Welcome to Part III of California Broker’s 2008 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. Read the responses and sell accordingly.

19. If covered, explain the process that allows the general dentist to refer to the specialist.

Aetna: For DMO plans, GPs 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.
Ameritas PPO and the FDH Networks: Specialist referrals are allowed any time from our general dentists. For the Dental Net DHMO plans, Anthem Blue Cross provides coverage for referrals to specialists, such as orthodontists, oral surgeons, endodontists, periodontists, and pedodonists (for children under five).
Anthem Blue Cross: With PPO dental plans, there is no formal process for general dentist to refer to a specialist, but Anthem Blue Cross PPO dental plans use pre-treatment and post-treatment professional review to monitor referral activity. In-house dental consultants (licensed dentists) perform all professional review. Under the Dental Blue PPO contract, pre-treatment review is recommended for procedures in over $350. Members can also self-refer to specialists with our PPO dental plans. 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 can refer a patient to a specialist without prior authorization. Dentists’ practice patterns have been scrutinized 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.
BEST Life: No referral is necessary. Insureds can visit a specialist
any time.
Blue Shield: The general dentist completes a specialty care referral form and provides a copy to the DHMO member. The member brings it to the participating specialist at the time of the appointment. DPPO members can self refer to a specialist
CIGNA Dental: DPPO plans do not require referrals and 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. Referrals are not needed for orthodontia or for individuals under age seven 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; referral by the general dentist isn’t required. For DHMO patients, the general dentist must submit documentation for review and approval. Approvals are returned to the dentist who directs the enrollee to the appropriate specialist. In an emergency, the general dentist can 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 now 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: Under our dental PPO plans, we do not require referrals to specialists. For the DHMO plan, any complex treatment requiring the skills of a dental specialist may be referred to a participating specialist dentist upon written approval. When the general dentist identifies the need for a referral, a specialty referral form is completed and submitted to us for review. After review, the general dentist, specialist, and member are notified of the determination.
Health Net Dental: Our PPO product does not require referrals for specialist care. For DHMO, standard plans employ a mix of direct referral (allowing general dentists to refer directly to contracted specialists), and standard referral (requiring approval by Health Net Dental, for pedodontics and orthodontics only).
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. For DHMO, standard plans employ a mix of direct referral (allowing general dentists to refer directly to contracted specialists), and standard referral (requiring approval by SafeGuard, a MetLife Company, for pedodontics and orthodontics only).
Principal Financial Group: Patients can choose any provider in the network; referrals are not required.
Securian Dental: No referral is required.
United Concordia: Although DHMO plan members must coordinate all care through their primary dental office, including referrals to specialists, no preauthorization on referral review is required, allowing 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 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?

Aetna: Yes, but we do not require specialists to be board certified to participate in our networks. Specialists must have completed residency training in an American Dental Association (ADA) accredited program for the specialty they represent. General dentists must have graduated from an accredited dental school and be licensed in the state in which they practice.
Ameritas PPO: Yes, all are board eligible or certified and are monitored during the PPO credentialing process.
Ameritas/FDH Network: Yes.
Anthem Blue Cross: All contracted specialists with Anthem Blue Cross must be board certified/board eligible.
BEST Life: Our contracted network, FDH, contracts with board-certified specialists.
Blue Shield: Yes, this 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 eligible/certified.
Golden West: Yes, all contracted specialists must be board-eligible/certified.
GroupLink: Yes, but leased
Guardian: Yes, many of our PPO specialists are board certified or eligible and all of the DHMO specialists are board eligible.
Health Net Dental: In order to participate with the PPO or DHMO, specialists must submit and keep any certifications and other factors necessary to maintain their specialty.
HumanaDental: All participating specialists must provide copies of their specialty licenses or residency certificates.
MetLife: In order to participate with the PPO or DHMO, specialists must submit and keep any certifications and other factors necessary to maintain their specialty.
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, the majority of our specialists are board eligible/certified.
Western Dental: All contracted specialists are board eligible/certified.

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 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. All are funded out of the premium charged to each group.
Anthem Blue Cross: The PPO and DHMO specialty care is paid through claims processed according to the provider’s fee schedule.
BEST Life: Our PPO and indemnity plans do not require special funding arrangements for specialty care.
Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member. The member brings it to the participating specialist at the time of the appointment. PPO plan members can self refer.
CIGNA Dental: DHMO and PPO specialists are compensated similarly through discounted fee-for-service, which is paid from a portion of the overall collected premiums.
Delta Dental: Specialty care is built into the premium. Specialists are reimbursed by a combination of maximum plan allowances by procedure (pre-contracted fees between Delta Dental and dentists) and co-payments paid by the covered enrollee.
Dental Health Services: Specialty care and treatment is paid for on a contracted basis and payment varies by procedure. These costs are built into each plan’s monthly premium rate.
Golden West: A percentage of sold premium is allocated for specialty care.
GroupLink: N/A
Guardian: Because our PPO specialists are paid on a fee-for-service basis, the plan is not required to fund the specialty care. For our DHMO plans, specialty care is funded through a portion of premium.
Health Net Dental: For DHMO, specialists 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.
HumanaDental: Specialists are paid on a fee-for-service basis according to a contracted fee-schedule amount or by reimbursement limit.
MetLife: For the DHMO, specialists are reimbursed based on a pre-determined fixed fee schedule. On standard plans, the member never pays more than the applicable copayment, if any, for any covered service provided by the member’s selected provider or referred specialist.
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: Specialists agree to accept an amount per procedure as payment in full. If the member’s copayment is less than the guaranteed amount, the plan will reimburse the specialist the difference between the negotiated fee and the member copayment.
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: All members can self-refer to an orthodontist. DMO members must choose a participating orthodontist.
Ameritas PPO and the FDH Networks: Insureds can self-refer.
Anthem Blue Cross: Members enrolled in the Anthem Blue Cross Dental Blue PPO program can self-refer. Members can seek services from a network specialist to realize the full cost savings advantage of their benefits. There is no paperwork involved since the member goes directly to the specialist. Once the specialist has performed an evaluation, they can submit a pre-treatment estimate, or on consent of the member, can perform the needed procedures without submitting a pre-treatment estimate. The same is true for our traditional Prudent Buyer dental PPO plans. Members enroll 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.
BEST Life: No referral is necessary on our PPO or indemnity plans.
CIGNA Dental: DPPO/DEPO and dental indemnity plans do not require referrals to visit a specialist. Our DHMO plans do not require members to get a referral to see a network orthodontist.
Delta Dental: Enrollees can self-refer. For DHMO plans, the enrollee can 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. General dentists in our DHMO network will refer the member to a participating orthodontist
Health Net Dental: Our PPO product does not require referrals for specialty or orthodontic care, so participants can self-refer. For DHMO, orthodontia needs a referral.
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. For DHMO, orthodontia needs a referral.
Principal Financial Group: A member can choose to seek services
from any provider.
Securian Dental: The member can self-refer.
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 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 GP’s usually provide a member with an immediate referral. Specialty payments are made on receipt and adjudication of the claim. Our goal is to process 90% of all claims within 15 calendar days. Reimbursement checks are mailed weekly.
Ameritas: N/A
Anthem Blue Cross: With Anthem Blue Cross PPO plans, the member can self-refer, so there is no timeframe. Our PPO plans do not require referrals to specialists. Members can go directly to any PPO specialist without any referrals. 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.
BEST Life: We have an average claims-payment time of less than four days. (Check our agent website: www.besthealthplans.com for weekly stats.)
Blue Shield: For DHMO plans, the general dentist completes a specialty care referral form and provides a copy to the member. The member brings it 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 about six days.
CIGNA Dental: Typical turnaround time for specialty referrals is five days for preauthorization and five days for payments on our DHMO.
Delta Dental: For fee-for-service patients, specialty care referrals are not required and payments to specialists are processed the same as for general dentists. In 2007, the average time for processing all claims was 5.3 days. For DHMO enrollees, 2007 specialty care referrals were processed within an average of 6 business days and specialists were paid within an average 4.6 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.
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. For our DHMO plans, payment to the specialist is within 30 days of receipt of the claim.
Health Net Dental: For DHMO, standard referrals are processed in an average of five business days for member notification and 14 business days for payment to the provider.
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. HumanaDental guarantees that 89% of claims and referrals will be processed within 14 calendar days.
MetLife: For DHMO, standard referrals are processed in an average of five business days for member notification and 14 business days for payment to the provider.
Principal Financial Group: N/A
Securian Dental: No referral is required.
United Concordia: All referrals are immediately effective. 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 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. If the referral in question is for urgent or emergency care when traveling outside the PDO’s treatment area, members can call Customer Service for an immediate authorization code to submit with the claim. Members submitting emergency care claims without an authorization code will get a rejection notice, but can contact Customer Service, supply the required information and have the payment immediately authorized.
Western Dental: Emergency referrals are handled within 24-hours. 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 total amount Aetna will pay for covered benefits.
Ameritas PPO and the FDH Networks: The maximum dollar amount of paid claims for which a covered individual can qualify.
Anthem Blue Cross: With Anthem Blue Cross PPO plans, the maximum dollar amount allowed refers to the amount allowed by the plan. With Anthem Blue Cross Dental Net DHMO plans, there are no annual or lifetime maximums.
BEST Life: Lifetime maximum applies to orthodontia benefits. BEST Life offers multiple choices of calendar year maximums for Preventive, basic and major procedures.
CIGNA Dental: For DHMO: There is no annual or lifetime maximum;
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 actually paid for covered services incurred within the annual period, or the member’s lifetime in the case of orthodontia. Participating PPO dentists can charge no more than the fee schedule amount for services on the fee schedule even when members have been reimbursed up to the plan annual or lifetime maximum.
Health Net Dental: For PPO, maximums affect only the total annual reimbursement amount available under a plan to an individual or family. For DHMO, there are no calendar or lifetime maximums.
HumanaDental: It is the maximum amount paid annually for basic and major services. Orthodontic treatment has a lifetime maximum.
MetLife: For PPO, maximums affect only the total annual reimbursement amount available under a plan to an individual or family. It does not limit access to our negotiated fees for services after the maximum is exceeded. For DHMO, there are no calendar or lifetime maximums as part of DHMO plans.
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: We send a monthly roster the first week of the month. Members in our DMO and DPPO plan and our Vital Savings program get ID cards that can be used to identify their eligibility.
Ameritas: Our system is real time with eligibility so providers are able to access membership. Our plans do not require preauthorization or mandated PPO usage.
Anthem Blue Cross: Our customer service representatives are available Monday through Friday from 5:00 a.m. to 7:00 p.m. (PST) to help members with locating network providers, verifying provider status, member eligibility, answering claim questions, quoting plan benefits, and mediating member complaints for resolution. An interactive voice response (IVR) system is also 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), and claim status information, hours of operation, and web site addresses. Members can also request ID cards through the IVR.
BEST Life: Providers can use BEST Life’s fax back eligibility system to determine if a member is eligible, outside of normal business hours. Offices routinely check eligibility before appointments and have a process in place for dealing with emergency situations.
Blue Shield: Eligibility lists for DHMO plans are distributed to the DHMO 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.
CIGNA Dental: Providers can view eligibility information in real time by visiting our secure provider website (24/7, 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. If a DPPO dentist wants to verify a member’s participation in the plan, they can check the provider portal or call our Member Services toll-free number.
Delta Dental: Eligibility and benefit information is available through a secure area of our Website. Delta Dental also automated toll-free telephone and facsimile services for dentists and enrollees, which provide information on benefit levels, co-payments, deductibles, and maximums. Dentists can call Delta Dental’s customer service department directly for the most information about enrollee eligibility. Eligibility for DHMO enrollees is provided twice a month. On 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 web site. In rare instances, a patient who is not on the dentist’s eligibility list, but is eligible, will be asked to pay the entire bill up front and the plan will reimburse them (less applicable co-payment).
Dental Health Services: Participating dental offices get eligibility rosters twice a month. If immediate eligibility is needed at any time, the dental office can call our 24-hour automated eligibility verification system or check eligibility online through our website.
Golden West: Eligibility is provided on a monthly basis to the 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. The plan maintains a 24/7 emergency phone number for after-hour emergencies.
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 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 8:00a.m. to 5:00p.m. Monday through Friday.
Health Net Dental: For PPO, dentists have a multi-channel platform to confirm eligibility by calling Customer Services by phone or through the Internet. For the DHMO, in addition to the options for PPO, eligibility data is forwarded once a month to each contracted DHMO dentist.
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: For PPO, MetLife has 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. Dental offices do have access to dedicated online and automated phone system benefit information services to verify eligibility and plan details at any time. For DHMO, eligibility data is forwarded once a month to each contracted DHMO dentist. As with the PPO, DHMO dentists have a multi-channel platform to confirm eligibility by calling Customer Services, by phone, or through the Internet. Transactions are processed in real-time except when the systems are undergoing scheduled or unscheduled maintenance or interruption.
Principal Financial Group: N/A
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: Dentists can access member eligibility and benefit information, 24/7, online through My Patients’ Benefits, or toll-free using United Concordia’s IVR system. DHMO providers also get printed eligibility rosters twice a month.
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: Quarterly claim payments cease on 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.
Anthem Blue Cross: Anthem Blue Cross’ contract with Dental Blue PPO participating dentists includes a provision that requires the dentist to complete work-in-progress in the event of contract termination.
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.
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 will prorate the amount over the number of months remaining in the initial 24 months of treatment, and the enrollee will make payments based on an arrangement with the contract orthodontist.
Dental Health Services: If a member’s coverage is terminated in the middle of orthodontic treatment, we encourage the member to participate in a COBRA individual plan that will allow the member to retain orthodontic benefits. If the member chooses not to maintain their coverage, the dental office can prorate any additional treatment fees. The member would then be responsible for only the prorated amount for completing their treatment.
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 determine the portion of charges incurred by the member before being covered by our plan, and deduct them 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 and their Guardian coverage terminates. We limit the benefit to cover only the period in which coverage was in force. We do not extend benefits.
Health Net Dental: Benefit consideration for orthodontic treatment will cease within the month that coverage terminates unless the participant gets continuation of coverage, in which case benefits would continue as long as coverage remains in effect.
HumanaDental: 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 which 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.
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 DHMO and PPO plans is 60 days if payments are being made monthly. However, 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?

Ameritas PPO and the 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.
Aetna: We consider these costs to be part of the office overhead.
Anthem Blue Cross: Our relationship with network providers is an independent contractor relationship. We are not, directly or in any manner, involved with how participating dentists run their offices.
BEST Life: OSHA costs are the responsibility of the provider.
Blue Shield: Our DHMO plans include a $5 sterilization fee, which is paid by the member.
CIGNA Dental: DHMO -- The plan pays an encounter fee to the dentist on behalf of the member 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. For each encounter form we get, we pay the dentist a fixed dollar amount, which they can apply towards OSHA-required infection control. As a side note, this process enables us to collect credible utilization data.
Delta Dental: The cost is included in regular dental office overhead. The dentist can not charge any additional cost back to the enrollee or to the plan.
Dental Health Services: The combination of member copayments, supplemental copayments, and capitation is designed to help cover costs associated with operating a dental office including necessary additional costs such as OSHA required infection control measures.
Golden West: It is at the discretion of the dentist.
GroupLink: N/A
Guardian: Most dentists have incorporated the cost of OSHA requirements into the fees for services and do not charge separately. If it is the office policy to charge separately for OSHA, we do not restrict or limit the fee as long as all patients, not just the PPO patients, are charged. Since there is no CDT/ADA code for OSHA, Guardian plans do not cover such charges and we do not allow participating DHMO offices to charge additional fees for this.
Health Net Dental: Each contracted provider office is responsible for meeting such guidelines and is considered part of their general overhead expenses. Health Net Dental does not allow providers to directly pass this charge onto our members. Offices report compliance with OSHA guidelines through our periodic audits.
HumanaDental: Most offices have incorpoated the cost of OSHA-required infection control in their overall service charges. These costs would be reflected in the data used to compile fee schedules. It’s not usually a separate billable expense.
MetLife: Most dentists include these charges as part of their general overhead expenses, which in turn, are part of the fees submitted to MetLife and SafeGuard, a MetLife Company. MetLife and SafeGuard use these fees as the basis for reasonable and customary data and for determining PPO or DHMO provider fee schedules, as appropriate.
Principal Financial Group: N/A
Securian Dental: The dentist must be in compliance with OSHA required standards including:
1. Meeting OSHA guidelines for hazardous material disposal including sharps.
2. Meeting all state and local requirements for safety and health. The participating office would absorb any costs associated with fulfilling this requirement.
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?

Ameritas: Depending on the type of plan funding and the level of information, utilization data is available in conjunction with HIPAA requirements.
Aetna: Yes. DMO -- We can provide a DMO Utilization and Retail Value Report, which provides the number and retail value of services (by type of service), annually at no additional charge. An additional charge can apply for more frequent reporting. DPPO - E.Plan Sponsor Monitor reports are available for most groups with at least 100 employees enrolled in the PPO plan.
Anthem Blue Cross: Yes, Anthem Blue Cross provides a complete standard utilization, reporting package for dental plans. The packages are also adapted to accommodate the reporting of a client’s dental experience
BEST Life: We will provide utilization information for larger groups.
Blue Shield: Yes. This is available on request for employer groups of 300 or more employees at renewal.
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: We provide a wide range of utilization reporting, including treatment access, specialty claims activity, and member service call activity on client or broker request.
Golden West: Yes, utilization data is available to groups and brokers.
GroupLink: Yes, at renewel 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 bases unless we got a specific release from the employee to do so.
Guardian: Yes, our standard reports are available monthly, quarterly or annually. They detail(a) paid vs. submitted charges showing 13 components of savings; (b) PPO savings; (c) PPO usage In-Network vs. Out-of-Network; (d) monthly summary report; (e) dental charges and payments by category; and (f) dental claim turnaround time.
Health Net Dental: Brokers are provided utilization data, if requested, as part of a proposal situation. Clients have online access to their utilization data or can be provided on request.
HumanaDental: We do, on request.
MetLife: Brokers are provided utilization data, if requested as part of a proposal situation. Clients have online access to their utilization data or can be provided on request.
Principal Financial Group: Yes, based on the request of the client and broker.
Securian Dental: Yes, we can provide this information to individually rated employer groups upon request.
United Concordia: Yes.
Western Dental: Yes utilization data can be provided on request to clients and brokers for large accounts.

Dental Survey Part I
Dental Survey Part II