12. What percentage of your network is closed to new enrollment? How many offices does this represent?
Aetna: About 6% of DMO GP locations are closed to new enrollment.
Ameritas PPO: 117 Offices (1% of the panel) are closed to new enrollment.
Ameritas/FDH Network: None.
BEST Life: All participating PPO dentists are accepting new patients.
Blue Cross: All our dental PPO providers are accepting new patients.
Blue Shield: 4.9% of the locations in our DHMO network are closed to new enrollment and 4% of our DPPO network providers maintain closed practices.
CIGNA Dental: In California, the total number of network locations is 1,480. Of those, 1,314 are open to new membership. The DPPO network offices do not close to new membership.
Delta Dental: Our fee-for-service dentists do not close to new enrollment. The number of DHMO dental offices closed to new enrollment varies, but is generally less than 10%.
Dental Health Services: About 5% of network dentists are closed to new enrollment.
Golden West: About 4% of our DHMO panel offices are closed to new members. This represents about 168 offices.
GroupLink: N/A
Guardian: In California, 10 participating dentist offices are closed to new PPO patients, which represents .04% of our network.
Health Net Dental: DHMO: Fewer than 10% of general dentist offices are closed to new enrollment. The PPO network is accepting all new Health Net Dental members.
HumanaDental: Under HumanaDental's provider contract, participating dentists must schedule and treat members without discrimination, including benefit or payer differentials. Closed practices are not common because this is a fee-for-service reimbursement program.
MetLife: Nationally, 1% of our participating PPO dentists have requested that their names be removed from our PPO provider listing for purposes of not accepting new MetLife-eligible patients.
Principal Financial Group: Fewer than 1% of the offices participating in our network are closed to new enrollment.
SafeGuard: DHMO: Fewer than 10% of SafeGuard's general dentist offices are closed to new enrollment.
Securian Dental: Providers in the network serving Securian Dental are open to new patients.
United Concordia: 62 DHMO offices are closed to new enrollment. 95.4% of facilities are open to new patients.
Western Dental: Fewer than 2% of our network providers are closed to new enrollments, which is about 32 offices.
13. Do all of your contracted offices accept every benefit level that your company sells or can they to choose the programs with co-payments?
Aetna: All DMO offices accept all of our coinsurance and fixed co-payment plan designs.
Ameritas PPO: All offices accept all coverages, except if sold with the FDH PPO. The FDH PPO plans only can use the FDH panel.
BEST Life: All contracted offices accept every benefit level that BEST sells. 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 Cross: Blue Cross of California encourages all Dental Blue providers to accept all plans offered.
Blue Shield: Offices are not allowed to choose which plan designs they accept.
CIGNA Dental: All of our contracted offices are required to accept every benefit level as part of our network contracts.
Delta Dental: Delta Dental dentists contract for the programs they want to accept. All contracted fee-for-service dentists are required to accept all benefit programs sold by Delta Dental to group purchasers. While not all Premier dentists participate in PPO, PPO enrollees can visit any Delta Dental dentist and pay the co-payment appropriate to the dentistÕs level of participation. However, not all fee-for service dentists (Premier and PPO) contract with the DHMO (DeltaCare USA) plan. Contracted DHMO offices are required to accept all DHMO benefit levels.
Dental Health Services: All new dentists are contracted for all plans offered by Dental Health Services.
Golden West: Most of our DHMO panel offices accept all of our plans. However, they can choose plans in which to participate.
GroupLink: Our leased networks would track this.
Guardian: All contracted PPO offices accept all of our plan designs.
Health Net Dental: PPO and DHMO providers accept all plans.
HumanaDental: The PPO contract is for all network-based programs, excluding DHMO, which requires a separate agreement.
MetLife: All participating MetLife PPO dentists accept all of our plan designs..
Principal Financial Group: Providers can choose to participate in our PPO and EPO networks. Within each option, providers are obligated to accept all benefit levels sold by our company.
SafeGuard: When SafeGuard contracts with a dental-care provider, it is understood that the dentist will accept all DHMO plans. A few contracted dentists do not participate in some of the older custom plans. All SafeGuard-contracted offices accept all PPO/indemnity plans.
Securian Dental: Securian Dental's network dentists accept all of our benefit designs
United Concordia: An office that is open to new enrollment accepts all plans.
Western Dental: All our plans are accepted by the large majority of contacted providers.
14. Do monitor how long a patient waits in the doctor's office?
Aetna: A Semi-annual written survey is collected from all Calif. DMO GP's and specialists.
Ameritas PPO: Yes, each dentist gets an office evaluation worksheet along with the initial application. The office-wait time is questioned at that point. In addition, surveys are performed to address insureds' satisfaction with office wait times.
BEST Life: FDH monitors accessibility and wait times through its Customer Service and Provider Relations departments.
Blue Cross: Yes, we monitor this metric in our member satisfaction surveys. Issues such as wait times are logged and monitored through our complaint tracking process. We also monitor appointment wait times and emergency wait times through surveys conducted by our organization.
Blue Shield: Yes, we document member complaints on this issue in our customer service workbench and track them electronically until they are resolved. Our annual member satisfaction survey includes questions about wait times with our network offices.
CIGNA Dental: The network management team monitors wait times in our DHMO general dentist facilities via monthly telephone calls. We can also identify lengthy wait times through our patient-satisfaction surveys.
Delta Dental: Delta Dental conducts random enrollee surveys each quarter, which include questions about how long it takes the enrollee to schedule dentist appointments and other customer satisfaction issues. The appointment availability at DHMO offices is also monitored via regular office visits from a Delta Dental representative.
Dental Health Services: Yes, we conduct frequent member surveys and regular on-site dental office visits.
Golden West: Yes, access is measured through member-satisfaction surveys in addition to on-site reviews and word-of-mouth from our members.
GroupLink: Our leased networks would track it.
Guardian: We do not monitor appointment scheduling or wait times for the PPO plan. However, we send member satisfaction surveys every month to randomly chosen PPO members who have been to a network dentist within the previous 90 days. Surveys include questions about wait times.
Health Net Dental: Yes, wait times are monitored through random provider office surveys, member surveys, and call data collected from Member Services. Deficiencies are noted in the audit summary letter sent to the provider.
HumanaDental: We rely on member calls to keep us apprised of scheduling issues. Sometimes, the member is limiting their own options (for example, after 5:00 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.
MetLife: We monitor patient impressions of wait time through monthly satisfaction surveys. For 2006, 98% of surveyed plan participants were satisfied with wait time.
Principal Financial Group: We do not monitor this.
SafeGuard: For the DHMO, SafeGuard monitors time that patients wait in the reception area and the operatory through the quarterly accessibility survey and service visit reports by provider-relations representatives. We also track wait times through a monthly report and member-satisfaction survey. For the PPO, there is no monitoring of wait times for PPO dentists, but insureds get help if they are experiencing excessive wait times in any of our contracted offices.
Securian Dental: Securian Dental measures members' satisfaction with the network, but does not monitor office-wait times.
United Concordia: Yes, it is monitored through member surveys, a customer service grievance process, and periodic phone audits of the offices.
Western Dental: Western Dental monitors patient's wait 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 tracks measurable items, such as wait times.
15. Are there plenty of providers who stay open late and are open on Saturdays?
Aetna: Each dental office sets office hours.
Ameritas PPO: Yes.
Ameritas/FDH Network: Yes.
BEST Life: Yes, with more than 14,834 providers in the state, many have extended and flexible hours.
Blue Cross: Blue Cross of California offers the option of dental offices with varying hours of operation, but this is the choice of the individual dental practice.
Blue Shield: This varies by provider, but some do stay open late and are open on Saturdays.
CIGNA Dental: Yes, many offices offer evening and Saturday appointments.
Delta Dental: Our online dentist directory contains information on hours and access, including maps and languages spoken. Enrollees can call a toll-free number to request a list of dentists in their area with extended and Saturday hours. In addition to posting hours and access, DHMO network dentists are required to provide 24-hour emergency services to DeltaCare USA enrollees.
Dental Health Services: Many participating dental offices offer extended hours, including weekend hours.
Golden West: Yes, many of our providers offer evening and Saturday appointments. Our Member Services Department can help members with details.
GroupLink: Our leased networks would need to advise on such schedules.
Guardian: Yes, many PPO provider locations have extended or weekend hours.
Health Net Dental: Yes, most providers offer extended service hours.
HumanaDental: Office hours are not tracked.
MetLife: As part of MetLife's credentialing criteria, all participating MetLife PPO dentists must provide acceptable hours of service and have established emergency care and off-hour protocols.
Principal Financial Group: Members can see any provider of their choice, which can include those who have extended hours.
SafeGuard: For the DMHO, SafeGuard contracts with dental practitioners, many who have evening and Saturday hours. For the PPO/indemnity. The plan contracts with individual dental practitioners, many of whom have evening and Saturday hours.
Securian Dental: Yes, Securian Dental's network includes more than 73,000 dentist locations and plenty are open late and on Saturdays.
United Concordia: Providers in every market have extended hours.
Western Dental: Yes, many of our IPA providers have evening and Saturday hours. Most Western Dental Staff Model Offices are open from 9:00 a.m. to 8:00 p.m., Monday through Friday and 8:00 a.m. to 4:00 p.m. on Saturdays.
16. With respect to your mid-range benefit level, what amount of capitation is paid to the general dentist? Do you offer validation for these amounts?
Aetna: This is proprietary information.
Ameritas: For the PPO and the FDH Networks, no capitation is paid to PPO providers.
BEST Life: We do not compensate our providers through capitation. Our indemnity and PPO plans allow patients to utilize providers of their choice.
Blue Cross: This is proprietary information.
Blue Shield: This is proprietary information.
CIGNA Dental: This is proprietary information.
Delta Dental: Delta Dental Premier and Delta Dental PPO are fee-for-service programs and are not capitated. For the DHMO plan, amounts vary by plan design and employer contribution. Groups can validate these amounts through standard group reports if they meet minimum enrollment requirements.
Dental Health Services: This is proprietary information.
Golden West: This is proprietary information.
GroupLink: We are not a DHMO, so this is not applicable.
Guardian: It is not applicable to the PPO dental products Guardian offers in California.
Health Net Dental: The plan pays a specified flat amount of capitation per plan. Amounts are confidential. The Advantage DHMO plans augment dentistÕs compensation by paying supplemental payments on frequently utilized services in addition to standard capitation.
HumanaDental: Managed dental care capitation varies by plan schedule and geographic location.
MetLife: N/A
Principal Financial Group: N/A
SafeGuard: DHMO: This is proprietary information. Capitation for DHMO plans is set actuarially by plan design. Capitation is augmented by supplemental payments for certain procedures. In addition, the plan pays fees for each member visit. There is no capitation with PPO/indemnity plans.
Securian Dental: All Securian Dental plans are fee-for-service. Capitation does not apply.
United Concordia: This is proprietary information. Our DHMO dentists get supplemental reimbursements in addition to monthly capitation payments
Western Dental: We pay the dentist a dollar amount for each plan. The amount varies by plan.
17. Are there incentives for the provider to be thorough?
Aetna: Quality assurance programs are designed to protect members and providers.
Ameritas PPO: Yes, a utilization review is performed quarterly. If standards are not met, the provider could be terminated from the plan.
Ameritas/FDH Network: N/A
BEST Life: FDH administers comprehensive utilizations reviews for dental necessity and appropriateness of care.
Blue Cross: Dentists cannot increase their revenue through incentive programs. When deemed necessary and appropriate, supplemental payments may be made to participating dentists. However, these payments are not part of any bonus or incentive program.
Blue Shield: Appropriate care provided by dentists in our networks is measured continuously through numerous oversight mechanisms. While dentists carry out routine treatment plans without prospective review, our dental consultants evaluate more complicated treatments. They assess the proposed treatments for appropriateness and benefit determination. All dentists involved in our review process are fully licensed. Our clinicians are also 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). Our dental consultants select a random sample of each dentist's records to review. Necessary recommendations are made to any dentists who do not meet our quality standards and follow-up audits are conducted to verify that corrective action has been taken.
CIGNA Dental: Our Integrated Quality Management Program drives quality and better outcomes across our entire network. While we do not provide incentives, we expect providers in our networks to meet professionally recognized standards of care.
Delta Dental: There are no financial incentives because Delta Dental's contract requires a dentist to be thorough and to deliver quality healthcare. Delta Dental monitors dentists' performance through enrollee complaints, on-site quality assessment surveys, and dental office reviews conducted by licensed dentists. Monitoring is based on our utilization management system.
Dental Health Services: Our supplemental payments and rigorous Quality Assurance program are designed as incentives to provide appropriate and thorough care.
Golden West: Yes, referrals to plan specialists are not charged back to the general dentist. On-site visits by quality assurance and provider relation representatives help ensure that panel dental offices meet quality assurance standards.
GroupLink: This is usually asked in context of a DHMO arrangement. Providers under our programs are paid based on a fee-for-service basis or a negotiated fee schedule.
Guardian: Our PPO fee schedules and plan provisions are adequate to encourage proper care. We do not offer incentives. Guardian requires participating dentists to treat PPO members the same as they would any other patients. We investigate all quality of care complaints from members.
Health Net Dental: No
HumanaDental: Fee-for-service reimbursement encourages thorough treatment. Our Quality Assurance Department reviews member complaints through our standard grievance process.
MetLife: Our participating provider contracts require providers to furnish appropriate services. There is no payment to dentists based on the number of covered plan participants they serve (for example, reimbursement is on a fee-for-service, not a capitated basis). Claims are considered for reimbursement based on generally accepted standards of dental care.
Principal Financial Group: Being thorough is an expectation. We do not provide incentives to meet expectations. All providers in our networks or those we might recommend must meet strict credentialing requirements. This means they have all been reviewed independently and found to have proper professional credentials and a verified history of responsible billings. However, a member is free to choose any provider.
SafeGuard: There are no monetary incentives to dentists, but they are expected to perform in accordance with the high standards of competence, care, and concern for the welfare and needs of SafeGuard enrollees and in accordance with the Principles of Ethics of the American Dental Association and California law.
Securian Dental: While Securian Dental regularly monitors providersÕ practice patterns, our philosophy is that the dentist and patient are in the best position to determine a treatment plan that is best suited to the patient. The dentist does not have an incentive to under-treat since all of our plans are fee-for-service.
United Concordia: Participating DHMO primary dentists get supplemental reimbursement on most highly utilized procedures in addition to monthly capitation and member co-payments.
Western Dental: Western Dental Services Inc. may pay the dentist a bonus based exceeding minimum 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?
Aetna: Yes.
Ameritas PPO/FDH Networks: Yes, all specialists are considered for claim reimbursement.
BEST Life: Yes, specialists are covered at full contract benefits as described in our Indemnity and PPO plan certificates. Our orthodontic plan is available for all of our PPO and Indemnity plans.
Blue Cross: Yes, specialist coverage is a benefit for the Dental Blue PPO plan, but referrals are not required. Dental Blue contracted dentists are credentialed providers. In addition, our contracted specialists, such as oral surgeons, periodontists, and endodontists participate in all three Dental Blue networks. For the Dental Net DHMO plans, Blue Cross of California provides coverage for referrals to specialists including, orthodontists, oral surgeons, endodontists, periodontists, and pedodonists (for children under 5).
Blue Shield: Yes.
CIGNA Dental: Coverage is provided for periodontic, endodontic, oral surgery, pediatric dentistry, and orthodontic specialty referrals for DHMO plans. Our DPPO/DEPO and dental indemnity plans do not require specialty referrals.
Delta Dental: Fee-for-service enrollees can visit any licensed dentist. Referrals are not required for specialty care. Enrollees are advised to confer with their general dentist to determine if specialty care is needed and if itÕs covered by their benefit plan. Delta Dental recommends that the enrollee ask the dentist to submit a predetermination request to Delta Dental if the treatment plan is complicated or expensive. This eliminates that guesswork about allowable costs and out-of-pocket expenses. For DHMO patients, referrals to specialists are not charged back against the dentistsÕ capitation payments. As a result, general dentists are not discouraged from making specialty referrals when necessary. However, while prosthodontic procedures performed by the general dentist are covered, services from a prosthodontic specialist are not covered under the DHMO plan. Group coverage levels and the groupÕs contractual agreement determine coverage for other specialist procedures.
Dental Health Services: Our plans provide specialty coverage for endodontics, periodontics, oral surgery, pedodontics, and orthodontics.
Golden West: Yes, our DHMO and PPO plans include coverage for most specialists.
GroupLink: N/A.
Guardian: Specialty care referrals are not required under GuardianÕs PPO plans. Members can get treatment from any specialist without advance approval. We provide coverage for all types of specialist dentists in the PPO network, including orthodontists if the memberÕs plan has orthodontia benefits.
Health Net Dental: Yes, all of our plans include specialty benefits.
Humana Dental: Members can be referred to in-network specialists and out-of-network specialists, depending on the accessibility of the appropriate specialist in his or her area.
MetLife: Our PPO product does not require referrals for specialist care. All claims for services by licensed dental practitioners are considered for reimbursement based on the participant's plan design.
Principal Financial Group: Generally yes.
SafeGuard: For the DHMO, plans cover endodontics, periodontics, oral surgery, pedodontics, and orthodontics. For the PPO/indemnity, insureds can self-refer to any endodontic, periodontic, oral surgery, pedodontics, or orthodontic specialist. Using the specialist listed in our directory will result in reduced fees.
Securian Dental: Securian Dental does not require referrals for any of its services. All specialists are paid based on the dental benefit contract.
United Concordia: Yes.
Western Dental: Specialty coverage is available in all 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, GPs may directly refer to a participating specialist based on published guidelines. Indemnity and PPO plans have direct access for specialty services.
Ameritas PPO/FDH Networks: Specialist referrals are allowed any time from our general dentists.
BEST Life: No referral is necessary. Insureds can visit a specialist at any time.
Blue Cross: Blue Cross of California PPO plans use a pre-treatment and post-treatment professional review to monitor referral activity. In-house dental consultants, who are licensed dentists, perform all professional reviews. Under the Dental Blue PPO contract, pre-treatment review is recommended for procedures in excess of $350. For the Dental Net DHMO, referrals that do not include the high-risk procedures are reviewed post-treatment. Using the Direct Referral program, the participating general dentist may refer a patient to a specialist without prior authorization. The dentistsÕ practice patterns have been scrutinized to ensure that they share in our commitment to providing quality healthcare. For the Dental Net DHMO products, the member's assigned general dentist may call the customer service hotline to get an immediate authorization for emergency services.
Blue Shield: The general dentist completes a specialty care referral form. The dentist also gives a copy to the DHMO member who brings it to the participating specialist at the time of the appointment. DPPO members may self refer to a specialist.
CIGNA Dental: DPPO plans do not require referrals. General dentists are not required to act as gatekeepers. For DHMO plans, general dentists act as gatekeeper for all specialty services except pediatrics (up to age seven) and orthodontic network dentists. For members under age seven, referrals are not needed for orthodontia or to visit a network pediatric dentist. General dentists refer members to network specialty care providers as deemed necessary. CIGNA Dental works directly with the specialists for preauthorization and direct payment when appropriate.
Delta Dental: Fee-for-service enrollees can self-refer. A referral by the general dentist isnÕt required. The general dentist must submit documentation for review and approval for DHMO patients. Approvals are returned to the dentist, who directs the enrollee to the appropriate specialist. In an emergency, the general dentist may call Delta Dental with the request.
Dental Health Services: The 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 eligible to get appropriate care from a specialist.
Golden West: The general dentist can self refer the member to a specialist without getting prior approval from the plan.
GroupLink: The general dentist can refer to any specialist.
Guardian: We do not require referrals to specialists under our dental PPO plans.
Health Net Dental: If the general dentist determines that the necessary services are out of their scope of practice, they simply submit a referral request to the plan for approval. This process is outlined in detail in the specialty referral guidelines sent to each network provider.
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.
MetLife: Our PPO product does not require referrals for specialist care.
Principal Financial Group: Patients can choose any provider in the network. Referrals are not required.
Safe Guard: For the DHMO, SafeGuard has plans with standard referral, direct referral, and self-referral. Each plan is created with a specialty process. SafeGuard standard plans include direct referral, which allows general dentists to refer directly to contracted specialists. They also include standard referral, which requires approval by SafeGuard for pedodontics and orthodontics only. Discounted specialty plans allow members to self-refer to contracted specialists. Orthodontia can be self-referred on the discounted specialty plans, but needs a referral from SafeGuard for the Preventive Plus and standard DHMO plans. For the PPO, all participants may self-refer to contracted specialists.
Securian Dental: Securian Dental members can see any specialist without prior authorization or a referral.
United Concordia: DHMO plan members must coordinate all care through their primary dental office, including referrals to specialists. However, no preauthorization on referral review is required. This allows the referral process for all specialty services to be completed immediately.
Western Dental: Once the general dentist determines that the necessary procedure is out of their scope, the office submits a written referral request to our plan. Western DentalÕs dental director 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?
Aetna: Yes.
Ameritas PPO: Yes, all are board eligible or certified and are monitored during the PPO credentialing process.
Ameritas/FDH Network: Yes.
BEST Life: Our contracted network, FDH, contracts with board-certified specialists.
Blue Cross: All contracted specialists with Blue Cross California must be board certified or board eligible.
Blue Shield: Yes, it varies by specialist.
CIGNA Dental: Yes.
Delta Dental: Yes, under state law, all specialists must be board certified or eligible.
Dental Health Services: Almost all of our participating specialists are board certified or eligible.
Golden West: Yes, all contracted specialists must be board-certified or eligible.
GroupLink: Yes, but leased networks would need to advise on detail.
Guardian: Yes, many of our PPO specialists are board certified or eligible, but it is not a requirement for participation in the DentalGuard Preferred PPO network.
Health Net Dental: Yes, all contracting specialists are board board-certified or eligible.
HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates.
MetLife: To participate in the MetLife PPO, specialists must submit and keep any certifications and other factors necessary to maintain their specialty. Specialists are listed as such in our various provider listings.
Principal Financial Group: Yes, all specialists must be board eligible, board certified or be a designated specialist by the ADA.
SafeGuard: All contracting specialists are board certified or eligible.
Securian Dental: Yes, Securian Dental's network includes board-certified or eligible specialists.
United Concordia: Yes, the majority of our specialists are board certified or eligible.
Western Dental: All contracted specialists are board certified or eligible.
21. How do you fund your specialty care?
Aetna: Specialty services are paid through the claim system on a fee-for-service basis.
Ameritas PPO/FDH Networks: Specialty care claims are paid out of the same claims reserve that is established for the groupÕs general dentist claims. All are funded out of the premium charged to each group.
BEST Life: Our PPO and indemnity plans do not require special funding arrangements for specialty care.
Blue Cross: PPO and DHMO specialty care is paid through claims processed according to the provider's fee schedule.
Blue Shield: Specialty care is paid on a fee for service basis for DHMO and DPPOs. Member and plan co-payments will vary, depending on the plan.
CIGNA Dental: DHMO and PPO specialists are compensated similarly through discounted fee-for-service, which is paid from a portion of collected premiums.
Delta Dental: Specialty care is built into the premium. Specialists are reimbursed with a combination of co-payments paid by the covered enrollee and maximum plan allowances by procedure (pre-contracted fees between Delta Dental and dentists).
Dental Health Services: Specialty care and treatment is paid for on a contracted basis. Payment varies by procedure. These costs are built into each plan's monthly premium rate.
Golden West: A percentage of sold premiums is allocated for specialty care.
GroupLink: N/A
Guardian: The plan is not required to fund the specialty care because our PPO specialists are paid on a fee-for-service basis. For the DHMO, specialty dentists are reimbursed based on a predetermined fixed fee schedule. On standard plans, the member never pays more than the applicable co-payment, if any, for any covered service provided by the member's selected provider or referred specialist. Funding of specialty care is done through the monthly fees paid on behalf of the subscriber. Specialty PPO dentists are reimbursed based on a predetermined fixed fee schedule. Funding is provided through the premium payment made on the insuredÕs behalf.
HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit.
MetLife: N/A
Principal Financial Group: Through normal plan provisions.
SafeGuard: For the DHMO, specialty dentists are reimbursed based on a predetermined fixed fee schedule. On standard plans, the member never pays more than the applicable co-payment, if any, for any covered service provided by the member's selected provider or referred specialist. SafeGuard does have plans with a discounted specialty care feature. The member gets a 25% reduction from the specialistÕs usual and customary fee. Funding of specialty care is done through the monthly fees paid on the subscriberÕs behalf. Specialty PPO dentists are reimbursed based on a predetermined fixed fee schedule.
Securian Dental: Specialty care is funded on a fee-for-service basis.
United Concordia: Specialists agree to accept an amount per procedure as payment in full. If the memberÕs co-payment is less than the guaranteed amount, the plan will reimburse the specialist the difference between the negotiated fee and the member co-payment.
Western Dental: We incorporate into our rates what we expect specialty care claims to be. We then pay the claims based on dental necessity and plan guidelines.
22. Can the member self refer or does the member have to be referred by the primary dentist to the orthodontist?
Aetna: All members may self-refer to an orthodontist. DMO and Vital Savings members must choose a participating orthodontist.
Ameritas PPO/FDH Networks: Insureds can self-refer.
BEST Life: No referral is necessary on our PPO or Indemnity plans.
Blue Cross: Members enrolled in the Blue Cross of California Dental Blue PPO program can self refer. Members can seek services from a network specialist to get the full savings advantage of their benefits. There is no paperwork since the member goes directly to the specialist. Once the specialist performs an evaluation, they may submit a pre-treatment estimate. Upon consent of the member, they may perform the needed procedures without submitting a pre-treatment estimate. Members who enroll in the 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 may refer the patient directly to the specialist without prior authorization.
Blue Shield: For DHMO 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. PPO plan members may self refer.
CIGNA Dental: DPPO/ DEPO and dental indemnity plans do not require referrals to visit a specialist. A new enhancement for our DHMO plans is the removal of the referral requirement for a member to see a network orthodontist.
Delta Dental: Enrollees may self-refer. For DHMO plans, the enrollee may self-refer only to a contracted DHMO orthodontist.
Dental Health Services: Members must get a referral from one of our network dentists before visiting a participating orthodontist.
Golden West: The member can self refer to the panel orthodontist office.
GroupLink: Members can self refer.
Guardian: PPO members can self-refer to all types of specialty care, including orthodontia. For the DHMO, orthodontia needs a referral from Health Net Dental PPO/indemnity: Insureds can self-refer to any contracted orthodontist.
HumanaDental: In our PPO, the member can self-refer to an orthodontist.
MetLife: Our PPO product does not require referrals for specialty or orthodontic care, so participants can self-refer.
Principal Financial Group: A member can seek services from any provider.
SafeGuard: For the DHMO, orthodontia can be self-referred on the discounted specialty plans. But a referral is required from SafeGuard for all other DHMO plans. For the PPO/indemnity, insureds can self-refer to any contracted orthodontist.
Securian Dental: Securian Dental does not require referrals for any of its covered benefits including orthodontia.
United Concordia: Under our DHMO plans, the primary dentist determines if a specialty referral is required, regardless of the specialty. Our PPO plans allow members to self-refer.
Western Dental: The member must 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. How long does it take to process a referral in terms of member notification and payment to the specialist?
Aetna: DMO GPs usually give the member an immediate referral. Specialty payments are made upon receipt and adjudication of the claim. Reimbursement checks are mailed weekly.
Ameritas: N/A
BEST Life: Our average claims-payment time is less than five days. Check our agent Website (www.besthealthplans.com) for weekly stats.
Blue Cross: With Blue Cross of California PPO plans, the member can self-refer, so there is no time frame. Our PPO plans do not require referrals to specialists. Members can go directly to any PPO specialist without any referrals.
Blue Shield: For DHMO 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. After receiving the claim, our average turnaround time is about six days for claims payment to the specialist.
CIGNA Dental: Typical turnaround time for specialty referrals is five days for preauthorization and five days for payments on our DHMO.
Delta Dental: Specialty care referrals are not required for fee-for-service patients. Payments to specialists are processed the same as for general dentists. In 2006, the average time for processing all claims was five days. For DHMO enrollees, 2006 specialty care referrals were processed within an average of 5.7 business days, and specialists were paid within an average 5.3 business days.
Dental Healt Services: Emergency referrals are processed immediately. Referrals are processed within one to two weeks in a non-emergency situation. Claims are paid within two to three weeks.
Golden West: The general dentist provides a real-time referral to the specialist. Plan approval is not required.
GroupLink: N/A
Guardian: Referrals are not required under our PPO plans.
Health Net Dental: The referral time is generally five business days. The time for payment depends on the receipt of bill from dentists. Payment is generally made within 20 business days.
HumanaDental: Most HumanaDental plans do not require a referral from a general dentist to a specialist. A member gets a higher benefit when seeing a participating dentist and specialist. HumanaDental guarantees that 89% of claims and referrals will be processed within 14 calendar days.
MetLife: N/A
Principal Financial Group: N/A
SafeGuard: For the DHMO, standard referrals are processed in an average of five business days for member notification and 30 business days for payment to the provider. PPO/indemnity insureds can self-refer to any specialist. Clean claims are processed within 15 business days of receipt.
Securian Dental: Securian Dental does not require referrals.
United Concordia: All referrals are effective immediately. 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 mailed to United Concordia, including specialist claims, are usually processed within14 days. Claims filed electronically through Xpress Claim are processed for payment immediately unless a review of an x-ray or other document is required. For urgent or emergency care when traveling outside the PDOÕs treatment area, members can call Customer Service for an immediate authorization code to submit with the claim. Members who submit emergency care claims without an authorization code will get a rejection notice, but they can contact Customer Service, supply the required information, and have the payment authorized immediately.
Western Dental: Emergency referrals are handled within 24 hours. Turnaround is three business days for non-emergency referrals. Turnaround is 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 total amount Aetna will pay for covered benefits.
Ameritas PPO/FDH Networks: The maximum dollar amount of paid claims for which a covered individual can qualify.
BEST Life: BEST Life offers multiple choices of calendar year maximums for basic and major procedures.
Blue Cross: The maximum dollar amount allowed by the plan. The maximum dollar amount is contractually determined and defined.
Blue Shield: DPPO annual plan maximums range from $1,000 to $2,000 and are based on the amount paid by the plan. DPPO orthodontic calendar maximums are $1,000. We do not have lifetime orthodontic maximums. The DHMO has no annual maximum.
CIGNA Dental: There is no annual or lifetime maximum for the DHMO. For DPPO/DEPO/dental indemnity, the maximum dollar amount refers to the maximum amount payable by CIGNA for covered services rendered.
Delta Dental: The maximum dollar amount refers to the maximum amount paid by the plan. Our DHMO plans do not have annual or lifetime maximums, except for the accidental injury provision.
Dental Health Services: The majority of our prepaid plan offerings have no annual dollar maximums, although this option is available by client request. PPO plan annual maximums range from $500 to $2,000.
Golden West: The maximum dollar amount is the total amount paid by the plan.
GroupLink: It is the maximum out-of-pocket benefit a patient would get.
Guardian: We don't limit access to services. The maximum refers to the total of benefit dollars paid for covered services incurred within the annual period or the member's lifetime in the case of orthodontia. Participating PPO dentists cannot charge more than the fee schedule amount for services that are on the fee schedule even when members have been reimbursed up to the plan annual or lifetime maximum.
Health Net Dental: It is the maximum allowable benefit amount that Health Net Dental reimburses for that service and period after the deductible. (PPO and indemnity plans).
Humana Dental: It is the maximum amount paid annually for basic and major services. Orthodontic treatment has a lifetime maximum.
MetLife: Access to services is never limited by annual or lifetime maximums. These maximums affect only the total annual reimbursement amount available under a plan to an individual or family.
Principal Financial Group: The maximum dollar amount refers to benefits paid.
SafeGuard: For the DHMO, there are no calendar or lifetime maximums as part of DHMO plans. Each PPO/indemnity plan has a calendar-year maximum as part of the benefit. The employee and all enrolled dependents are allowed up to that amount in treatment during the calendar year. If a plan has orthodontia, a lifetime maximum is the amount identified within the benefit summary. That total amount would be paid towards ortho treatment under the plan.
Securian Dental: The amount Securian Dental will pay for benefits per member.
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 that United Concordia pays in benefits annually or over the member's lifetime.
Western Dental: The DMO plans do not have an annual or lifetime maximum.
25. How and when do you provide eligibility information to your dental offices? How do you make sure that your offices provide services to a member after regular plan hours if they are not on the eligibility list?
Aetna: We send a monthly roster to each DMO dental office. Eligibility for all of our dental plans is also available through online resources and through Aetna Voice Advantage (24/7 speech recognition technology).
Ameritas: Our system is real time with eligibility so providers can access membership. Our plans do not require pre-authorization or mandated PPO usage.
BEST Life: Providers can use BEST LifeÕs fax back eligibility system outside of normal business hours to determine if a member is eligible. Offices routinely check eligibility before appointments and have a process for dealing with emergencies.
Blue Cross: Our customer service representatives help members locate network providers, verify provider status and member eligibility, answer claim questions, quote plan benefits, and mediate member complaints for resolution. An interactive voice response (IVR) system is available to answer calls 24 hours a day, seven days a week. Through the IVR, members and providers can get eligibility and benefit information (voiced or faxed), claim status information, hours of operation, and Web site addresses. Members can also request ID cards through the IVR.
Blue Shield: Eligibility lists for DHMO plans are distributed to the DHMO dental center by the 15th of the month. Providers are responsible for contacting our customer service department to verify eligibility if a member is not on their list. Our IVR, which is available 24 hours a day, seven days can verify eligibility and assign members.
CIGNA Dental: Eligibility information is available online through our secure provider portal (24 hours a day and seven days a week except maintenance). In addition, eligibility information is sent to our DHMO general dentists on a monthly basis. The general dentist can also call the plan for automated verification for a member who is assigned to a particular office, but is not on the eligibility list. This automated system will fax the dentist a written confirmation of eligibility. There is no eligibility listing given to DPPO providers. Members can seek treatment from any DPPO network dentist at any time. A DPPO dentist can check the provider portal or call our member services toll-free number to verify a member's participation in the plan.
Delta Dental: Eligibility and benefit information is available through a secure area of our Website. Automated toll-free telephone and fax services for dentists and enrollees provide information on benefit levels, co-payments, deductibles, and maximums. Dentists can call Delta DentalÕs customer service department for the most information about enrollee eligibility. Eligibility for DHMO enrollees is provided twice a month. Upon request from a dental office, Delta Dental will call in or fax DHMO eligibility verification to the dentist during business hours. After hours, the plan covers emergency pain relief for eligible enrollees. Eligibility and benefit information is also available on our Website. In rare instances, a patient who is eligible, but not on the dentistÕs eligibility list will be asked to pay the entire bill up front and the plan will reimburse them (minus applicable co-payment).
Dental Health Services: Participating dental offices get eligibility rosters twice a month. To get immediate eligibility at any time, the dental office can call our 24-hour automated eligibility verification system or check eligibility on our Website.
Golden West: Eligibility is provided on a monthly basis to prepaid providers. Eligibility lists are available in electronic format if the dental office selects this method of notification. A customer service representative can also phone or fax in member eligibility. An emergency phone number is available 24 hours a day, seven days a week.
GroupLink: Automated eligibility is available. A fax-back system is accessible 24 hours a day, seven days a week via an 800 number.
Guardian: We do not provide eligibility lists for the PPO plan. Dentists can call our toll-free line to get 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.
Health Net Dental: Monthly rosters are mailed to the DHMO providers. In addition, a dentist can confirm eligibility by calling Member Services during business hours, by touch-tone phone 24 hours a day, or through an interactive Website.
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.
MetLife: MetLife developed a multi-channel technology platform for customer service inquiries including Web, fax, or phone. Through dedicated, real-time channels, dentists have access to the same plan information provided to employees at the time of service. Employees are not required to have ID cards due to our instant access services mentioned above. Dental offices do have access to dedicated online and automated phone system benefit information services to verify eligibility and plan details at any time.
Principal Financial Group: The maximum dollar amount refers to benefits paid.
SafeGuard: Eligibility data is forwarded once a month to each contracted DHMO dentist. A dentist can confirm eligibility by calling Member Services during business hours, by touch-tone phone 24 hours a day, or through our interactive Website.
Securian Dental: Members have an ID card indicating their coverage plan and a toll-free phone number the provider can call if they need further evidence of coverage.
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 memberÕs lifetime.
Western Dental: Western Dental provides eligibility listings to our Staff Model Offices electronically and 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: Quarterly claim payments cease upon the member termination.
Ameritas PPO: PPO provider discounts are determined with the treatment start date. Any ongoing treatment associated with the already started plan will get the discount.
Ameritas/FDH Network: FDH is not involved with plan designs or eligibility/benefit information.
BEST Life: Coverage terminates at the end of the month the member is no longer eligible.
Blue Cross: Blue Cross of California's contract with Dental Blue PPO participating dentists requires the dentist to complete work-in-progress in the event of contract termination.
Blue Shield: Once the member's coverage is terminated, the cost of treatment is the responsibility of the member.
CIGNA Dental: Terminated DHMO members are covered for services through the end of the month of their termination.
Delta Dental: The enrollee's coverage ends when the contract terminates. Payments for fee-for-service orthodontic services will be pro-rated based on the remaining treatments. A DHMO enrollee is responsible for the balance due up to a maximum amount defined in the benefit level. The contract orthodontist prorates the amount over the number of months remaining in the initial 24 months of treatment and the enrollee makes payments based on an arrangement with the contract orthodontist.
Dental Health Services: We encourage the member to participate in a COBRA individual plan to retain orthodontic benefits. If the member chooses not to maintain their coverage, the dental office may prorate any additional treatment fees. The member would then be responsible for only the prorated amount for completing treatment.
Golden West: In most cases, the member pays a pro-rated amount for the remaining time of treatment. The amount is pro-rated over the number of months to treatment completion.
GroupLink: Benefits end on the day coverage is terminated.
Guardian: When an orthodontic appliance is inserted before the member's effective date, we will cover a portion of treatment. Based on the original treatment plan, we deduct the portion of charges the member incurred before being covered by our plan from the total charges. What we pay 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 when their Guardian coverage terminates, we pro-rate the benefit to cover only the period during which coverage was in force. We do not extend benefits.
Health Net Dental: The member can remain with the orthodontist, but will not be eligible for any benefits. Most often, the orthodontist will honor the original co-payment arrangement.
Humana Dental: HumanaDental will prorate to provide the appropriate amount given during the time the member was in the plan.
MetLife: Benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant gets continuation of coverage. In that case, benefits would continue as long as coverage remains in effect.
Principal Financial Group: On individual terminations, some of our plans allow for extended benefits that provide one month of additional coverage.
SafeGuard: For the DHMO, member who is receiving orthodontic treatment is responsible for any additional incurred charges on any remaining treatment. For the PPO/indemnity, orthodontia benefits terminate when coverage ends.
Securian Dental: Securian Dental pays in advance. When Securian pays the six-month payment, we are actually paying through to the 12-month payment. The 12-month payment is for the rest of the treatment.
United Concordia: The extension of orthodontic coverage for DHMO and PPO plans is 60 days if payments are made monthly. However, if payments are 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: We consider these costs to be part of the office overhead.
Ameritas PPO/FDH Networks: All paid procedures are based on the CDT codes. Inflation control is not a covered procedure. We strongly advise our providers to include this in their cost for all procedures.
BEST Life: OSHA costs are the provider's responsibility.
Blue Cross: We have an independent contractor relationship with network providers. We are not involved with how dentists run their offices.
Blue Shield: Our DHMO plans include a $5 sterilization fee, which the member pays.
CIGNA Dental: For the DHMO, the plan pays the dentist an encounter fee on the member's behalf to help offset their added cost for OSHA-required infection control. Each time a member visits the general dentist, the office submits an encounter form to plan, telling us which patient they saw and which procedures were performed. We pay the dentist a fixed dollar amount for each encounter form we get. They may apply it towards OSHA-required infection control. As a side note, this process enables us to collect utilization data.
Delta Dental: The cost is included in regular dental office overhead. The dentist may not charge any additional cost to the enrollee or the plan.
Dental Health Services: The combination of member co-payments, supplemental co-payments, and capitation is designed to help cover costs associated with operating a dental office including OSHA infection control measures.
Golden West: It is at the dentist's discretion.
GroupLink: N/A
Guardian: Most dentists have incorporated the cost of OSHA requirements into the fees for services and do not charge separately. If the office policy is to charge separately for OSHA, we do not restrict or limit the fee as long as all patients are charged, not just the PPO patients. Since there is no CDT/ADA code for OSHA, Guardian plans do not cover such charges.
Health Net Dental: Each contracted office is responsible for meeting such guidelines. Health Net Dental does not allow providers to pass this charge to our members. Offices report compliance with OSHA guidelines through our periodic audits.
HumanaDental: Most offices have incorporated the cost of OSHA-required infection control into their service charges. These costs would be reflected in the data used to compile fee schedules. ItÕs not usually a separate billable expense.
MetLife: Infection control procedures and costs are included in the charges submitted for payment by the dentist, similar to all office overhead expenses.
Principal Financial Group: N/A
SafeGuard: SafeGuard contracted offices do not charge an additional fee for OSHA-required infection control.
Securian Dental: Securian Dental's administrative fees cover the cost of any additional OSHA required infection control practices.
United Concordia: Our progressive reimbursement programs are designed to ensure that dentists are appropriately compensated for OSHA costs and other procedures.
Western Dental: Western Dental handles the additional cost of infection control in its rates and does not charge a co-payment.
28. Do you provide utilization data to your clients and brokers?
Aetna: Yes, reports are available for most groups with at least 150 employees enrolled in the PPO plan.
Ameritas: Depending on the type of plan funding and the level of information, utilization data is available with HIPAA requirements.
BEST Life: We provide utilization information for larger groups.
Blue Cross: Yes, Blue Cross of California provides a complete standard utilization reporting package for dental plans. The packages are also adapted to accommodate the reporting of a clientÕs dental experience
Blue Shield: Yes, it is available at renewal upon request for employer groups of 300 or more.
CIGNA Dental: Yes, utilization data is provided when requested.
Delta Dental: Yes, Delta Dental provides utilization data to client groups and brokers in accordance with state laws. The plan does not disclose any personally identifiable information. We do not disclose information at the enrollee level.
Dental Health Services: Upon client or broker request, we provide a wide range of utilization reporting, including treatment access, specialty claims activity, and member service call activity.
Golden West: Yes, utilization data is available to groups and brokers.
GroupLink: Yes, at renewal if requested. It is only provided in summary formats based on new HIPAA standards. Individual private health information would not be provided on a routine basis unless we got a release from the employee to do so.
Guardian: Yes, our standard reports area available monthly, quarterly or annually. They include the following: paid versus submitted charges showing 13 components of savings, PPO savings, PPO usage in-network versus out-of-network, monthly summary reports, dental charges and payments by category, and turnaround time for dental claims.
Health Net Dental: Yes, upon request for employer groups with 251 employees or more.
Humana Dental: We do so on request.
MetLife: If requested, brokers get utilization data as part of a proposal situation. Clients have online access to their utilization data any time through MetLink, our automated benefits administration Website. Utilization and other plan level data are also provided to clients during renewal meetings.
Principal Financial Group: Yes, upon the client or brokerÕs request.
SafeGuard: Yes
Securian Dental: Yes, Securian Dental provides utilization data to large clients and brokers.
United Concordia: Yes.
Western Dental: Yes, utilization data can be provided upon request to clients and brokers for large accounts.
29. Please provide contact information for your company
