12 dental benefit terms new dentists should know

Bundling? Downcoding? Least expensive alternative treatment?

The world of dental benefits can seem like it comes with its own language, and learning the terms can feel like cramming for a vocabulary test — a test dentists need to ace to resolve issues that arise during claim adjudication.

The American Dental Association offers a full glossary of dental benefit and other administrative terms at ADA.org/CDT. Below are 12 terms from that glossary that dentists should know.

• Alternate benefit: A provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed.

• Audit: An examination of records or accounts to check their accuracy; a post-treatment record review or clinical examination to verify information reported on claims.

• Bundling of procedures: The systematic combining of distinct dental procedure codes by third-party payers that results in a reduced benefit for the patient/beneficiary.

• Downcoding: A third-party payer claim adjudication process that uses a procedure code that is different from the one reported on the claim so that the reimbursement amount is less than would be allowed for the submitted code.

• Employment Retirement Income Security Act, or ERISA: A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and welfare benefit programs. To date, self-funded health benefit plans operating under ERISA are exempt from most state insurance laws, although courts have held that states can regulate the medical care provided under such plans, including by requiring mandatory review of adverse HMO determinations.

• Hold harmless clause: A contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in contracts between dental benefit organizations and an individual dentist and contracts between dental benefit organizations and a group plan sponsor.

• Inappropriate fee discounting practice: An intentional practice that forces a dentist who does not have a participating provider agreement to accept discounted fees or be bound by the terms and conditions set forth in the participating provider contract. Some examples include issuing reimbursement checks that result in the dentist accepting the amount as payment in full upon signing and using claim forms that require the dentist to accept the terms of the plan’s contract upon signing.

• Least expensive alternative treatment: Contractual language that allows a plan to pay only for the least expensive treatment if there is more than one way to treat a condition.

• Most favored nation clause: Contractual language that requires a dentist to give the beneficiaries of a dental plan the same lower fee the dentist may have charged another patient.

• Nonduplication of benefits: One of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid.

• Prompt payment laws: Also known as fair claims practice regulations, these laws are enacted state by state and set standards for the prompt, fair and equitable settlements of insurance claims by requiring that a set amount of interest be paid on “clean claims” that are paid beyond the established time frame. “Clean claims” are claims that are submitted to a payer on its standard claim form using current procedural codes and information sufficient to adjudicate the claims in accordance with the payer’s published filing requirements.

• Waiting period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for a given benefit.