From the Summer 2018 Journal of the Colorado Dental Association
Take this quick quiz to see how well you know Colorado’s new non-covered services law, passed in 2017.
Scenario 1:
William Smith comes into your dental office and has a need for a crown. William is covered by a limited ABC Dental plan that covers only exams, diagnostic services, cleanings and basic restorative procedures (fillings and extractions). Will’s specific patient plan does not ever cover crowns, though as a provider you accept other ABC plans that do cover crowns. What fee can you charge William for the crown?
- I must bill the insurer contracted rate
- I can bill my usual and customary fee
- Either A or B may apply (depends on the insurance plan)
Scenario 1 Correct Answer:
B. With the non-covered services bill, the key distinction is what services are covered (paid for) by the particular patient’s individual plan, not by other plans you accept by the same carrier.
Scenario 2:
Mary Diaz comes into your dental office to be fitted for a denture. Mary is covered by a People’s Choice Dental plan, which has a $1,500 annual maximum. Mary’s plan would cover her denture, but she has already met her plan’s annual maximum with extractions and oral surgery required to prepare her mouth for the denture. Can you bill Mary your usual and customary fee to provide the denture?
- Yes
- No
- Depends on your contract terms with the carrier
Scenario 2 Correct Answer:
B. The non-covered services bill does not apply if the carrier would pay for the services if the patient had not already met the annual maximum (or lifetime maximum or waiting periods). If the dental plan would pay you as a carrier for the service if performed on the first day of your patient’s plan, then the service is not subject to the non-covered services bill. In most cases, you are obligated to bill the patient the insurer contracted rate, though your contractual obligations (provider agreement with the carrier) will ultimately dictate how you must bill the service.
Scenario 3:
Jane Johnson comes into your dental office and needs three fillings. Jane is covered by a MediBest Dental PPO dental plan, which covers fillings—but downcodes to pay the amalgam rate for composite fillings. Jane has composite fillings placed and MediBest Dental PPO pays the amalgam filling rate to your office. Can you bill Jane for the difference in fees?
- Yes
- No
- Depends on your contract terms with the carrier
Scenario 3 Correct Answer:
B. If the dental plan pays for an “alternative benefit” (such as an amalgam filling instead of a composite filling), the treatment is considered a “covered service” for purpose of the law and the dentist must charge only the dental plan’s contracted rate.
Scenario 4:
Chris Williams comes into your office for an implant. Chris is covered by an employer sponsored, multi-state dental plan through MetroPlus Dental. Chris’ plan does not include any coverage for implants. What fee can you charge Chris for the crown?
- I must bill the insurer contracted rate
- I can bill my usual and customary fee
- Either A or B may apply (depends on the insurance plan)
Scenario 4 Correct Answer:
C. Technically, the non-covered services bill only applies to Colorado state regulated plans, which include about 100-150 individual, small group, large group and employer sponsored plans each year. Most well-recognized dental carriers offer at least one state regulated dental plan. To avoid confusion, a number of major dental carriers have amended their provider contracts to allow Colorado dentists to bill their usual and customary fee for any non-covered service, regardless of whether the plan is Colorado state regulated or not. However, carriers are only obligated to honor the non-covered services bill for Colorado state regulated plans (as that is the jurisdictional limit of the Colorado state legislature). For plans that are not state regulated (often federally regulated ERISA plans), dentists must review their provider contracts or check with the carrier to determine whether they may bill their usual and customary fee.
Scenario 5:
Lindy Brown comes into your office for an exam and cleaning. Due to her fear of dental procedures, she needs some nitrous oxide to tolerate the procedure. Lindy is covered by an Acceptable Choice Dental plan, which sometimes covers nitrous oxide after prior authorization. Though prior authorization was sought, Lindy’s plan did not authorize and declined to pay for nitrous oxide for her current treatment plan. What fee can you charge Lindy for the nitrous oxide used during her procedure?
- I must bill the insurer contracted rate
- I can bill my usual and customary fee
- Either A or B may apply (depends on the insurance plan)
Scenario 5 Correct Answer:
B. The non-covered services law requires that the person’s policy actually covers and provides payment for the service (in an amount that is reasonable and not nominal or de minimis) in order for the carrier to set the fee for the service.
Scenario 6:
George Rodriguez comes into your office for an exam and cleaning. George is covered by a SafeCo Dental plan that has a $250 deductible. Due to the plan’s high deductible, the plan does not actually pay anything for George’s visit, though the services would have been covered benefits if his deductible had been met. What fee can you charge George for his visit?
- I must bill the insurer contracted rate
- I can bill my usual and customary fee
- Either A or B may apply (depends on the insurance plan)
Scenario 6 Correct Answer:
A. The non-covered services bill does not apply if the carrier would pay for the services if the patient’s deductible, copayment or coinsurance had already been met. In most cases, you are obligated to bill the patient the insurer contracted rate, though your contractual obligations (provider agreement with the carrier) will ultimately dictate how you must bill the service.
Scenario 7:
Anthony Johnson comes into your dental office for an exam and cleaning. Anthony is covered by a Savers Dental plan, which covers only two cleanings per year. Anthony would like to have a third cleaning performed, but a third cleaning is not covered by his plan. Can you bill Anthony your usual and customary fee to provide a third cleaning?
- Yes
- No
- Depends on your contract terms with the carrier
Scenario 7 Correct Answer:
B. The non-covered services bill does not apply if the carrier would pay for the services if the patient had not already exhausted the number of allowed services (frequency limitations). If the dental plan would pay you as a carrier for the service if performed on the first day of your patient’s plan, then the service is not subject to the non-covered services bill. In most cases, you are obligated to bill the patient the insurer contracted rate, though your contractual obligations (provider agreement with the carrier) will ultimately dictate how you must bill the service.
Scenario 8:
Alexa Jones comes into your dental office and needs a crown. Alexa is covered by a Colorado Plus dental plan, which does not cover crowns. Your typical fee for the crown is $3, but Alexa’s crown case is complex, and her insurance company has not been reimbursing you well for her other procedures. Can you bill Alexa $5 for the crown?
- Yes
- No
- Depends on your contract terms with the carrier
Scenario 8 Correct Answer:
B. No. You may bill the patient “in any amount determined by the dentist and agreed to by the patient that is equal to, or less than, the usual and customary amount that the dentist charges individuals who do not have coverage” for that CDT code.
Please note that this quiz is intended to help dental offices better understand common applications of Colorado’s non-covered services bill but is not intended to serve as legal advice. If you need guidance on a non-covered services question in your office, we encourage you to contact a qualified Colorado attorney.