ needs.
BEN-E-LECT: The majority of BEN-E-LECT’s plans compete very well in the large group market. The benefit design and structure of these plans remain consistent across the small and large group markets.
BEST Life: Rates vary by plan design, group size and employer contribution. Typically the larger the group, the lower the rates. However, we offer a lot of plan design flexibility for groups with 10 or more enrolling. Waiting periods for major and ortho services are waived for groups with 10 or more employees enrolling – regardless of employer contribution. Some benefits are standard regardless of size. We offer a dental supplemental accident benefit on all of our dental plans. A child vision benefit is also standard on plans with orthodontic coverage..
Blue Shield: There are different underwriting considerations for each business segment. Our ability to customize offerings for groups with more than 300 employees typically results in lower rates and more choices to meet the employer’s needs. Group plans come in a range of deductibles and annual benefit maximums. Our individual, family and Medicare Supplement dental plans may vary in waiting periods, deductibles, and annual benefit maximums based on the plan selection. All dental plans include generous benefits, competitive premiums, and strong California and national provider networks that are available to all members; we don’t differentiate our provider network for small groups or individual or family markets.
BRIGHTER: Our small group plans enable employees to reduce dental expenses for their families by an average of 30 – 50% without paying high dental premiums. So, in any given year they can often receive the same amount of care that they would through a large group plan, and do so at a fraction of the cost they would have otherwise paid through premiums, deductibles & co-insurances.
Cigna: Dental plan designs and rates for small groups are similar to those of large groups. There are a series of standard DHMO plan designs and DPPO/indemnity plan designs. Cigna offers an individual plan in the state of California, available as a buy-up option to our medical plan offering. That plan is a DPPO offering, very similar to our group plans aimed at businesses trying to control costs while offering a broad network. Larger groups generally want more robust and flexible plans, while smaller groups gravitate toward standard offerings. We can custom-fit DPPO plans to offer a variety of cost-savings options for employers that want to keep claims costs low, such as missing tooth limitations, class shifting, low maximums, varying coinsurance, deductibles, waiting periods, etc. Our DHMO plans start with basic coverage, specialty discount, split copays, and other cost savings mechanisms and go up to very rich, low-copay plans at the higher end of the cost spectrum, including plans with coverage for surgical implants and related procedures. Cigna can also deliver solutions for the smaller employer segment through the Cigna Voluntary limited benefit dental plan as well as leveraging the small segment capabilities of the former Great West distribution channel.
Delta Dental: While benefits offered to smaller groups are comparable to those offered to larger groups, larger groups have more options in terms of plan designs. Rates can be slightly higher for smaller clients and individuals, but Delta Dental strives to be competitive while balancing our financial risk. With individual DHMO plan benefits, we offer three different plan options – two for individuals and families and one customized for seniors. The individual and family plans offer a wide range of covered services. The senior plan is designed to offer services most utilized by this particular population.
Dental Health Services: Dental Health Services works with its group clients on customizing dental benefit solutions that meet their needs. All individual plans offer the same high-quality benefits and services at competitive rates.
Guardian: Guardian offers nearly the same plan options to small group employers as to large employers, plus an array of cost-reducing options. We also offer dental benefits through the California state exchange.
Health Net Dental: DHMO plans offered to individuals provide a comprehensive schedule of benefits at a monthly fee that is slightly higher than rates quoted for groups. Small groups (two to 50 employees) have two comprehensive Health Net Plus DHMO and 3 DPPO plans from which to choose. Mid-market groups (51 to 250 employees) may choose from five DHMO plans and 15 new DPPO plans. Mid-market rates are based on location, benefit plan chosen, employer contributions, and participation. Individual and small group rates are based on book rates. Risk evaluation is taken into consideration when underwriting larger groups (over 250 eligible employees).
HumanaDental: We offer flexible plan designs with a range of deductibles, co-payments, and out-of-pocket expense limits to meet the needs of small to large groups. We also offer large groups the additional flexibility to customize plan options. All our dental plans provide employees with incentives for preventive dental care, which promotes their overall health. Customers who see dentists participating in the HumanaDental PPO Network receive deep discounts. A vision discount program is included with all HumanaDental plans.
Principal Financial Group: We do not have individual dental plans. The only significant rating difference between our small and large group rates pertains to experience rating which is used on groups with 150+ employees. The benefits are the same for small and large groups.
Securian Dental: Small group rates are developed on a pooled basis. Large group rates are developed on a custom basis.
United Concordia: While larger clients have more flexibility in customizing benefit options than smaller clients, United Concordia offers an array of standard client products and options that provide small businesses and individual consumers with cost-effective, quality choices. To keep the small client premiums comparable to those found in larger clients, slightly higher deductibles, lower coinsurance percentages and lower maximums are more commonplace within this market segment.
Western Dental: Our individual and small group rates are a little higher for standard benefit plans. Customized benefits plans are available for large groups.
3. Is your plan(s) better than previous incarnations? If so, how?
Aetna: We continuously review which services should be covered based on major dental studies, new clinical advances, recommendations from the leading health and dental organizations, consultations with academic leaders on the latest technology and techniques now taught in dental schools. We offer the following:
• Freedom-of-Choice Plan Design — packages our DMO plan with one of our indemnity or PPO plan options. Members pay one rate and can switch between the plans as often as monthly. It can be a lower cost alternative to a PPO plan.
• Aetna Dental Preventive Care — a low-cost PPO or indemnity plan covers preventive and diagnostic procedures from 70% to 100%. Members may also get reduced fees from dentists who participate in Aetna’s PPO network for non-covered services like fillings, adult orthodontia, and cosmetic tooth whitening.
• Aetna DMO Access — a fixed-co-pay DMO plan offers broader network access at a lower cost. There are no out-of-pocket deductibles for the member to pay and no claim forms to file. It also includes the Aetna Dental Access discount network, which gives members access to more dentists and discounts of 15% to 50% for non-covered services like bleaching.
• Aetna Dental Care Reward — By going to the dentist for preventive services in one plan year, Aetna will cover a greater percentage of coinsurance and/or annual maximum next plan year.
Aflac: Employers are seeking ways to shift costs and employees are looking for more value. The Aflac Dental plan is designed to increase the policy year maximum, which will satisfy both employers and employees.
Ameritas: We are known for our flexibility and expertise in dental. We listen to employers all over the country to learn about their needs. Our plans are updated constantly to meet those needs. We have released several industry firsts including a rollover maximum product; fully insured LASIK eye benefits; dollar reimbursement plans; combined dental/vision deductible,frequency and maximum plans; shared family maximum plans; $5000 maximum plans, and stand-alone hearing care benefits. Our newest individual plan release, vision, is very popular across the nation.
Anthem Blue Cross: Yes, our plans are significantly better than previous incarnations. Our Dental Prime and Dental Complete plans are open-access models that include the freedom to see any dentist — with lower out-of-pocket costs at in-network dentists. These plans are better than previous incarnations because they (a) incorporate evidence-based benefit designs and claims processing guidelines, for greater savings and consistency with clinical oral health science, (b) include a more robust California provider network and (c) automatically include access to the national Dental GRID, one of the nation’s leading dentist networks, with dentists in all 50 states. The GRID is exclusively for customers of participating Blue Cross and Blue Shield plans. In short: our new plans have better benefit designs and a larger network locally and nationwide.
BEN-E-LECT: BEN-E-LECT plans offer more employer and employee options than any other dental plan in the market. They can be written stand-alone or the employer may combine various BEN-E-LECT plans for a complete package offering PPO, DHMO and fully self-funded options
BEST Life: Our current dental plans offer a lot more options compared to the dental plans we’ve offered in the past. We offer a MAC reimbursement option and all of our dental plans can be tailored to offer rich or lean benefits, depending on a company’s needs. We continually evaluate our dental plans to ensure the competitiveness of the benefits, and our underwriting guidelines.
Blue Shield: Yes, we are always looking to enhance our plans and provide richer benefits. For 2014, we are introducing four new group dental HMO plans and four new dental INO plans with a $1,500 calendar year maximum. Compared to our existing dental HMO plans, our new dental HMO plans offer lower copayments to deliver a richer benefit to our members. The new dental INO plans offer a lower price alternative to our INO plans with $2,500 calendar year maximums. In addition to new plan designs, all BSC plans include oral cancer screening coverage as a value-added benefit, which comes at no out-of-pocket cost to the member. We also offer enhanced dental services for pregnant women to all dental PPO plans. Pregnant women receive one additional routine adult prophylaxis, and/or one course (up to four quadrants) of periodontal scaling and root planing, and/or periodontal maintenance if warranted by a history of periodontal treatment. Treatment is payable at 100% of the allowable amount for in and out of network.
BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs.
Cigna: The new Cigna Dental Care® DHMO 09 Series of patient charge schedules (PCSs) includes many features and options from which to choose. This series provides a spectrum of schedules with multiple copay structures, so we can design the plan that meets our clients’ needs. Below is a summary of new features and enhancements that only apply to the 09 Series of schedules: • Surgical Placement of Implant Coverage – We are one of the few DHMO carriers to offer coverage for surgical placement of implants and related procedures such as sinus augmentation, bone grafting, and cone beam CT x-rays. • Same Day, In office Services – Members are able to take advantage of upgrading certain procedures which require material fabrications (veneers, crowns, inlays, onlays, and post and core) to same-day, in office service using CAD/CAM technology for a fixed copay. • Temporomandibular Joint (TMJ) Coverage – TMJ coverage is now standard on our plans and coverages, and includes an exam, diagnostic cone beam CT x-ray, and an orthotic occlusal devise to treat TMJ. • Expanded Periodontal Maintenance Coverage – We have expanded coverage for periodontal maintenance cleanings to four per year to increase our focus on prevention. Additional Application of Fluoride and Fluoride with Varnish – At a minimal copay, we now allow additional applications of fluoride for those members who may need them.
Delta Dental: Most mid- to large-range plans offered by Delta Dental are customizable within basic parameters, and we incorporate changes in treatment standards and technology as they evolve.
Dental Health Services: Yes. Dental Health Services’ plans are better than previous incarnations. The company frequently performs comprehensive evaluations of its plans to ensure covered benefits, monthly premium rates, and copayments for services are appropriate and competitive.
Guardian: The key is flexibility, especially in today’s market as employers and employees are trying to balance costs with benefits. Guardian offers customized options to fit each employer’s needs and budget. Our recent focus has been on innovative plan designs with flexible solutions, options like Guardian FreedomSM, which is a new lower cost dental option that gives members a choice of networks with access to providers in Guardian’s premier PPO network, DentalGuard Preferred, or in Guardian’s DentalGuard Alliance PPO, which offers even greater claims savings through a select pool of dentists. We also are focusing heavily on developing more voluntary options, a market we see poised for tremendous growth particularly with the legislative changes on the horizon.
Health Net Dental: Health Net offers DPPO plans for small and mid-market groups. All of our DPPO plans include extra services for pregnant women in their second and third trimesters, including extra cleanings, scaling and debridement covered at 100% in and out of network and not subject to the plan’s deductible. Our Mid Market Classic Plus DPPO Plans include MaxAdvantage, our rewards program that allows members to carry over a portion of their calendar year maximum into the next calendar year. Our Basic DPPO is a unique plan offering in- and out-of-network coverage for preventive, diagnostic and restorative procedures (oral surgery, endodontics, periodontics, major services and orthodontia not covered).
HumanaDental: Yes, we continually explore ways to offer more choices and flexibility for our customers. Please see next response.
Principal Financial Group: Our current plan offers significant flexibility in plan design, optional coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points. Employers can design any combination of plan options to meet their needs. In addition to our Maximum Accumulation feature which allows members to carry over a portion of their unused annual maximum for use in future years, we also have a Preventive Passport feature. This feature allows for preventive charges to not accumulate towards the annual maximum.
Securian Dental: Yes, we have added greater flexibility.
United Concordia: In recent years we have done the following: • Introduced more voluntary plan options and added optional coverage for posterior composite restorations and implants to clients with 10 or more enrollees. • We launched Preventive Incentive, which covers diagnostic and preventive services without counting them toward the member’s annual maximum. • Enhanced our employee oral health educational offerings. • Launched a series of plan designs through iDental, our dental product for individuals and families without coverage elsewhere. • New for 2014, we are introducing a value suite of products to include lower premium options, greater discounts on non-covered services and a lean product option. • Launched a dental discount program for Individuals through DentalPlans.com. • Introduced the UCWellness Oral Health Rider in 2012, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment. UCWellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for UCWellness benefits.
Western Dental: Western Dental Benefits Division recently launched the DHMO Series 7 dental plans. Our new plans offer an increase of covered procedures to include the availability of cosmetic alternatives and more orthodontic options for children and adults
4. What have been the most recent changes in your plan(s)?
Aetna: New DMO fixed co-pay plans that cover Implants were added.
Aflac: Along with an increased policy year maximum, Aflac Dental continues to provide a simple, no direct-cost option for employers to enhance employee benefits offerings. The Aflac Dental plan provides the ease of administration without the hassle of network restrictions, deductibles, precertification for treatment, or annual premium reviews.
Ameritas: Ameritas developed ACA-certified plans that are offered in most states. We also have developed our new Better Benefit product, through which certified pediatric dental benefits can be added to traditional dental plans. Pediatric dental claims are processed through both their traditional plan design and the ACA-certified design, and Ameritas pays the better of the two..
Anthem Blue Cross: We revised our Dental Net DHMO. Our new Dental Net DHMO plans cover approximately 300 procedures — approximately 62 percent more procedures than our existing Dental Net plans. In addition, our Dental Net network includes more than 8,000 general dentist and specialist access points in California. And, we still have our Dental Prime and Dental Complete products, which include modernized benefit designs, lower premiums, and a more robust dentist network locally and nationally.These plans include benefits, such as dental implants, annual maximum carryover and composite fillings on all teeth. Plus, there are more options for out-of-network reimbursement, including the 90th percentile of FAIR Health. Voluntary plans are available with a minimum of five enrolled employees.
BEN-E-LECT: BEN-E-LECT has evaluated its Freedom PPO benefits portfolio and narrowed it down to four plans that have proven to be most beneficial to its members. By focusing on development of those four plans, BEN-E-LECT is now more able to create sustainable rates for its groups taking into account size and location. BEN-E-LECT has also eliminated the waiting period for groups and new hires on its employer-paid plans for added convenience. We have also added an EPO option to our portfolio which allows for even more cost savings and offers one of the strongest networks available.
BEST Life: Beginning in 2015 we will offer certified-pediatric plans that meet or exceed ACA standards to complement our product offerings. So the great Dental solutions from BEST Life continue to meet the changing needs of our groups in California.
Blue Shield: For 2014, we are introducing two new dental PPO plans in our small group portfolio designed to fill a gap in the upper end of the benefit spectrum.
BRIGHTER: Brighter has introduced the industry’s first Proactive Remittence Organization (PRO) which is a dental care system enabled by our cloud-based platform that streamlines the interactions amongst members, providers and payers to lower claims costs through new efficiencies in benefits payments, network fee schedules, utilization review and group plan designs.
Cigna: Cigna Dental Oral Health Integration Program® We developed the Cigna Dental Oral Health Integration Program® in 2006 to reinforce the importance of good oral health in relation to overall health. We continue to stay abreast of new clinical research showing associations between oral health and certain medical conditions and as a result, we have enhanced the program to reflect the latest medical and dental research. The new program includes the following list of clinical conditions:
• cardiovascular disease
• cerebrovascular (stroke)
• chronic kidney disease
• head and neck cancer radiation
• organ transplants The program also provides 100 percent reimbursement of copays and coinsurance on certain dental procedures associated with treating gum disease. In April of 2014 we enhanced our customer experience with this program. Previously, customers submitted a reimbursement form each time an eligible service was performed. Now, customers only need to register once (for each eligible condition) and their coinsurance/copays for qualifying procedures will automatically be reimbursed within 2-3 weeks from when we receive the claim from their dentist. We have made several enhancements to our DPPO products to provide additional benefit flexibility including cost saving capabilities with our dental code classification process thru improved class shifting functionality.
Delta Dental: To help make dental plan administration even easier for our network fee-for-service dentists, Delta Dental launched new online Provider Tools — a suite of helpful services that enables real-time processing of certain claims and pre-treatment estimates (those that don’t require clinical review, for example). With real-time processing, dentists and patients can see the patient’s payment portion and what Delta Dental will pay within moments. Provider Tools also gives dental offices other useful features, including a list of their Delta Dental patients and eligibility and benefits details, access to the status of submitted claims, a reference library, a list of Delta Dental’s payments and more. Provider Tools are fast, friendly, free — and an easy way to reduce paper use, too. In addition, Delta Dental recently introduced a new online health risk assessment tool that provides a structured set of questions that produces a risk assessment score that identifies specific issues related to the individual’s oral health. The tool’s risk assessment form is meant not only to inform the respondent as to likely risks of oral disease, but also to serve as a discussion piece with the individual’s dentist. The risk assessment form can be printed and shared with the patient’s dentist at their next appointment. The intent of this risk assessment tool is to inform the patient and their dentist of specific risk factors for oral disease and help guide preventive measures.
Dental Health Services: Dental Health Services now offers dental implants as a covered benefit. Specialized crowns and upgrades are also now available.
Guardian: Guardian constantly develops new, innovative ideas in order to meet our customers’ needs by helping keep their teeth healthy and saving them money. Guardian Freedom allows members to choose between networks, and members are still free to see out-of-network dentists. We also offer dental benefits through the California state exchange. Members can easily access an electronic ID card or find a dentist near them (in English or Spanish) at www.GuardianAnytime.com or on their smart phones with GuardianAnytimeSM Mobile.
Health Net Dental: All of our Classic Plus, Classic, Essential and Basic DPPO plans include extra benefits for pregnant members in their second and third trimesters.
HumanaDental: Plans in our new generation of products are available as voluntary plans, and to groups with as few as two employees. Our new plans offer an extended maximum benefit, in which members get 30% coinsurance on services rendered after they reach their annual maximum (implants and orthodontia excluded). In addition, no waiting periods for major services for voluntary groups with 10 or more enrolled, open enrollment options, and orthodontia benefits. Updates include reimbursement options for out-of- network reimbursement: maximum allowable fee, or based on in-network fee schedules. Additional deductible choices, implant coverage, and acrylic filling coverage have also been added. Due to the connection between oral health and overall health, we have added, free of charge, oral cancer screenings to all of our products, excluding DHMO/prepaid plans.
Principal Financial Group: Our current plan offers significant flexibility in plan design, optional coverage for cosmetic services, TMJ treatment, dental implant coverage, accident coverage, employee choice options and multiple price points. Employers can design any combination of plan options to meet their needs. In addition to our Maximum Accumulation feature which allows members to carry over a portion of their unused annual maximum for use in future years, we also have a Preventive Passport feature.
Securian Dental: Enhanced benefit plans. Escalating Annual Maximum and Lifetime Deductible options where available.
United Concordia: In recent years we have done the following: •Expanded our PPO network by 12,000 dentists, to create our Alliance network. ?? not exactly sure of the final #s, but something to this effect. • We re-credentialed our PPO network of dentists, and now more than 8X% accept our discounted allowances for non-covered services and services over the annual maximum. Members can find which dentists have agreed to this cost saving measure, by looking at our website. The dentists are clearly noted. • We launched Preventive Incentive®, which covers diagnostic and preventive services without counting them toward the member’s annual maximum. • Enhanced our employee oral health educational offerings. • Introduced Smile for Health – Wellness®, which offers enhanced coverage for members with diabetes and other diseases to clear away concerns they may have on the cost of treatment. This coverage is now standard with all plans. Smile for Health – Wellness also provides oral health education and program details for all members and targeted messaging to motivate those eligible for Smile for Health – Wellness benefits.
Western Dental: Our Series 7 plans cover more procedures and now include Implants, veneers and external bleaching.
5. Can an insured use their own dentist even if they are not on your participation list?
Aetna: PPO — We offer a national network of dentists. Each covered family member can visit any licensed dentist for covered services. When members visit dentists who participate in our network, their out-of-pocket costs are generally lower.
Aetna: DMO — Members must seek care from a participating DMO provider unless a state allows a member to seek out of network care. We make this easy by consistently offering the largest DMO network in the industry.
Ameritas: Insureds can use any provider, but they may incur additional out-of-pocket expenses.
Anthem Blue Cross: Members of our Dental PPO plans, including Dental Prime and Dental Complete, can see any dentist they want. However, members who choose a network provider generally experience lower out-of-pocket costs. Plus, members never need to file a claim when they see one of our in-network providers — the dentist files the claim for them. The DHMO plans are in-network only.
Aflac: Policyholders may use any dentist they choose since Aflac Dental does not have network requirements.
Anthem Blue Cross: Yes, they can with all of our PPO plans. Members who choose a provider, within the Dental Blue network, get the most savings in their dental costs. However, members can choose a non-Dental Blue dentist, but their out-of-pocket costs may be higher. The same is true for our traditional Prudent Buyer PPO dental plans. The DHMO plans are in-network only.
BEN-E-LECT: Yes, BEN-E-LECT’s plans offer in and out-of-network coverage with multiple options for coverage and benefits. The members maintain complete control over the dentist they choose to utilize.
BEST Life: Yes, group and individual products allow members to visit any dentist of their choice and receive coverage for services.
Blue Shield: Yes, dental PPO plan members can choose to go to any dentist, although their benefits will be covered at a higher percentage when choosing a network dentist, with less out-of-pocket expense.
Cigna: Insureds can use their own dentist in the DPPO and dental indemnity plans. However, there are no out-of-network benefits with DHMO, CignaPlus Savings dental discount plans (not insurance) or with DEPO. Individuals can nominate their dentist to join our plan and if the dentist wants to participate and meets our criteria, he/she will be credentialed and added to the network. Additionally, DPPO and DEPO plans may include savings on most non-covered services (in states where allowed by law). Most of our DPPO network dentists offer their negotiated contracted fees to customers and their covered dependents for most non-covered services (in states where allowed by law). And the savings also apply to covered services when an individual exceeds his or her annual maximum or other plan limitations, such as frequency, age or missing tooth. We are continuously expanding our network to meet the needs of current and potential clients.
Delta Dental: Delta Dental Premier enrollees can visit any licensed dentist for care, although there are advantages to visiting one of more than 48,000 dentist locations for Delta Dental Premier dentists in California. Enrollees can go to any dentist, but they are only guaranteed to get in-network benefits and avoid balance billing when visiting a Delta Dental dentist. Delta Dental PPO enrollees also have freedom of choice, but can benefit from the protections associated with selecting one of more than 31,000 dentist locations for Delta Dental PPO dentists in California. PPO enrollees have access to Delta Dental PPO and Premier dentist networks with different levels of savings. DHMO enrollees must use a participating general dentist or approved specialist, except for emergency care. There are more than 5,100 dentist facilities for DeltaCare USA in California.
Dental Health Services: Members of Dental Health Services’ prepaid (D-HMO) and EPO plans choose their dentist from the company’s exclusive Quality Assured network. Participating dentists on all prepaid (D-HMO) plan networks are subjected to credentialing, background checks and a 107-point quality checklist. They are also regularly monitored by the company’s Professional Services staff, and plan benefits are only available at these Quality Assured dentists. The company’s PPO and reimbursement plans allow members to receive treatment from any dentist
Guardian: Members covered under our PPO plans can visit any dentist; however, benefits may be paid at a lower coinsurance rate for non-participating dentists. DHMO members must choose a participating primary care dentist.
Health Net Dental: Our dental PPO plans offer members freedom of choice; members may receive services from any licensed dentist, but we will reduce their out-of-pocket costs by receiving services from a participating PPO dentist. Under Health Net Dental DHMO plan, members must use a participating dentist to receive benefits.
HumanaDental: PPO members can visit the dentists of their choice. Out-of-pocket savings are greater when members visit participating network dentists.
Principal Financial Group: Yes, our members can see any dentist even if the dentist is not on the “participation” list if they are enrolled in either our PPO or POS design. If a member is enrolled in our EPO design, network dentists must be seen for services in order to receive benefits under the plan.
Securian Dental: Yes.
United Concordia: Our FFS and PPO plans allow members to visit any dentist. However, out-of-pocket costs are lower when visiting a participating network provider. DHMO members must use network dentists.
Western Dental: Through the DMO plans, the member must use a dentist who participates in our network in order to have coverage.
6. If the dentist bill exceeds U&C, can the dentist bill the patient for the difference?
Aetna: For covered services, network dentists are contractually prevented from balance billing above the negotiated rate. Non-covered services are also available for a discount in some states. Dentists who are not in our networks may balance bill members.
Aflac: Aflac Dental pays benefits based on a Table of Allowances and not on UCR. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance. Ameritas: Ameritas PPO/First Dental Health (FDH) Networks — Ameritas PPO dentists and FDH PPO dentists are bound by contract not to balance bill the difference between their normal charge and PPO maximum allowable charges.
Anthem Blue Cross: No, not when visiting an in-network dentist with our PPO plans, including Dental Prime and Dental Complete. Anthem Blue Cross participating provider contracts include negotiated fee agreements that prohibit balance billing. A participating dentist may not balance-bill members for amounts that exceed the negotiated and contractually agreed on fee. Members are not responsible for amounts in excess of negotiated rates. However, if a member visits an out-of-network provider, there is no contract and the provider can bill the patient for the difference. With our DHMO plans, the patient is only responsible for co-payments and non-covered services when accessing services through their participating dental provider. BEN-E-LECT: The member does have the option to choose this method upon enrollment.
BEST Life: Members will not be balanced billed if they receive treatment from a contracted PPO provider. All our dental PPO plans offer a regional and national PPO network. Members can access their in-network benefits anywhere in the country and will not be balance billed.
Blue Shield: No, in-network providers cannot bill members for fees that exceed the negotiated rate. Non-network providers, however, may bill for charges that exceed the plan’s allowed amount. BRIGHTER: Not if the dentist is participating on our platform.
Cigna: DHMO. Network general dentist and specialist contracts contain clauses that prohibit dentists from charging members any additional fee, surcharge, or other cost for services, other than applicable patient charges as defined in the patient charge schedule (PCS) or contract payment schedule for covered procedures. For services we do not cover, dentists may charge their usual fees. For certain orthodontic procedures, network dentists may charge incremental costs associated with optional/elective materials, including, but not limited to ceramic, clear, lingual brackets, or other cosmetic appliances. DEPO/DPPO. Cigna’s network dentists’ contracts include language to ensure that members are only charged in accordance with the contracted fee schedule amounts. They are prohibited from balance billing members. Network fee schedules apply for covered services even after members have reached their annual maximums or exceeded frequency limitations, or if the applicable dental plan imposes missing tooth limitations or other similar limitations. For noncovered services, members are responsible for paying the dentist’s usual fee or contracted fee for that procedure. Since the DEPO plan does not cover out-of-network services, members are responsible for the out-of-network dentist’s usual fees for any treatment received out-of-network. Out-of-network dentists may balance bill the difference between the DPPO plan’s payment and their usual charges. Indemnity. We do not prohibit balance billing for our traditional indemnity plan coverage; dentists may balance bill the difference between the plan’s payment and their usual charges. Members pay dentists at the time services are rendered and then submit claim forms to us, or dentists submit the claim forms directly to us for payment.
Delta Dental: Contracted dentists agree not to balance bill patients for services covered under the program for which the dentist has contracted service fees. Delta Dental holds its Delta Dental PPO and Premier dentists to their contracted fees when providing services to eligible enrollees. DHMO enrollees do not pay more than their set copayment for covered benefits under the DeltaCare USA plan. Specialists are paid the difference for charges exceeding the enrollee’s copayment for all preauthorized services. When an enrollee chooses a more costly procedure not covered under the plan, the enrollee is responsible for the difference in cost between the network dentist’s usual fees for the covered procedure and the optional treatment, plus applicable copayment for the covered procedure.
Dental Health Services: No. Dental Health Services guards against balance billing for specialty claims and also has separate safeguards in place to protect your clients’ members from other types of overcharging. Dental Health Services contracts with participating specialists who specifically prohibit balance billing. The specialist can only charge the agreed-upon fee for a particular service. This and other proactive initiatives designed to advocate for members have resulted in Dental Health Services’ 97% retention for satisfied group clients and their members.
Guardian: Guardian’s PPO dentists are prohibited from billing members for any difference between the billed fee and the contracted fee schedule amount, less applicable deductibles and coinsurance.
Health Net Dental: When receiving services from a participating PPO dentist, members cannot be billed any charge in excess of the maximum allowable charge established by the plan. If the member goes to a non-participating dentist, the dentist can bill the patient for the difference between the allowed amount for the plan benefit and the dentist’s submitted charge.
HumanaDental: Members are encouraged to visit in-network providers to experience lower out-of-pocket costs. In-network providers have agreed to accept the amount listed on their PPO fee schedule as payment in full, less all copayments, coinsurance, deductibles and non-covered services. They may not balance bill for amounts that exceed their PPO fee schedule. Out-of-network members are responsible for any charges that exceed the maximum amount that Humana will reimburse for a specific service.
Principal Financial Group: Dentists cannot bill over the UCR/fee schedule allowance amount if they are part of our PPO or EPO networks. If the dentist is not a part of one of our networks, he/she can bill the amount over UCR.
Securian Dental: If the dentist is part of our network – no. If the dentist is not part of our network – yes.
United Concordia: Contractually, United Concordia participating dentists agree to accept our allowances as payment in full for covered services (less any deductibles and coinsurances or co-payments).
Western Dental: Since this is a managed care plan, members pay only the applicable co-payment listed on their benefit schedule. Members are financially responsible for non-covered procedures at a discount.
7. How does the dental plan protect against over billing or waiver of co-payments?
Aetna: Our explanation of benefits shows the member’s out of-pocket responsibility. Additionally, the vast majority of our network dentists accept the contracted amount for non-covered services and any services over the annual maximum a copy is sent to member and provider. If necessary, the provider relations area helps resolve any issues whether related to over billing, waiver of co-payments, or other issues.
Aflac: Aflac Dental does not have network requirements. If the dentist’s charge exceeds the benefit amount paid, the dentist may bill the patient for the remaining balance.
Ameritas: The explanation of benefits automatically calculates the insured’s portion of the bill to prevent these kinds of problems.
Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we protect members against inappropriate billing through our provider contracts, claim review, and our continuous analytic monitoring of the treatment and claim submission patterns of each dentist that submits claims to us. For our DHMO programs, our quality assurance teams assess claims and providers regularly to ensure our DHMO members are getting the highest level of service and satisfaction.
BENELECT: Provider network discounts are applied automatically when a claim is submitted. We also make pre-determination services available to inform members what their charges will be prior to receiving service. The members also receive an explanation of benefits which clearly illustrates network savings and patient responsibility.
BEST Life: We do this in several ways: 1) Provider network discounts are applied at the time a claim is processed; 2) Predetermination services are available to inform members what their charges will be prior to receiving service, 3) We provide easy-to-understand EOBs that clearly illustrate network savings. 4) We have educational flyers that inform members on how their dental plan works and why they should go to a network provider.
Blue Shield: We prohibit network dentists from balance billing a member for the difference between billed amount and the amount received. Members are only charged the applicable copayment or coinsurance. We monitor and address any network dentist who attempts to bill for this difference.
BRIGHTER: We track all utilization of the plan to ensure both the members and sponsor are billed appropriately.
Cigna: Balance billing for covered procedures is strictly prohibited. We counsel network dentists who do not comply. Continued balance billing may be referred to our Credentialing Committee for review of future participation in the network. Cigna monitors allegations of overcharging through enrollee feedback, surveys, and the dental network management staff. For DHMO plans, the collection of copays is between the patient and the dentist. We encourage dentists to collect copays at the time treatment is rendered. For DPPO/Indemnity plans, it is illegal in some states for dentists to routinely waive deductibles. Since our group contracts indicate that Cigna is not responsible for any charge the patient is not required to pay, we may reduce our claim payment by the copay amount waived by the dentist. Our Special Investigations Unit may also contact the dentist and the patient for further information and has the ability to review claims on an ongoing basis.
Delta Dental: Delta Dental Premier and PPO dentists contract with us to establish acceptable fees as well as formally agree to certain protections for Delta Dental enrollees. Protections include no balance billing — contracted dentists cannot charge enrollees for the difference between their contracted Delta Dental fee and their submitted charge for a service, and they may only collect the patient portion (copayment plus any deductible and/or amount over the annual maximum) at the time of service. Delta Dental dentists also agree not to unbundle a procedure that is on file with Delta Dental as one procedure. Waiver of plan copayments and deductibles is considered fraudulent and is handled by notifying the dentist of the violation and possible network termination. DHMO network dentists agree to be paid by Delta Dental on a guaranteed capitation basis. They also contractually agree to accept enrollee copayments as payment in full for covered dental procedures and not to seek additional fees. If a dentist consistently demonstrates a disregard for their contractual obligations with Delta Dental, their participation may be restricted or terminated.
Dental Health Services: Dental Health Services’ Professional Services Staff regularly audits the company’s participating dentists’ charts on-site to ensure dental care and treatment provided to members meet the company’s quality standards and policies. In addition, plan members receive extensive patient education and tools to help them understand their plan benefits so they can question charges that may not be in compliance with plan benefits. Members are encouraged to contact the plan for assistance if they feel they are being overcharged.
Guardian: Guardian’s PPO dentists may only charge members for any covered charges other than the deductible or coinsurance that may apply to the discounted fee schedule amount. Explanation of benefits statements sent to members specifically identifies the discounts taken and the member’s responsibility.
Health Net Dental: Under our DPPO and DHMO plans, participating dentists are contractually prohibited from balance billing a member more than the maximum allowable charge or the contracted copayment amount. Practices are in place to discipline network dentists who attempt to bill members more than these contracted amounts. If it is determined that a participating dentist has overcharged a member, our Customer Service team will contact the provider on behalf of the member to confirm benefits and re-educate the office about proper plan collection from a member. If the provider refuses to comply with the plan design, the issue is escalated to the Professional Relations Department for follow-up with the provider. Depending on the circumstances, the issue could be escalated to our Quality Management Team, which follows state mandates for a full investigation, including the request for patient records from the office and a review by a dental professional. These investigations must be completed within 30 days and written communications are sent to the member and provider. If the provider still refuses to comply, our legal department would be contacted and steps may be taken to terminate our relationship with the provider. In these rare instances, it might become necessary for the plan to reimburse the member or provider depending on the circumstances and to ensure a positive member experience.
HumanaDental: The dentist and the patient get an explanation of benefits to ensure that the dentist does not overcharge or omit fees. The claims processing systems adjudicate the claim based on the contracted fee schedule. Waiving co-payments does not apply under a PPO.
Principal Financial Group: Provider utilization patterns are studied and issues are addressed as uncovered.
Securian Dental: We systematically check every submitted claim.
United Concordia: United Concordia participating dentists contractually agree to only bill members for applicable deductibles, coinsurance, or amounts exceeding the plan maximums. In addition, members receive explanations of benefits that clearly describe the services received and their financial responsibility. Members can also access the My Dental Benefits tool on our website (UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our dental advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring.
Western Dental: Providers are bound by contract to accept the member’s schedule of benefits. Members can also access the My Dental Benefits tool on our website (www.UnitedConcordia.com) to view their benefits and eligibility information, claim details, procedure history, maximum and deductible accumulations, and more. Plus, United Concordia’s responsive customer service representatives are available to assist members with questions regarding their benefits. Our Utilization Review area also analyzes thousands of claims each year to ensure the acceptability of treatment and quality of services. Our Dental Advisors and consultants also continuously review dentists’ fees and practice patterns for statistical variation from their peers. Dentists who fall outside of the norm are targeted for education and additional monitoring.
8. How many provider locations do you have?
Aetna: As of 6/1/14: DMO over 11,000 dentist locations nationally and 98,000 in California, PPO: over 225,000 dentist locations nationally and 37,000 in California.
Aflac: Aflac Dental does not have network requirements. Policyholders may visit any provider they choose.
Ameritas: Ameritas/FDH Network: 79,516 California provider access points, (54,542 Ameritas; 24,974 FDH); 19,172 California locations, (12,582 Ameritas; 7,090 FDH)
Anthem Blue Cross: We’ve had a lot of growth in our dental networks the last couple of years. Dental Complete members have access to more than 16,600 unique dentists and nearly 40,000 access points in California alone — and more than 96,000 unique dentists and 228,100 access points nationwide. That’s 75% more dentists nationwide than we had in 2011. Our Dental Net DHMO network includes nearly 10,000 provider locations in California to choose from. Additionally, all Anthem dental members have access to our international emergency dentist network, with 24/7 assistance with locating an English-speaking provider for dental emergencies in approximately 100 countries worldwide. Services received through this program do not count toward the member’s annual maximum if their plan has one.
BEN-E-LECT: BEN-E-LECT’s dental plans utilize the Health Smart (Interplan), First Dental Health, Dentemax, PPO USA and Western Dental networks, which contain thousands of offices statewide.
BEST Life: We offer access to a regional and a national PPO networks — First Dental Health (FDH) and DenteMax. Our California network has over 68,672 access points and an additional 9,593 provider locations throughout the state. Our national network has over 285,000 provider locations, which offers our members network access when they are outside of California.
Blue Shield: Members have network access to over 16,000 dental HMO and 25,000 dental PPO providers in California, and more than 218,000 providers nationwide. These are two of the largest statewide provider networks in the industry.
BRIGHTER: While Brighter can be used at any dentist, with discounts at over 190,000 Access Points nationwide, it currently is only available to employers with a significant portion of their employees located in Southern California as that is where we deliver the greatest savings and member experience.
Cigna: Across all specialties, Cigna has over 131,300 unique DPPO dentists nationally and over 20,500 in California. For DHMO, Cigna offers access to 19,200 offices across the country, with 5,020 DHMO offices in California.
Delta Dental: Our networks offer access to more than 48,000 dentist locations for Delta Dental Premier, more than 31,000 dentist locations for Delta Dental PPO and more than 5,100 dentist facilities for DeltaCare USA in California.
Dental Health Services: Dental Health Services’ exclusive, Quality Assured dental network consists of 927 general practice offices with 4,354 participating dentists and an additional 1,924 specialists.
Guardian: There are over 244,321 PPO dentist locations across the country and more than 34,882 in California. We are one of the largest PPO networks in the state based on unique dentists. The DentalGuard Alliance PPO network has over 5,803 dentist-locations in California. For the DHMO, there are 14,367 locations across the country and 7,093 in California. Guardian’s PPO network now includes more than 56 dental offices in Mexico. International Assist, a value-added service available, provides dental members with access to dental care if needed while traveling outside of the U.S. Also, a supplemental listing of out-of-network dentists, Out-of-Network Plus, provides Guardian members greater selection in finding an affordable dentist.
Health Net Dental: As of May 2014, our California PPO network includes 40,722 access points in 11,367 locations. Our California DHMO network includes 2,382 locations.
HUMANA Dental: Nationally, Humana has more than 215,000 provider locations. In California, we have approximately 30,000 provider locations.
Principal Financial Group: We have approximately 48,000 PPO provider locations and 25,700 EPO provider locations.
Securian Dental: More than 190,000 dentist access points.
United Concordia: To support our diverse product portfolio consisting of fee-for-service, DHMOs and PPOs, we maintain some of the largest dentist networks in the nation. Our largest network provides access to 92,500 dentists at almost 235,000 access points. In California alone, we have 15,800 providers at 37,833 access points. Our DHMO network includes more than 2,600 primary dental offices and almost 1,700 specialists nationwide, with over 1,657 primary dental offices and 776 specialists in California.
9. Can Insureds change providers easily if they are unhappy?
Aetna: Yes, members in our PPO/indemnity plan can change any time and do not need to notify us. Members in our DMO plan can choose a new provider as often as once per month through Navigator, our online web tool for members, or by calling the toll-free telephone number on the back of their ID card.
Aflac: Yes. Policyholders can change providers at any time.
Ameritas: Ameritas PPO and the FDH Networks – Insureds can choose any provider at any time for procedures.
Anthem Blue Cross: Yes. Our PPO networks, including Dental Prime and Dental Complete, are open-access models: The member does not have to pre-select a dentist and can always see the dentist of his/her choice. DHMO members can change providers once a month.
BEN-E-LECT: Yes. Members may change providers at any time by selecting to use another provider. No further documentation or process is necessary.
BEST Life: Members may choose any dentist they desire without calling BEST Life to switch providers. We also provide immediate access to customer service, who can assist members with selecting a provider.
Blue Shield: Yes. Dental PPO plan members have the flexibility to see in-network or non-network providers while dental INO members can only see network providers. However, dental PPO and dental INO plan members may change providers at any time without notice; Dental HMO plan members may change their primary care dentist as needed; changes will be effective the first of the following month.
BRIGHTER: Brighter members can choose the best dentist that matches their needs. Using our online dental shopping platform, members choose dentists based on location, ratings or price.
Cigna: DHMO – Members may transfer to a new dental office once a month and for any reason, as long as the member has paid his/her account, in full, at the current office. Members can call our customer service department to speak with a representative, transfer using the online Dental HealthCare Professional Directory on myCigna.com or use our automated transfer option which can process transfers 24 hours a day. Transfers are effective the first of the following month. We suggest that members complete any dental treatment-in-progress before transferring to another dental office. DPPO — Cigna DPPO members have the freedom to visit either a network dentist or any licensed dentist at any time. However, we do recommend that they complete any treatment-in-progress and pay outstanding balances full before changing dentists. DEPO — Cigna DEPO members may seek care from any network dentist; however, we do recommend that they complete any treatment-in-progress and pay outstanding balances in full before changing dentists. Indemnity Cigna Traditional indemnity members have the freedom to visit any licensed dentist at any time.
Delta Dental: Fee-for-service enrollees can change dentists any time without notifying us. DHMO enrollees can change their contract dentist by contacting customer service or online at www.deltadentalins.com. Requests submitted prior to the 21st of each month are effective the first of the following month.
Dental Health Services: Yes. Member satisfaction is Dental Health Services’ top priority, which is why members can change their dentist at any time by contacting their Member Service Specialist or by simply visiting the Dental Health Services website at www.dentalhealthservices.com.
Guardian: Members covered under Guardian’s PPO plans can change dentists at will, regardless of whether the dentists are participating or non-participating. Members covered under our DHMO plan may change dentists by using our on-line web tool, GuardianAnytime.com, or by calling our toll-fee number. We also offer a dual choice monthly switch plan which enables members to switch between the DHMO and PPO as often as desired on a monthly basis.
Health Net Dental: With our PPO plan design, there is no need to select a primary care dentist or to obtain referrals for specialty care. Under our DHMO plans, members may change their primary care dentists once a month by calling Health Net Dental Member Services or via our on-line Web portal. The change is effective the first of the month, provided that the request is made by the 20th of the previous month.
HumanaDental: With the PPO plan design, the member can change dentists without notifying the dental plan.
Principal Financial Group: Yes
Securian Dental: Yes.
United Concordia: Yes, members can change PPO providers at any time without notice. DHMO participants may change dentists by writing or calling our customer service department and requesting a new DHMO provider, as long as there is no existing balance due to the current dentist or treatment in progress.
Western Dental: Our membership can change providers, on a monthly basis, by phone or in writing.
10. How do you ensure that your dentists are aware of the benefits of your plan(s)? Do you have a way of knowing if the dentists are soliciting or recommending services that are not compensated for by your plan?
Aetna: Participating dental offices receive our helpful Dental Office Guide, which provides clear information about plan designs, policies, and procedures. We also offer a website specifically designed for dentists. The site includes real-time eligibility and benefits information, a 24/7 speech recognition system called “Aetna Voice Advantage.” Also, our dental solutions team is trained to know what is important for provider service. Unusual treatment patterns may be discovered during our review of utilization reports. This usually results in an office audit that includes a review of patient files and general office practices. We talk with the dentist about the findings and develop recommendations for improvement where needed.
Aflac: Aflac has materials that may be provided to dentists with information on how to file claims and access online materials. A dedicated section on aflac.com provides dentists with claim forms and instructions, as well as online access to verify policy benefit amounts. If the dentist has any additional questions, he or she may call Aflac’s Customer Service Center toll-free -1.800.99.AFLAC. Ameritas: Providers can access individual plan information using the toll-free voice response system, the fax-back system, or our online benefit Website. We hope this educates both the provider and insured about covered benefits. If not, periodic surveys and automated utilization review mechanisms help provide a way to monitor issues regarding plan coverage misunderstandings.
Anthem Blue Cross: We inform participating dentists of plan benefits through a variety of communication vehicles. Dentists can access updated information on our Website, through our interactive voice response system, directly from our provider relations and customer service representatives, and through our provider mailings. Practice patterns of participating providers are monitored continuously and reported through monthly utilization reports and claims experience. We involve our dental director when we suspect over- or under-utilization patterns. In such cases, our dental director contacts the dentist to discuss findings along with a plan of action to help bring the practice within the standard.
BEN-E-LECT: The members are given material specific to the dentist to ensure benefits are understood. BEN-E-LECT also offers extended customer service hours with a department dedicated to assisting dentists with benefits information. BEN-E-LECT also has regular outside auditors review claims for this information in addition to scrub during time of payment.
BEST Life: Dentists may contact BEST Life for information about member benefits by calling 800-433-0088. All calls are answered by a live person, every time, no exception. We also have a fax back line dentists can use to obtain benefit information.
Blue Shield: We strive to make it easier for dentists to participate in our network by automating as many administrative processes as possible. Because administrative capabilities vary among dental offices, multiple approaches exist to facilitate dentist communication-from web-based applications to direct telephone contact-to ensure that all offices have access to critical dentist information and support. Communication channels available 24 hours a day, seven days a week, include: • The Interactive Voice Response (IVR) system offers real-time eligibility verification and claims status inquiry. The IVR also provides fax-back capability for hard copy eligibility verification. • A website enables eligibility verification, benefit confirmation and claims status inquiry. • Electronic Claims Filing — we contract with a number of clearinghouses or trading partners to receive electronic claims submissions. • Electronic Claims Payment — The capability exists to pay our providers electronically if they so choose. Claims are paid on a daily basis (Sunday-Friday). Network dentists can control costs and increase efficiency by submitting data electronically, using our website and interactive voice response (IVR) system.
BRIGHTER: Our dentists utilize our simple online platform to process interactions with our members so mistakes are minimized. This also empowers us to track all recommended treatments and proactively remove providers that are over-utilizing (recommending unecessary services) from being seen by our members.
Cigna: Our Internet-based platform allows contracted dentists the ability to conduct transactions over a secure website directly linked to Cigna. This website provides one-stop online access to information that the dental offices will find helpful to manage day-to-day operations and increase operational efficiency. Our website at www.cigna.com also provides an easy way for dental offices to access information about participating in the Cigna Dental Care or Cigna DEPO/DPPO network. The network management staff communicates regularly with dental office personnel by phone, periodic newsletters, site visits to provide information about regulations, practice management, patient satisfaction, policies, procedures, and high level news about Cigna. DHMO –The Cigna Dental Care Reference Guide, Patient Charge Schedules (PCSs) at a Glance and Specialty Referral Guidelines are provided to each network dental office on the plan. We produce a periodic newsletter to communicate information about regulations that affect dentists, nationwide and state-specific policies, procedures. This bulletin is mailed with monthly payment packages to the dental offices to which the information is applicable.
DEPO/DPPO – The Cigna DPPO Office Reference Guide and fee schedules are provided to each network dental office on the plan. These documents describe the policies and procedures to administer the plan, assist members; contracted fee schedules for the dental office and the advantage of participating in the Cigna DEPO/DPPO network. In addition to the savings generated by our thorough and efficient claims and treatment plan review process, another key aspect of the utilization management program is the analysis of network dentist practice patterns (dentist profiling). Our utilization database containing millions of claims and encounters from more than 140,000 dentists across the country provides us with a comprehensive and statistically sound basis for establishing utilization norms. DHMO – When a dentist submits an encounter form, we enter and store in our database. We generate a statistical report monthly for each network dental office. This report provides a means to systematically evaluate each facility by presenting a clear profile of our dentists’ practice patterns. The report also includes state and regional normative data to facilitate the identification of outliers for each listed category, as well as the development of appropriate follow-up action plans. Based on the evaluation of the outliers by our dental directors, we initiate corrective action activity. If unacceptable practice patterns continue, we may end the network dental office contract.
DPPO/DEPO – Cigna Dental uses our provider profiling application as part of our utilization review program. The application uses claims data to generate a report showing the practice profile for a given provider that can be compared with the average practice profile of his or her peers. The profiling report provides details on the following types of practice patterns: The database for any given period compares a single dental office with submitted procedures of over 400 American Dental Association (ADA) codes, with a frequency total of tens of millions of procedures. action. Through our utilization review and dentist profiling efforts, as part of our overall utilization management program, Cigna has been able to ensure network dentists provide adequate and appropriate care. Plus, we have saved our clients billions in the process. .
Delta Dental: Detailed program information for all enrollees, including maximums, deductible and benefit levels, is available through a secure area of our website and through a toll-free telephone number. Additionally, Delta Dental issues a bimonthly newsletter to network dental offices, which covers Delta Dental policy, industry news, seminars, new Delta Dental clients, tips on submitting claims and other useful information. We issue a quarterly quality-related newsletter to participating dentists that provides useful information to help improve the quality and efficiency of the care they provide. In addition, Delta Dental holds regular seminars to keep dentists up to date. Regular enrollee surveys seek information on various quality issues, such as services rendered that are not covered by the program; services delivered as claimed; office cleanliness and appearance; and customer service.
Dental Health Services: Dental Health Services regularly provides on-site training, auditing, and service visits for the company’s participating prepaid (D-HMO) dentists. Additionally, each dental office receives a manual that contains comprehensive information about Dental Health Services’ dental benefit plans. The company monitors all services and treatment received by its members through monthly utilization reports.
Guardian: Dentists can access plan benefits online at www.GuardianAnytime.com or through their practice management system. All PPO dentists receive information about Guardian’s plans through local network recruiters as well as email newsletters or mailings of pertinent information. Our claim system tracks and monitors each dentist’s practice patterns for bundling, over-utilization, etc. We consult with dentists who are not meeting our expectations, and if they are unable to do so, we may discontinue their network participation. All offices that join our DHMO network receive an orientation that fully explains the plan. Additionally, our DHMO Regional Network Managers periodically visit the offices to review the plan. Dental Offices submit encounter data of services provided to DHMO members which is reviewed quarterly by our Quality Assurance Committee.
Health Net Dental: We educate our providers about our administrative policies, including guidelines on appropriate care. Providers are encouraged to submit pre-treatment plans for review in order to learn what procedures would be covered under the member’s benefit plan and the level of reimbursement. In the process of reviewing pre-treatment estimates and in completed claims, we track and monitor each provider’s practice patterns. Providers with aberrant patterns receive focused review, including statistical analysis and record audits, which may result in appropriate corrective action plans. Our Professional Network Relations Reps meet with providers to counsel them and to answer any questions about planning care for members. Our Internet portals provide real-time information to providers and members on their benefits.
HumanaDental: HumanaDental notifies dentists, according to their contract, of any new product 45 days in advance of introduction. Providers are encouraged to check eligibility and benefits prior to treatment. Through monitoring of member communications and through utilization review, we would become aware of any situation where a dentist may be recommending non-covered procedures on a routine basis.
Principal Financial Group: We provide online, telephone and fax service options for providers to verify benefits and eligibility. We encourage pre-determinations to be performed for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery.
Securian Dental: Dentists can verify benefits by calling our toll-free customer service phone number or via our Web site.
United Concordia: Dental offices can confirm benefit coverage information on our website via “My Patients’ Benefits,” through our telephone interactive voice response (IVR) system, or by speaking to a customer service representative. In some instances, we also inform dentists of important benefit changes through written communications, via our quarterly newsletter, through a stuffer included with dentist checks and/or with an automated telephone call. Dentists can also reference benefit information using our Dentist Reference Guide, available on our website. Professional relations representatives are also available to provide assistance when necessary. We identify abnormal practice patterns through a comprehensive quality assurance process. United Concordia reviews thousands of claims each year to ensure the acceptability of treatment and quality of services. Advisors and consultants also review dentists’ fees and practice patterns. Dentists who fall outside of the norm are targeted for education and additional monitoring.
Western Dental: Each provider is trained and given training materials to ensure that they are knowledgeable about Western Dental programs. Western Dental Services also monitors customer service inquiries and grievances in addition to reviewing utilization data supplied by each provider.
11. How many provider offices have you lost over the past year? If asked, will you provide the names and phone numbers of at least three of these offices?
Aetna: In 2013, we lost 1.9% or providers in our DMO network and 1% in our PPO network. This is the voluntary termination rate. We are not at liberty to provide specific dentist information, such as names and phone numbers.
Aflac: Aflac Dental has no provider networks. Policyholders have the freedom to choose any dentist without restriction.
Ameritas PPO: 12,171 provider access points were lost (Ameritas = 3,808, FDH = 8,363). Yes, we would provide names, if requested.
Anthem Blue Cross: In the past 12 months, our Dental Prime and Dental Complete networks have grown significantly and less than 1 percent of dentists have terminated participation (primarily through retirement or death). Anthem does not make it a practice to provide names and phone numbers of dental offices that have left the network.
BEN-E-LECT: For all plans combined, the turnover is less than 2%. Many offices have been terminated due to lack of meeting credentialing standards, retirement or death of the provider. BEN-E-LECT does maintain the information for these offices; however it is not common practice to release the information.
BEST Life: (First Dental Health (FDH) and DenteMax: We have no control of this number. However, our provider locations have actually increased a total of 11,398 locations in the past 12 months. Less than 2.5% of providers have left our PPO networks in the past 12 months. The majority of these terminations are due to a provider’s retirement, death or the moving or closing of a practice. We maintain a clean and thorough network that involves regular network clean-ups.
For the sake of privacy, our network does not share such information for the purpose of a general interview. Our networks also focus on growth. Our national network has added 249 access points in California in May 2014.
Blue Shield: Dental PPO: For 2012, the voluntary turnover rate (excluding deaths, retirements and practice relocations) was less than 1%.
Dental HMO: For 2012, the voluntary turnover rate (excluding deaths, retirements and proactive relocations) was 2%. If requested, Blue Shield can provide the names and phone numbers of at least 3 offices that have left our network within the past 12 months.
BRIGHTER: Brighter maintains a high retention rate of 97% annually.
Cigna: Cigna’s dental network turnover rates have been lower than published industry average data. Dentist and dental office information can be shared with clients and brokers if required.
Delta Dental: Nationally, the dentist locations for our Delta Dental Premier network increased by 10.7%; our Delta Dental PPO network increased by 14.35%; and our DHMO network increased by 9.69% general dentist facilities. In California, there were 270 Premier terminations and 311 PPO terminations. Delta Dental does not release specific information on its contracted dentists.
Dental Health Services: Although roughly 5% of participating dentists have been lost over the past 12 months, our overall network size has made up for this and has increased by 5% over the previous year through a focus on seeking out only the most qualified dentists while improving accessibility and availability. The names and phone numbers of all offices are available on request.
Guardian: Guardian has a 97% network retention rate.
Health Net Dental: In 2013, our DHMO turnover rate for voluntary terms was 0.67% and our PPO turnover rate was 0.25%. We do not release specific information on our contracted dentists.
HumanaDental: In the past 12 months, there were 97 providers termed in California, including 5 due to not meeting our credentialing requirements. We do not provide the names and phone numbers of termed offices.
Principal Financial Group: Less than 5%.
Securian Dental: Very few providers choose to leave the DenteMax network. Less than 3 percent of our network dentists discontinue participation with DenteMax every year. The majority of these terminations are due to a provider’s retirement or death or the moving or closing of a practice. We would be willing to provide names and phone numbers of terminated offices upon request.
United Concordia: In California, we grew our PPO network from 15,800 individual dentists and 37,833 access points to 16,240 dentists and 41,168 access points. In addition, our DHMO network of primary dental offices remains consistent with just over 1,652 primary dental offices. Yes, if requested, we can provide the names and phone numbers of dental offices that no longer participate in our network.
Western Dental: Turnover is about 3% for the past year. Yes, we will provide the names and phone numbers for 3 of these offices, if requested.
12.What percentage of your network is closed to new enrollment? How many offices does this represent?
Aetna: For California, approximately 4% of our DMO participating providers are closed to new patients. All of our PPO providers are open to new patients.
Aflac: Aflac Dental has no provider networks. Policyholders may visit any dentist they choose.
Ameritas PPO: Only 106 Ameritas Offices and 26 FDH Offices are closed to new enrollment. This represents approximately 0.2%.
Anthem Blue Cross: Our Dental Prime and Dental Complete network model is open-access, and we do not contractually require providers to report on new-patient status. We have not heard reports of any members having issues with finding a participating dentist that is open to new patients.
BEN-E-LECT: All of BEN-E-LECT’s dental PPO providers are accepting new patients. For the DHMO product, less than 3% of the offices are closed to new enrollment representing approximately 60 offices.
BEST Life: All participating PPO dentists are accepting new patients.
Blue Shield: In 2012, less than 1% of dental HMO plan network providers maintained closed practices; this represents approximately 30 offices.
BRIGHTER: All Brighter dentists are accepting new patients.
Cigna: DHMO — Our systems include data on dentist capacity and current and projected Cigna Dental Care member loads. Network managers regularly monitor capacity and projected growth. They contact dentists as necessary to discuss capacity expansion through staff increases or office hour changes. If these actions are not feasible, we will consider adding more dental offices. Nationwide, approximately 8 percent of the Cigna Dental Care network dental offices are closed or capped to new members. DPPO/DEPO — Network dentists do not cap or close their offices. Members are not required to select a primary network dental office
Delta Dental: 0%. Under the PPO/Premier plans, enrollees are free to see any licensed dentist. Contracted dentists can close their practices to new patients but cannot close their practice exclusively to new Delta Dental patients; 2.92% DHMO dental facilities are closed to new enrollment.
Dental Health Services: About 8% of network general practice dentists are closed to new enrollment (63 offices). No specialty offices are closed to new members.
Guardian: In California, only 0.4% of our PPO network and 5.7% of our DHMO network is closed to new patients.
Health Net Dental: As of April 2013, for DHMO, currently 3% of our General Dentist unique locations are closed to new enrollment. For PPO, currently 0.8% of our dentists’ offices are closed to new enrollment.
HumanaDental: Under HumanaDental’s provider contract, participating dentists have payer differentials. Because this is a fee-for-service reimbursement program, closed practices are not common.
Principal Financial Group: Less than 1% of the offices participating in our network are closed to new enrollment.
Securian Dental: All of our network dentists are open to new enrollment.
United Concordia: In California, more than 99% of our PPO dentist network is open to new enrollment, as well as more than 95% of our DHMO dentist network.
Western Dental: Less than 3% of our network providers are closed to new enrollments – about 60 offices.
13. Do all of your contracted offices accept every benefit level sold by your company or do they have the option to pick and choose only the programs with co-payments they want to accept?
Aetna: For California, approximately 4% of our DMO participating providersare closed to new patients. All of our PPO providers are open to new patients.
Aflac: Aflac Dental has no provider networks.
Ameritas: All providers accept patients from all plans sold through Ameritas Group Dental.
Anthem Blue Cross: Anthem Blue Cross recommends all participating providers accept all plans offered. Providers cannot cherry pick DHMO plans, they either accept all DHMO plans under the specific contract, or they do not contract. Providers can choose to participate with Dental Prime and Dental Complete, or Dental Complete only; however as for plan or benefit designs under each product, providers cannot cherry pick which PPO design they will accept.
BEN-E-LECT: All benefit levels are accepted and to date no offices have limited or requested to limit the programs they will accept.
BEST Life: All contracted offices accept every benefit level. Furthermore, by contract, all providers will honor the PPO discounts on all procedures, including non-covered services. They must also honor a discount for members who are within a waiting period or who have exceeded their annual maximum.
Blue Shield: Offices are not allowed to pick and choose which plan designs they accept.
BRIGHTER: All contracted offices must participate in each benefit level we sell.
Cigna: All contracted DPPO offices accept all of the insured benefit DPPO plan designs that we offer. All contracted DHMO offices accept all of the DHMO plan designs that we offer. For our discount dental programs, not all DPPO contracted dentists are required to participate. They may opt out of participation in these discount dental programs if they desire.
Delta Dental: Delta Dental holds contracts with individual dentists for participation with each network (Premier, PPO and DeltaCare USA [DHMO]). Dentists can choose to participate only in those programs with copayments they wish to accept.
Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services.
Guardian: All contracted PPO and CA DHMO offices accept all of the plan designs that we offer.
Health Net Dental: All participating PPO dentists accept all of our plan designs. Contracted DHMO providers accept all Health Net Dental DHMO plans.
HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement. Dentists can opt-out of participation in the Medicare and Access (discount) programs, which are a subset of the PPO.
Principal Financial Group: Providers can choose to participate in our PPO and/or EPO networks. Within each option, providers need to accept all benefit levels sold by our company.
Securian Dental: Yes, they accept every benefit level sold by our company.
United Concordia: All contracted PPO dentists accept all United Concordia PPO plans. All contracted DHMO dentists accept all United Concordia DHMO plans.
Western Dental: The entire network accepts all of the new Series 7 plans.
14. Do you have a way to monitor the length of time patients have to wait in the doctor’s office?
Aetna: We do not monitor average wait times in a dentist’s office.
Aflac: Since policyholders can choose any dentist without restriction, Aflac does not monitor wait times.
Ameritas: We monitor patient wait time through random customer and patient surveys. Providers are contacted, if necessary, to discuss specific feedback.
Anthem Blue Cross: Yes, we monitor this as a metric in our member satisfaction surveys. Through our complaint/grievance tracking processes, issues such as wait times are logged and monitored. Additionally, we monitor appointment wait times and emergency wait times through surveys conducted by our organization.
BEN-E-LECT: This information is tracked closely for Freedom Pre-Paid Dental Plans. Surveys and questionnaires for the PPO products track this information.
BEST Life: Network accessibility and wait times are included as part of the credentialing and ongoing monitoring processes.
Blue Shield: Yes. We monitor and track wait times several ways. We document member complaints on this issue in our customer service workbench and track them electronically until they are resolved. We also conduct an annual member satisfaction survey, which contains specific questions about wait times with our network offices.
BRIGHTER: Yes. Additionally, Brighter maintains an unprecedented high level of member satisfaction through an exceptional member service team that follows up with each patient to ensure their experience at the Brighter dentist met their expectations. Brighter backs this up with a satisfaction guarantee.
Cigna: The dental network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. Additionally, we are able to identify lengthy wait times through our patient satisfaction surveys.We investigate inquiries about excessive wait time and take corrective action if we determine that timely and efficient dental care was available, but not provided. If we determine that excessive wait time was the result of insufficient patient capacity, we initiate actions to expand the dentist’s capacity or recruit additional dentists in that particular area.
Delta Dental: Delta Dental conducts random enrollee surveys semi-annually for the fee-for-service enrollees and annually for DHMO enrollees. Surveys include questions about dentist access (for example, number of dentists from which to choose and appointment availability with their dentist) as well as other customer satisfaction issues. For the DHMO, the appointment availability is also monitored via regular office visits from a Delta Dental representative.
Dental Health Services: Yes, we monitor our members’ experiences through frequent member surveys, regular on-site dental office visits and quarterly access surveys.
Guardian: We send monthly member satisfaction surveys, which include questions concerning wait times, to randomly chosen PPO members who have been to a network dentist within the previous 90 days. The DHMO has established access standards and monitors this quarterly through access monitoring forms, member satisfaction surveys, and transfer and grievance data. Telephone calls are utilized on an as-needed basis.
Health Net Dental: We monitor individual wait times in the dentist’s waiting room through our member satisfaction surveys and provider access surveys. Results of these surveys are a critical tool in assessing a member’s experience with network dentists and their specific offices. In addition, we receive feedback on office wait times from members calling our toll-free Health Net Dental Member Services number.
HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting their options (i.e., after 5 p.m.), which is discovered through discussion with our customer-relations representatives. If the issue becomes chronic, the information is forwarded to our National Dental Network department because additional providers may be needed in the area.
Principal Financial Group: We do not monitor this.
Securian Dental: We do not monitor this.
United Concordia: Yes, it is monitored through member surveys, a customer service grievance process and periodic phone and written survey audits of the offices.
Western Dental: Western Dental monitors patient’s length of time by onsite reviews, surveys, and questionnaires. In addition, our staff model offices use the Quality Assurance Management System. The state-of-the-art, proprietary software tool tracks measurable items, such as wait times, which ensures that our members have timely access to quality dental care.
15. Are there plenty of providers who stay open late and are open on Saturdays?
Aetna: Office hours are set by each individual dental office. We document dentists’ office hours as part of the credentialing process. We use the information to balance networks by contracting with dentists who offer weekend and evening hours.
Aflac: Aflac Dental does not have a network of providers. Policyholders may visit any dentist they choose, which includes those with extended hours.
Ameritas PPO: Yes, each office sets its own hours. Those hours are available to all our members on our on-line provider listings. Our goal is to balance care availability throughout the area to ensure needed care.
Anthem Blue Cross: Each dental office sets its own office hours. However, as part of the credentialing process, we document dentists’ office hours and use the information to ensure our networks include dentists who offer weekend and evening hours.
BEN-E-LECT: Yes, many of BEN-E-LECT’s provider offices offer extended evening and early morning hours in addition to weekend hours for ease of access.
BEST Life: Yes, many providers have extended and flexible hours.
Blue Shield: This varies by provider, but many do stay open late and/or are open on Saturdays.
BRIGHTER: Yes, Brighter’s provider network includes practices that are open late and/or on the weekend.
Cigna: DHMO — There are 3,405 network offices (24 percent of the total DHMO network) offering Saturday office hours, and 5,353 network offices (38 percent of the total DHMO network) offering evening hours (6:00 p.m. or later). DEPO/DPPO — Members are able to visit any licensed dentist for care; therefore, we do not measure evening or weekend hours for DPPO network dentists. Additionally, our dentist contracts require dentists to provide or arrange for emergency care 24 hours a day, 7 days a week and to provide emergency appointments within 24 hours.
Delta Dental: Our online dentist directory contains information on hours and access, including maps, directions and languages spoken. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency service to enrollees seven days a week.
Guardian: Many PPO and DHMO provider locations have extended or weekend hours.
Health Net Dental: The office hours of each dentist location is listed in our online provider directory. This information is also available to all members through Health Net Dental Member Services. As part of our dentist agreement, all locations are required to have an emergency contact available for members whenever the dental office is closed.
HumanaDental: Members can see the provider of their choice and they are encouraged to contact their dentist for appointment availability. Based on today’s busy lifestyles, many providers are extending their hours to meet the needs of their patients.
Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours.
United Concordia: Yes.
Western Dental: Yes, many of our IPA providers have evening and Saturday hours. The Western Dental Staff Model Offices are open from 9:00 AM to 8:00 PM, Monday through, Friday and 8:00 AM to 4:00 PM on Saturdays.
16. With respect to your mid-range benefit level, what is the specific amount of capitation paid to the general dentist? Do you offer validation for these amounts?
Aetna: We establish varying compensation rates under each customer’s benefits plan for subscribers, spouses, and children. Monthly compensation rates are based on community averages and plan design. Actual capitation amounts are proprietary.
Aflac: Aflac Dental does not offer capitation plans.
Ameritas PPO and the FDH Networks: Neither of these networks is used for dental HMO purposes, so no capitation is paid.
BEN-E-LECT: This is not applicable for BEN-E-LECT’s PPO plans. All dentist capitation has been added to the dentist premium amounts collected for the DHMO products.
BEST Life: We do not compensate our providers through capitation. Our Indemnity and PPO plans allow patients to utilize providers of their choice.
Blue Shield: This information is considered proprietary.
Cigna: Network general dentists’ payment consists of the following four components: fixed monthly payments (capitation), patient charges (copays), office visit payments, and supplemental payments for certain covered procedures. Network specialists are paid based on a fixed fee schedule.
Delta Dental: Capitation rates are developed based on the plan design, annual utilization data, enrollee/dependent mix and employer contribution. Compensation is designed to reimburse approximately 60% to 65% of usual fees.
Dental Health Services: Dental Health Services’ compensation system involves many more components than capitation and is designed to keep the participating dentists whole while providing incentives for appropriate treatment and care.
Guardian: DHMO capitation amounts paid to the general dentist vary based on plan design, adult or child, and region.
Health Net Dental: Capitation information is proprietary.
HumanaDental: Managed dental care capitation varies by plan schedule and geographic location.
Principal Financial Group: N/A
Securian Dental: We do not offer capitation plans. We offer PPO and Indemnity plans.
United Concordia: Specific capitation amounts are considered proprietary information. United Concordia also compensates participating DHMO providers with supplemental payments on over 80 procedures. The supplemental compensation not only provides incentives for participating dentists to appoint patients and render necessary care but also provides a mechanism for the dentists to report utilization and thus allowing United Concordia to report DHMO utilization to our customers.
Western Dental: Series 7 plans reimburse providers with capitation and supplemental payments. Total compensation, as with fee-for-service designs, depends on how much treatment is provided.
17. Are there incentives for the provider to be thorough?
Aetna: Quality management programs are designed to help protect members and providers.
Aflac: It is expected that the dentists selected by the policyholders treat their patients with the utmost respect and provide the highest standards of quality care without requiring incentives to do so. If the policyholders are unhappy with the service received, they may change dentists at any time.
Ameritas PPO: Provider thoroughness is an expectation; we do not offer an incentive for this. We do, however, monitor patient care through quarterly utilization review. If standards are not met, it could result in the provider’s termination from the network.
Anthem Blue Cross: We do not offer incentive programs to dentists because we expect quality of care with or without incentives.
BEN-E-LECT: Yes. BEN-E-LECT may offer bonuses to providers who exceed quality of services and accessibility standards.
BEST Life: Our networks administer comprehensive utilizations reviews for dental necessity and appropriateness of care.
Blue Shield: We expect all network dentists to provide our members with high-quality, thorough care; we continuously measure appropriateness of care through numerous oversight methods. While routine treatment plans are carried out by dentists without prospective review, more complicated treatments are evaluated by our dental consultants who assess the proposed treatment(s) for appropriateness and benefit determination. All dentists involved in our review process are fully licensed. Our clinicians are also actively involved in the annual review of dentist records. These quality-of-care audits involve the use of comprehensive guidelines established by the American Academy of Dental Group Practice, the California Dental Association, and the American Dental Association (through the University of North Carolina School of Dentistry). A random sample of each dentist’s records is selected for scrutiny by our dental consultants. Recommendations are made to any dentists who do not meet our quality standards, and follow-up audits are conducted to verify corrective action has been taken.
BRIGHTER: All Brighter members have the ability to rate their experience with a Brighter dentist. Poor ratings will impact their visibility on Brighter’s online shopping platform and, ultimately, ability to attract new patients.
Cigna: Our Integrated Quality Management Program drives overall quality across our all of our dental networks. While we do not provide incentives as part of our Quality Management Program, the expectation is that the dentists in our networks meet professionally recognized standards of care. DHMO — Incentives play an important role at increasing participation. Payment for network dental offices is made up of four elements: fixed monthly payments, office visit payments, supplemental payments from Cigna, and patient payments made directly from the member to the dentist. This model is designed to encourage preventive dentistry and to protect the dental office from over-utilization. When these standard forms of payment do not satisfy a quality dentist, Cigna will work with the dentist to achieve the best outcome. Cigna’s network general dentists are able to earn bonus payments when they meet performance goals set for preventive care, specialty procedures and patient satisfaction through the DHMO pay for performance rewards program. DEPO/DPPO — Network dentists are paid based on discounted fee schedules that vary by 3-digit zip code. Our discounted schedules encourage preventive dentistry by offering more aggressive payment on preventive services while holding deeper discounts on Class II and Class III procedures. For noncovered services, members are responsible for payment of the dentist’s usual fee for that procedure.
Delta Dental: Delta Dental does not pay any special incentives. We expect all credentialed network dentists to provide high-quality care within professionally accepted standards and to maintain the dental health of enrollees, with the intention to reduce the need for more invasive care later. Dentists who provide quality care and service retain their assigned enrollees, and as a result, gain enrollment and greater overall compensation.
Dental Health Services: As a prepaid dental plan, Dental Health Services provides plans designed to remove the incentive for dentists to over treat, by using a different reimbursement structure. Through a combination of guaranteed monthly capitation payments, selected supplemental payments and reasonable patient copayments, dentists are rewarded for bringing patients to a state of optimum oral health and then maintaining this state. Dentists are required to submit encounter (utilization) data to the plan so that the services performed can be monitored and compared to expected parameters, resulting in the same monitoring ability as claims-based dental programs, while leaving very few actual submitted claim forms. (Specialty claims and claims for out-of-network emergency care being the common exceptions.)
Guardian: Our PPO fee schedules and plan provisions encourage proper care. Guardian requires participating dentists to treat PPO members the same as any other patients and we investigate all quality of care complaints from members. Our DHMO reimbursement schedules, capitation payments, office visit fees, supplemental payments, and chair-hour guarantees encourage appropriate care. Participating dentists treat DHMO members the same as any other patient, and we have a grievance process in place to follow up on all quality of care complaints from members.
Health Net Dental: We do not offer financial incentives to our dentists. Our expectation is that our dentists perform in accordance with high professional standards without incentives. Our extensive credentialing process ensures that our contracting dentists are of the highest caliber.
HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Member complaints are reviewed by our Quality Assurance Department and through our standard grievance process.
Principal Financial Group: Being thorough is an expectation and we do not provide incentives to meet expectations. All providers in our networks must meet strict credentialing requirements. This means they have all been independently reviewed and found to have proper professional credentials and a verified history of responsible billings. However, a member is free to choose any provider.
Securian Dental: All DenteMax dentists undergo a rigorous credentialing process to ensure the highest quality dentists are treating our members.
United Concordia: Our expectation is that all services performed by participating dentists will meet the high standards of the dental industry. In addition, participating DHMO primary dentists get supplemental reimbursement on the most highly utilized procedures in addition to monthly capitation and member co-payments, which encourage dentists to provide the services necessary to ensure the oral health of members. Participating providers are routinely evaluated through utilization analysis and onsite quality assurance assessments.
Western Dental: Western Dental Services Inc. may pay the dentist a bonus based on exceeding standards specified by Western Dental with regard to accessibility of services and quality of care.
18. Do you provide coverage for all types of specialist referrals?
Aflac: The Aflac Group Dental plan does not require referrals.
Assurant Dental Network: Yes.
Ameritas PPO and the FDH Networks: Yes, specialty coverage can be a part of any Ameritas plan design. Our networks comprise a full spectrum of specialists to cover the needs of our customers.
Anthem Blue Cross: Yes, specialist care is available for both our Dental PPO and DHMO plans. No referrals are required on our Dental PPO plans, including Dental Prime and Dental Complete. On our DHMO plans, the member’s general dentist can refer them to a specialist when needed.
BEN-E-LECT: Specialist referrals are not necessary. Coverage is available for all types of specialty procedures including, but not limited to, endodontic, periodontic, cosmetic, orthodontics, oral surgery and pedodontics.
BEST Life: Yes, specialists are covered at full contract benefits as describe in our Indemnity and PPO plan certificates of insurance. Our orthodontic plan is available for all of our PPO and Indemnity plans either at a deductible or lifetime maximum.
Blue Shield: Specialist care is available for all dental plans. Dental PPO/INO plan members may self-refer to any specialist, although INO members can only see network providers. For dental HMO plan members, the primary care dentist is responsible for referring the member to a participating specialist; however, there is no coverage for prosthodontic specialists.
BRIGHTER: Yes and Brighter features a provider network with specialists in all areas of dental.
Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are valid for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment, if covered on their plan design or for pediatric care for children up to age seven as long as individuals visit network specialists. The network dentist may submit a request for pre-authorization to Cigna Dental for oral surgery, endodontic and periodontal services. Individuals are responsible for the applicable patient charges listed on the Patient Charge Schedule for all covered procedures. After specialty treatment is complete, the individual should return to the network general dentist for care. If it is determined that a network specialist is not available, the general dentist will refer the patient to a non-network specialist and the patient will only be responsible for charges listed on the Patient Charge Schedule.
DPPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental PPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses.
DEPO –There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna Dental EPO plan. Members can visit any network specialist or general dentist at any time to receive coverage.
INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time.
Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received. Dental Health Services: Yes. Dental Health Services’ plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics.
Guardian: We provide coverage for all types of dental specialists.
Health Net Dental: Health Net Dental DHMO plans cover a wide range of specialty care, including endodontics, periodontics, oral surgery, pedodontics and orthodontics. If the procedure is covered under the plan, the member must first see general dentist for a specialty care referral to a general dentist
HumanaDental: HumanaDental provides coverage for specialist referrals; members are encouraged to refer to their certificate of coverage to confirm the service being sought is a covered benefit under their plan. Humana- Dental encourages members to check if the specialist referred by their dental provider is in-network. Humana has a provider directory available on our website, www.Humana.com. Members can also call the customer service number on the back of their insurance card. Members should request a pre-treatment estimate from the provider.
Principal Financial Group: Generally yes.
Securian Dental: Our plans do not require referrals. We provide coverage based on plan benefits.
United Concordia: Our PPO plans do not require specialist referrals. Our DHMO plans require referrals from the general dentist office for specialty coverage for endodontics, periodontics, pedodontics, oral surgery and orthodontics. However, the DHMO referral process is open, in that there is no requirement for United Concordia to pre-authorize the referrals. The services provided by specialists that are considered for benefit reimbursement are limited to the specifics of the dental contract for each covered member.
Western Dental: Specialty coverage is available in all of our group plans. Oral surgery, periodontics, endodontics, pedodontics, and orthodontics are covered specialties.
19. If covered, explain the process that allows the general dentist to refer to the specialist.
Aetna: For DMO plans, general practitioners can refer to a participating specialist directly based on published guidelines. DMO members have direct access to participating orthodontists and do not need a specialty referral. Indemnity and PPO plans have direct access for specialty services.
Aflac: The Aflac Group Dental plan does not require referrals.
Ameritas PPO and the FDH Networks: Specialist referrals are allowed at any time from our general dentists. There is no gate-keeper involved in this process.
Anthem Blue Cross: With our Dental Prime and Dental Complete plans, we do not require referrals. For the Dental Net DHMO, referrals that do not include high-risk procedures are reviewed post-treatment. Using the direct referral program, the participating general dentist can refer a patient to a specialist without prior authorization. Dentists’ practice patterns are reviewed to help ensure that they share in our commitment to providing access to effective healthcare. For the Dental Net DHMO products, the member’s assigned general dentist can call the customer service hotline in an emergency to get an immediate authorization for emergency services.
Assurant Dental Network: The member does need a referral from the dentist. They may self-refer to a specialist.
BEN-E-LECT: Referral is not necessary for any of BEN-E-LECT’s plans. The member may select a specialist and schedule an appointment upon making a phone call or personal visit.
BEST Life: No referral is necessary. Insureds can visit a specialist at any time.
Blue Shield: For DHMO plan members, the general dentist completes a specialty care referral form and provides a copy to the member, who provides the form to the participating specialist at the time of the appointment. Dental PPO plan members may self-refer to a specialist.
BRIGHTER: There is no formal referral process with Brighter. Members are free to choose their dentist or specialist using our online platform.
Cigna: DHMO – Network general dentists initiate patient referrals for endodontic, oral surgery, and periodontal treatment. Referrals are confirmed for 90 days from the approval date. Specialty referrals are not required for orthodontic treatment or pediatric care for children up to seven years old, as long as members visit network specialists. The network dentist may submit a request for preauthorization to Cigna for oral surgery, endodontic and periodontal services. Members are responsible for the applicable patient charges listed on the patient charge schedule (PCS) for covered procedures. After specialty treatment is finished, the member should return to the network general dentist for care. If a network specialist is not available, the general dentist will refer the member to an out-of-network specialist, and the member will only be responsible for charges listed on the PCS; however, Cigna Dental Care (DHMO) network general dentists render the range of services that are required for graduation from dental school, including diagnostic treatment, preventive treatment, operative dentistry, crown and bridge, partial and complete dentures, root canal therapy, minor oral surgery, preliminary periodontal therapy, and pediatric dentistry.
DPPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DPPO plan. Members may choose to seek service from any in- or out-of-network specialist or general dentist at any time. Of course, network dentists have agreed to our reduced fee schedules, which lower out-of-pocket expenses.
DEPO – There is no need for a referral by a primary care dentist to obtain services from a specialist with the Cigna DEPO plan. Members can visit any network specialist or general dentist at any time to receive coverage.
INDEMNITY – Cigna Traditional indemnity members are always free to seek care from any licensed dentist at any time. Delta Dental: Fee-for-service enrollees can self-refer; referral by the general dentist isn’t required. For DHMO enrollees, the primary care dentist is responsible for submitting the predetermination request and directing the enrollee to the appropriate specialist once authorization is received.
Dental Health Services: The participating general dental office sends Dental Health Services a specialist referral authorization. Upon approval, the authorization is sent back to the general dentist who informs the patient that they are now eligible to get appropriate care from a specialist.
Guardian: For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a participating specialist dentist. Our DHMO plans offer direct referral in which the member may be referred directly by their primary care dentist to a participating specialist without pre-authorization.
Health Net Dental: For DHMO plans that require pre-authorization, the contracting primary care dentist completes a specialty referral form and submits to Health Net Dental. Approvals are returned to the primary care dentist, member and specialist. Upon receiving the approval, the member contacts the specialty office to schedule an appointment for completion of treatment. For plans that have direct referral, the primary care dentist may directly refer the member to a participating specialist by visiting our website or by contacting our customer service. Our PPO dental plans allow self-referrals to participating or non-participating specialists as needed.
HumanaDental: General dentists are encouraged to refer members to participating specialists to provide the highest level of benefit to the member. The general dentist can refer out-of-network if there are no specialists within a reasonable distance.
Principal Financial Group: Patients can choose any provider in the network; referrals are not required.
Securian Dental: No referral is required.
United Concordia: If a general dentist determines that a patient requires referral to a specialist, all care must be coordinated through the primary dental office. The primary dental office should refer the patient to a participating specialist located in our Concordia Plus Specialist Directory and also complete the specialty care referral Form. The patient should be given a copy of the referral form to give to the specialist at the time of their appointment. The specialist will then be responsible to submit the claim, corresponding documentation and referral form to United Concordia for reimbursement. There is no requirement for United Concordia to pre-authorize the referral, thus providing better access to care when it is needed.
Western Dental: Once the general dentist determines that the necessary procedure is out of his or her scope of practice, the office will submit a written referral request to our plan. Western Dental’s dental director then determines whether the referral is medically necessary and whether the procedure is covered under the benefit plan.
20. Are any of your specialists board eligible/certified?
Ameritas PPO: Yes, all are board-eligible or certified and are monitored during the PPO credentialing process.
Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible.
Aflac: Aflac Group Dental has no provider networks, however, for benefits to be payable, the specialist must be licensed by his or her state to perform the required treatment.
Assurant Dental Network: Yes.
BEN-E-LECT: Yes. BEN-E-LECT requires that all participating specialists be board certified.
BEST Life: All of our specialists are certified and must meet a rigorous credentialing process to be admitted into the network. DenteMax credentials its specialists using the following elements:
• License to Practice • DEA/CDS Certificates
• Education/Board Certification • Work History
• Malpractice Claims History • Malpractice Insurance
• Application and Attestation Content • Sanctions Against Licensure
• Medicare / Medicaid Sanctions • Medicare Opt Out
Blue Shield: Yes, but certification varies by specialist. Dental specialists may be certified, but it is not an industry requirement. Therefore we do not track board certification. We ensure that members receive the best possible care by credentialing and re-credentialing dentists following NCQA guidelines.
BRIGHTER: All Brighter dentists go through a rigorous certification process that includes validation of industry eligibility and certifications.
Cigna: DHMO/DEPO/DPPO – Network dentists contracted to provide specialty care have successfully completed postgraduate dental specialty programs in their fields. Our networks include specialists in periodontics, orthodontics, endodontics, pediatric dentistry, and oral surgery. We accept dentists who are recognized specialists, including those that are board certified or board eligible.
INDEMNITY – Network related issues are not applicable to the Cigna traditional indemnity plan. Members may choose any licensed dentist to provide care.
Delta Dental: Delta Dental requires board certification where it is required by state law. Under the fee-for-service plans, Delta Dental credentials all of its participating specialists in the same manner, whether they are board eligible or board-certified. Under the DHMO plans, Delta Dental requires all
DeltaCare USA network specialists to be board-qualified.
Dental Health Services: Yes. Majority of Dental Health Services’ dental specialists are board certified.
Guardian: Many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible.
Health Net Dental: Yes.
HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates.
Principal Financial Group: Yes. All specialists are required to be board eligible, board certified or be a designated specialist by the ADA.
Securian Dental: 100% of the specialists in our network are board certified or board eligible.
United Concordia: Yes, as part of our credentialing process, we verify each dentist’s education, license and certifications.
Western Dental: All contracted specialists are board-eligible/certified.
21. How do you fund your specialty care?
Aetna: Specialty services are paid on a fee-for-service basis.
Aflac: Aflac Group Dental insurance pays a set amount per procedure based on a table of allowances. Additionally, insureds have the freedom to choose their own providers without precertification.
Ameritas PPO and the FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the group’s general dentist claims. If employers are fully insured, all are funded out of the premiumcharged to each group. If employers are self-funded, the specialist claims would be included in the claim funding bill provided to the employer.
Anthem Blue Cross: Claims for specialty care for both Dental PPO and
DHMO plans are paid according to the provider’s fee schedule.
Assurant Dental Network: Proprietary
BEST Life: Specialty care is built into the premium. Specialty care received by a network provider is reimbursed at a discounted fixed fee schedule. Specialty care received by a non-network provider is reimbursed on what is usual and customary for that area, procedure and specialty.
Blue Shield: Specialty care is paid on a discounted fee for service basis for dental HMO, INO and PPO plan designs. Member and plan copayments vary, depending on the plan design.
BRIGHTER: The employer sets its own funding & specialty amounts.
Cigna: DHMO –We contract with an extensive network of specialists to ensure that we provide our members with the needed services at negotiated fee levels. We pay specialists based on a reduced fee schedule. Patient charges listed on the patient charge schedule (PCS) apply at the specialist’s office once we have authorized payment. We review referrals to specialists for eligibility and coverage.
DEPO – The DEPO plan uses our national DPPO network. Specialists are part of the Cigna DPPO network, and members can seek care from any network specialist without a referral. Like network general dentists, network specialists are contracted on a discounted fee-for-service (FFS) schedule based on average charges in a geographic area.
DPPO – Specialists are part of the Cigna DPPO network; members can seek care from an in-network or out-of-network specialist without a referral. Like network general dentists, we contract with network specialists on a discounted fee-for-service schedule based on average charges in a geographic area. We pay out-of-network dentists according to maximum reimbursable charge levels or fixed schedules, depending on the plan design.
INDEMNITY – The Cigna Traditional indemnity plan is not a network-based plan. Delta Dental: Specialty care is built into the premium. Under the fee-forservice plans, specialists are reimbursed by a combination of maximum plan allowances by procedure (contracted fees between Delta Dental and dentists) and coinsurance paid by the covered enrollee. Under the DHMO plan, network specialists are reimbursed for preauthorized services on a per-claim basis according to contracted fee schedule and copayment paid by the enrollee.
Dental Health Services: Specialty care and treatment are paid for on a contracted basis and payment varies by procedure. These costs are built into each plan’s monthly premium rate.
Guardian: Our PPO specialists are paid on a fee-for-service basis. For our DHMO plans, specialty care is funded through a portion of premium.
Health Net Dental: For both our DHMO and DPPO plans, we underwrite and rate dental plans based on an assumed specialty care claims liability and build an allowance into our dental premiums.
HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit.
Principal Financial Group: Through normal plan provisions.
Securian Dental: Network dentists (general and specialty dentists) are reimbursed on the basis of a discounted fixed fee schedule. Network dentists agree to accept the fee schedule amount as full consideration, less applicable deductibles, coinsurance and amounts exceeding the benefit maximums and will not balance bill the member.
United Concordia: Both PPO and DHMO specialists are paid on a negotiated fee-for-service basis.
Western Dental: We incorporate into our premiums what we expect specialty care claims to be. We then pay the claims based on dental necessity and plan guidelines.
22. Does the member have to be referred by the primary dentist to the orthodontist or can he or she self-refer?
Aetna: Member can self-refer.
Aflac: The Aflac Group Dental plan does not require referrals. Insureds may self-refer.
Ameritas PPO and the FDH Networks: No, every member can self-refer.
Anthem Blue Cross: We do not require referrals in our PPO plans, including Dental Prime and Dental Complete. Members enrolled in the Anthem Blue Cross Dental Net DHMO program must be referred by their primary dentist to an orthodontist. Using our direct referral program, the participating general dentist can refer the patient directly to the specialist without prior authorization.
Assurant Dental Network: They can self-refer.
BEN-E-LECT: Members may self-refer to any orthodontist they prefer. In-network versus out-of-network and plan selection will determine coverage provided.
BEST Life: No referral is necessary.
Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Dental PPO/INO plan members may self-refer.
Delta Dental: Under the fee-for-service plans, enrollees can self-refer. For DHMO plans, the assigned network dentist submits a referral request for orthodontic treatment to Delta Dental. The network dentist is notified upon approval and is responsible for advising the DeltaCare USA enrollee who then contacts the assigned network orthodontist for an appointment.
Cigna: None of our plans require a referral for orthodontic care.
Dental Health Services: Yes. Members must get a referral from a participating Dental Health Services dentist before visiting a participating orthodontist.
Guardian: PPO members can self-refer to all types of specialty care, including orthodontia. General Dentists in our DHMO network will refer the member to a participating orthodontist. The referral does not require plan authorization.
Health Net Dental: Our DPPO product does not require referrals for specialty or orthodontic care, so participants may self-refer. For DHMO, there are three types of specialty referral processes based on the member’s schedule of benefits. For plans that require pre-authorization, a specialty referral form must be submitted by the primary care dentist. For plans that have direct referral, the primary care dentist may directly refer the member to a participating orthodontist by visiting our website or by contacting our customer service. For plans that allow self-referral, the member may go directly to a contracted specialist by visiting our website or by contacting our customer service.
HumanaDental: In our PPO, the member can self-refer to an orthodontist. HumanaDental encourages members to ensure any dental provider is in network. Humana has a provider directory available on our website, www. Humana.com. Members can also call the customer service number on the back of their insurance card.
Principal Financial Group: A member can choose to seek services from any provider.
Securian Dental: The member can self-refer.
United Concordia: Our PPO plans allow members to self-refer. Under our
DHMO plans, the primary dental office determines if a specialty referral is required, regardless of the specialty.
Western Dental: The member has to be referred by the primary dentist to the orthodontist for our IPA Dental Plan. Our Western Centers-only plan allows the member to self-refer.
23. What is the time frame for processing a referral in terms of member notification and payment to the specialist?
Aetna: DMO general practitioners usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim.
Aflac: Aflac Group Dental doesn’t require referrals because insureds have the freedom to choose their own dentist without restriction.
Ameritas: Since this is a self-referring process, this question is not applicable.
Anthem Blue Cross: With our PPO plans, there is no need for a referral. With Anthem Blue Cross Dental Net DHMO plans, referrals are usually processed within 48 hours through the use of our Direct Referral program. Referrals for emergency reasons are usually processed within the same day.
Assurant Dental Network: N/A
BEN-E-LECT: Referral is not necessary. Members may call and schedule the appointment as desired.
BEST Life: No referrals are required. Members may self-refer to any specialist they choose.
Blue Shield: For dental HMO plans, the general dentist completes a specialty care referral form and provides a copy to the member, who brings this to the participating specialist at the time of the appointment. Our average turnaround time for claims payment to the specialist after receipt of the claim is approximately six days. Our dental PPO plans do not require referrals.
Delta Dental: For PPO and Premier patients, specialty care referrals are not required, and payments to specialists are processed the same as for general dentists. For DHMO enrollees, preauthorizations for specialty care processed within five business days.
Dental Health Services: Emergency referrals are processed immediately. In a non-emergency situation, referrals are processed within one to two weeks. Claims are paid within two to three weeks.
Guardian: Referrals are not required under our PPO plans. For our DHMO plans, payment to the specialist is within 30 days of receipt of the claim.
Health Net Dental: The average turnaround time in processing a nonemergency referral is 48 hours and then 7-10 business days for the EOB to be received by the member. Once the claim is submitted by the specialist, our average turnaround time in processing is 10 business days of receipt and then 7-10 business days for specialists to receive payment in the mail. If claim was sent electronically, it will be sooner.
HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. The member gets a higher benefit when seeing a participating dentist and specialist. In 2013, 97% of claims were processed within 14 calendar days
Securian Dental: No referral is required.
United Concordia: All referrals are immediately effective. There is no requirement for specialty referrals to be pre-authorized by United Concordia. The member is instructed to provide the referral to the specialist at the time of service and the specialist files the referral with the claim. All claims, including specialist claims, mailed to United Concordia are usually processed within 14 days. Claims filed electronically are processed during the weekly cycle.
Western Dental: Emergency referrals are handled within 24-hours. The turnaround for non-emergency referrals is three business days. Specialists can expect payment in 10 business days for clean claims.
24. If you limit services with an annual or lifetime maximum, what does the maximum dollar amount allowed refer to?
Aetna: The maximum dollar amount refers to the total amount Aetna will pay for covered benefits.
Aflac: The annual maximum refers to the maximum amount of benefits that may be received within a policy year per covered person. Annual maximums do not apply to wellness and X-ray benefits.
Ameritas: The maximum is the total amount of dollars payable to a member under their policy during the specified plan year.
Anthem Blue Cross: Our Dental PPO plans have an annual maximum, which refers to the maximum dollar amount that will be paid by the plan in a calendar year. With Anthem Blue Cross Dental Net and Dental Select DHMO plans, there are no annual or lifetime maximums.
Assurant Dental Network: Our PPO plans have a variety of annual maximums.
BEN-E-LECT: The maximum dollar and lifetime maximum refers to all services and procedures unless specified otherwise by benefit.
BEST Life: Lifetime maximum applies to orthodontia benefits. We offer multiple choices of calendar year maximums for preventive, basic and major procedures.
Blue Shield: The “maximum” is the maximum amount paid for covered benefits under the plan. The dental HMO plans have no annual maximum or lifetime maximum.
Dental PPO annual plan maximums range from $1,000 to $2,000 and encompass all dental services received except orthodontics. Dental INO plans have a $2500 annual maximum. There are no lifetime maximums for dental PPO/INO plans. Orthodontia is offered to adults and children in many dental PPO plans as an additional benefit, which does not apply to the plan annual maximum. Group dental PPO/INO plans provide a generous calendar year orthodontic maximum of $1,000; there is no lifetime orthodontic maximum. Individual and family dental PPO plans offer low copayment and a two-year lifetime orthodonture benefit. Dental HMO plans have no annual maximum.
BRIGHTER: Services & claims payments actually utilized.
Cigna: DHMO – There is no annual or lifetime maximum.
DPPO/DEPO/Dental indemnity – The maximum dollar amount refers to the maximum amount payable by Cigna for covered services rendered.
Delta Dental: Under the fee-for-service plans, the maximum dollar amount refers to the maximum dollar amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums.
Dental Health Services: The majority of Dental Health Services’ prepaid (D-HMO) plan offerings have no annual dollar maximums, although this option isavailable by client request. PPO plan annual maximums range from $500 to $2000. Please call or email your broker advocate, and a client service manager will help you and your clients receive excellent, innovative and custom benefit programs that fit their needs.
Guardian: The maximum refers to the total of benefit dollars actually paidfor covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. With Preventive Advantage, only Basic and Major services count toward the annual maximum. We also offer an option to cover cleaning after the maximum is reached.
Health Net Dental: The maximum dollar amount is the total amount the plan will pay for covered benefits.
Humana Dental: Annual maximum refers to the maximum amount paid annually for services, excluding orthodontia. Orthodontic treatment has a lifetime maximum.
Principal Financial Group: The maximum dollar amount refers to benefits paid.
Securian Dental: The annual and lifetime maximum refer to the maximum dollar amounts we will pay for covered services in a calendar year (annual maximum) or over the coverage lifetime (lifetime maximum). Our plans generally include an annual maximum for non-orthodontic covered services and a separate lifetime maximum for orthodontia.
United Concordia: DHMO plans do not have annual or lifetime maximums. PPO plan annual and lifetime maximums vary by benefit plan and refer to the total amount paid in benefits by United Concordia annually or over the member’s lifetime.
Western Dental: The Series 7 DMO plans do not have an annual or lifetime maximum.
25. How and when do you provide eligibility information to your dental offices? How can you ensure that your offices will provide services to a member if they are not on the eligibility listing and it is after regular plan hours?
Aetna: Eligibility is available to our providers 24/7 by calling our automated telephone inquiry system or by accessing the online eligibility roster.
DMO providers receive eligibility rosters the first week of each month.
Aflac: Providers may verify eligibility online — aflac.com — or by calling Aflac’s customer service center at 1.800.99.AFLAC. Aflac Group does not require prequalification for treatment.
Ameritas: They will want to verify eligibility through our real time system. Our plans do not require preauthorization or mandated PPO network usage.
Anthem Blue Cross: Participating providers can confirm eligibility via our secure website 24/7. Also, our customer service representatives are available toll-free Monday through Friday from 5:00 a.m. to 5:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and receiving member complaints. An interactive voice response (IVR) system is also available to answer calls and provide information 24 hours a day, seven days a week.
Assurant Dental Network: Prepaid/DHMO eligibility is provided on a monthly basis. A call center is available during regular business hours for eligibility issues.
BEN-E-LECT: BEN-E-LECT provides electronic eligibility 24/7 through our Empowr web portal for providers and members. The Pre-Paid product will provide services upon collecting information from the member. This information will be transferred to BEN-E-LECT’s system electronically.
BEST Life: Providers can use our fax back eligibility system to determine if a member is eligible, outside of normal business hours. Offices routinely check eligibility prior to appointments and have a process in place for dealing with emergency situations.
Blue Shield: Eligibility lists for dental HMO plans are distributed to the dental HMO dental center during the 1st week of each month. Providers are responsible for contacting our customer service department to verify eligibility, if a member is not on their list. Our Interactive Voice Response (IVR) is available 24 hours, seven days a week and has the capability to verify eligibility and assign members.
Brighter: For every appointment scheduled via our online platform we are able to provide real-time eligibility information to the dental office prior to
treating the patient.
Cigna: Our dental health care professionals’ website, CignaforHCP.com, allows dentists to:
• verify members’ network participation and eligibility
• check members’ benefit information and details on their YTD accumulation toward maximums and deductibles
• view claim status
• enroll in EFT and receive payments faster
• access and download payment reports, office management reports and financial reports in a printable PDF format (DHMO)
• print forms – American Dental Association (ADA) claim, referral, and more
• download policy manuals including the general dentist dental office reference guide
• access patient charge schedule at-a-glance booklet (DHMO only)
• take continuing education courses at no charge (contracted health care professionals only)
• access information about the Cigna Network Rewards Program®
Delta Dental: Dental offices can verify eligibility by contacting Delta Dental via our website, calling our automated information line or speaking with a customer service representative. Under the fee-for-service plans, a patient who is not shown as eligible may be asked to pay the entire amount of the bill up front. The dental office would be responsible for refunding the patient their overpayment after receiving Delta Dental payment. Under the DHMO plans, in addition to verifying eligibility as listed above, network dentists also receive eligibility lists at the beginning of each month. If an enrollee is not contained in Delta Dental’s eligibility database and claims to be eligible for benefits, Delta Dental contacts the client or the client’s benefit administrator to verify eligibility. If the eligibility verification is for an enrollee who has urgent or emergency needs, our customer service representatives will extend an urgent care authorization.
Dental Health Services: Participating dental offices receive eligibility rosters twice a month. If immediate eligibility is needed at any time, the dental office can call Dental Health Services’ 24-hour automated eligibility verification system or check eligibility online through the company’s website.
Guardian: Dentists can use our online self-service website, GuardianAnytime.com or call our toll-free line and receive a faxed verification of benefits from 3:00 a.m. to 8:00 p.m., Monday through Friday and from 3:00 a.m. to 1:00 p.m. on Saturday, Pacific Time. Eligibility rosters for the DHMO plan are provided to the offices twice a month, at the first of the month and the 10th of the month. Dental Offices may also call our Member Services Department from 8:00 a.m. to 5:00 p.m. Monday through Friday.
Health Net Dental: Our DHMO dentists receive a monthly updated eligibility list that includes member name, member status (active, dropped, suspended or transferred), member ID number, dependent names and eligibility status, fee schedule code, group number and capitation amount, if applicable.
DPPO dentists do not receive an eligibility roster as members are not required to select a primary care general dentist. Members would simply choose any network dentist (or non-participating dentist, if they desire) and schedule an appointment. DPPO and DHMO dentists can verify eligibility information via our interactive voice response system and Web site, which are both accessible 24-hours a day, seven days a week. Because the IVR and Web site are available 24/7, eligibility can be verified anytime of the day regardless of whether the need occurs during business hours.
HumanaDental: Participating offices are encouraged to check eligibility before providing treatment. They can verify members and benefits by calling our toll-free customer service line or through our automated information line to get 24 hour-a-day, seven-day-a week eligibility verification. There are no eligibility rosters for PPO business.
Securian Dental: Dental offices can use a toll free number to call customer service to verify eligibility and benefits. Dental offices can also access www.securiandental.com to verify eligibility.
United Concordia: PPO dentists can verify eligibility at any time via our Dental Customer Service toll free number, or by using our online system, My Patients’ Benefits. Primary dental offices can verify DHMO members’ eligibility and benefit information 24 hours a day, 7 days a week through My Patients’ Benefits available online at UnitedConcordia.com or by using United Concordia’s IVR system, which can be accessed by dialing our toll free Dental Customer Service phone number at (866) 357-3304.
Western Dental: Western Dental provides eligibility listings to our staff model offices electronically and printed eligibility listings to our IPA Providers. This information is updated on the 1st and 15th of each month. For members who are not on the eligibility listing, we offer guaranteed capitation to our network of providers.
26. How do you handle early termination of coverage when a member is still in the middle of orthodontic treatment?
Aetna: We stop issuing our quarterly payments when the member is no longer covered.
Aflac: Benefits will cease upon termination of coverage.
Ameritas PPO: PPO provider discounts are determined using the treatment start date. Our PPO providers are contractually obligated to honor those discounts for any ongoing covered treatment under their plan.
Anthem Blue Cross: While details vary by plan, with our Dental Prime and Dental Complete programs, benefit payment is pro-rated based on the services completed.
Assurant Dental Network: Benefits are calculated to pay out through the period in which they will be banded, as long as they are still active members. If coverage terms in the middle of treatment, no additional benefits will be paid.
BEN-E-LECT: Payment for benefits will cease at the end of the month for which the termination became effective.
BEST Life: Coverage terminates at the end of the month in which a member is no longer eligible.
Blue Shield: Once the member’s coverage is terminated, the cost of treatment is the responsibility of the member.
BRIGHTER: We empower the employer, and their broker, to set their own policy for such situations and we pay claims accordingly.
Cigna: Coverage for a dental procedure that was started before disenrollment from the plan (crowns, root canal treatment, bridges, dentures, and partials if the teeth were fully prepared or the final impressions) will be extended for 90 days after disenrollment unless it was due to nonpayment of premiums. Coverage for orthodontic treatment which was started before disenrollment from the dental plan will be extended to the end of the quarter or for 60 days after disenrollment, unless it was due to nonpayment of premiums. Our standard DEPO/DPPO/Indemnity extension of coverage is 90 days; however, other arrangements can be made.
Delta Dental: Delta Dental’s obligation to pay toward orthodontic treatment terminates following the date the enrollee loses eligibility or upon termination of the client’s contract.
Dental Health Services: If a member’s coverage is terminated in the midst of orthodontic treatment, members are encouraged to participate in a COBRA individual plan that will allow them to retain orthodontic benefits. If the member chooses not to maintain his or her coverage, the dental office can prorate any additional treatment fees. The member would then only be responsible for the prorated amount of the full treatment cost.
Guardian: When an orthodontic appliance is inserted prior to the PPO member’s effective date, we will cover a portion of treatment. Based on the original treatment plan, we determine the portion of charges incurred by the member prior to being covered by our plan and deduct them from the total charges. Our payment is based on the remaining charges. We limit what we consider of the proposed treatment plan to the shorter of the proposed length of treatment, or two years from the date the orthodontic treatment started. Also, we enforce the plan’s orthodontic benefit maximum by reducing the total benefit that Guardian would pay by the amount paid by the prior carrier, if applicable. If a member is undergoing orthodontic treatment and his or her Guardian coverage terminates, we pro-rate the benefit to cover only the time period during which coverage was in force. We do not extend benefits. Our DHMO agreement provides for the contracted orthodontist to complete treatment at the contracted patient charge on a number of our plans. As an additional contract rider we can allow for supplemental transfer coverage for Orthodontia under our DHMO.
Health Net Dental: Upon termination of coverage, we will pay for orthodontic cases in progress on a prorated basis up to the last effective date of coverage. Benefits are no longer payable after the member terminates and are the responsibility of the member and/or the new dental carrier.
HumanaDental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.
Principal Financial Group: On individual terminations, most of our plans allow for extended benefits that provide one month of additional coverage.
Securian Dental: Benefits are paid based on the services received while the member was covered by Securian Dental.
United Concordia: The extension of orthodontic coverage for PPO plans is 60 days if payments are being made monthly. However, if payments are being made on a quarterly basis, coverage will be extended to the end of the quarter in progress or 60 days, whichever is later.
Western Dental: Western Dental has designed a termination clause to protect the member. The member does not incur any additional fees for the early termination of a provider.
27. How do you handle the additional cost of OSHA required infection control in your participating offices?
Aetna: These costs are a part of doing business.
Aflac: Since Aflac Group Dental doesn’t have network requirements, insureds can choose any dentist without restriction. It is the responsibility of
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