Understanding Primary and Secondary Dental Insurance Coverage and Coordination of Benefits

Understanding Primary and Secondary Dental Insurance Coverage and Coordination of Benefits

There are many insurance companies with versatile business plans to assist your patients with the required treatments. The goal is to provide dental coverage that can help patients book appointments in the treatment of choice. However, with so many insurance plans options, it becomes consequential for dental practitioners to have in-depth knowledge of each of them. Being well-versed with  insurance policies is a great asset.  It ensures clean claims submissions and procures payer eligibility, coverage, and bill for services.

What does Primary and Secondary Dental Insurance Coverage Means?

According to Delta Dental, the plan that covers you as an enrollee is the primary plan. Additionally, the insurance plan that provides coverage for treatment for the dependent enrollee is the secondary plan. Such insurance plans are also known as dual coverage- when patient treatment is secure by two or more than one dental insurance plan. However, having access to two dental insurance plans does not mean that your monetary coverage gets doubled. It has its limitations and unambiguously results that you will enjoy a lower out-of-pocket cost for your dental care. Once the primary plan covers the assigned expenses for the desired dental treatment, the secondary plan must pay an amount by the coordination of benefits provision. 

Below are the general guidelines: 

  • For adults, the primary carrier is the main policyholder through his or her employer. Your spouse or domestic partner dental plan is secondary. 
  • For dependent children, the birthday rule is to apply to determine the primary coverage. The parent whose birthday (month and day, not year) falls first in the year is the primary carrier. In the case of divorce or remarriage, dental insurance coverage is subject to the court. 
  • When an insurance holder has two jobs, and both provide dental insurance plans, the plan that covers the longest is primary. Practitioners need to determine which insurance plan is primary to eliminate ineligible claims as dual coverage depends on specific plan provisions. 

How Coordination of Benefits (COB) Work?

When a patient is entitled to dual coverage to fill the gaps, to eschew over-insurance or duplication of benefits on the treatment. Coordination of Benefits (COB) helps to maximize the healthcare coverage for the patients to undergo the necessary or desired treatments. Legally, Coordination of Benefits (COB) has a specific sequence. The claim first goes to the insurer, if  the primary plan does not cover the full amount of the treatment, then it is paid by the secondary plan. Below are the types of COB that determine how patient coverage gets settled to avoid dental claim denial. 

  • Traditional: If a plan has this COB policy, the payee will receive up to 100 percent of the total cost of treatment from a combination of the primary and the secondary carrier. 
  • Non-duplication COB: Under this type of coordination of benefits policy, the amount is carved-up between the primary and the secondary plan, subject to the amount paid by the primary policyholder. For instance, if both the primary and the secondary insurance plan covers 80% of the benefit, then the secondary plan will not pay anything additional for the treatment. However, if the primary pays 50% for the service, then the secondary would pay the difference. Considering an example, if the cleaning procedure is $95 and both primary and secondary covers at 80%, the primary will pay $76, and there will be no payment from secondary. The difference amount is $19 to be paid by the patient. 
  • Maintenance of Benefits (MOB): In this arrangement, the secondary plan pays less than it would have paid a fee-for-service under a traditional method. As a result, the patient has to share some of the out-of-pocket costs. In particular, this benefit reduces the insured amount paid by the primary carrier. It then applies the coinsurance and deductible eligibility criteria.
  • Carve-Out: Let us take a breather with this coordination method that first calculates the defined-benefit plan, and then subtract the amount paid by the primary carrier.

Therefore, by understanding the coordination of benefits, the health insurance companies plan to avoid errors. At the same time still, the patient holds the coverage that gets sanctioned. 

Codes of Filing Claims 

  • It is a mandate that all dental insurance billing claims for primary and secondary claims must be applied. 
  • As per the American Dental Association (ADA), it is necessary to submit your full fee for dental claims
  •  while filling the primary and the secondary insurance.Dental practitioners need to examine the Explanation of Benefits (EOB) forms to confirm that everything is under compliance for a lower denial rate over a clerical error. Following such processes can help dental practitioners to open doors for new patients and reap the best results with an effective RCM. 
  • Dental practitioners are recommended to store EOBs as per HIPAA compliant protocols for at least one year. In the case of a disputable claim, dental practitioners can hold EOBs for seven years. 
  • Standard fees and other lowest contracted fees such as PPO fees, or any other practice operating fee should never reveal  outgoing insurance claims. 

Following these steps, dental practitioners can achieve a high clean claim submissions ratio and avoid high claim denial. It will further lower the claim reimbursement turnaround time, and even manage more customers with fewer claims concerns. 

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