CDA Member Insurance Reform Survey Definitions

Molly PereiraUncategorized

The CDA cares about dental access and barriers to care, and we want your help as we plan for our future legislative policy initiatives.

Please take the 2024 CDA Member Insurance Reform Survey based on your experience, however, we encourage you to consult with your office or practice manager to best identify the barrier that your dental practice/clinic faces.

For the purpose of this survey, dental insurance refers to non-publicly funded (“private”) insurance coverage. For more information on terms and definitions, please see the below information

This information will be used to help set our future policy priorities. The survey will close on Friday, Feb. 23, 2024.

Survey Term Definitions:

Annual Maximum Coverage Amount: An annual maximum is the maximum dollar amount a patient’s dental insurance will pay toward the cost of dental services and/or treatment in a benefit plan year, typically a 12-month period. Each time a dental claim is submitted, the dental insurance provider subtracts the cost that they have paid for the service from the patient’s maximum.

Provider Reimbursement Rate Benchmark: A benchmark is a point of reference that serves as a basis for evaluation or from which a measurement may be made. Provider reimbursement rates vary widely based on geography, insurance contracts and carriers, etc. Establishing a benchmark standard for provider reimbursement rates can support providers and patients by providing data for the amounts charged by providers and amounts allowed for reimbursement by payors.

Credentialing: Insurance credentialing is the process of becoming affiliated with insurance companies. Insurers are typically not mandated to complete provider credentialling within a specified time after receiving a provider application.

Prior Authorization / Predetermination: Prior authorization and predetermination are processes that payers make available to dentists to clearly determine the potential benefits for a specific patient.

Assignment of Benefits: Assignment of benefits means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract, or dental services plan.

Downcoding and Bundling: Downcoding is when dental plans use a procedure code different from the one submitted to determine a benefit in an amount less than would be allowed for the submitted code. Bundling is the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit.

Least Expensive Alternative Treatment: Dentists’ fees for services not covered by plans are often capped by insurers, and a dental plan may not allow benefits for all treatment options. A least expensive alternative treatment (LEAT) provision is a limitation found in many plans which reduces benefits to the least expensive of other possible treatment options as determined by the benefit plan design.

Provider Network Leasing: Provider Network Leasing is when third-parties gain access to participating dental provider contracts, sometimes without full disclosure of the agreement provided to the dentist in a timely fashion, and a lack of transparency regarding how the dentist may “opt out” of network leases.

Clean Claim: A clean claim has all procedures properly coded with accurate demographic and carrier information, as well as any necessary documentation.