Dual coverage:
Coordinating claims submission
and claims processing tips
DeltaPremier and DPO
When a patient is covered
by both Delta Dental Insurance Company's DeltaPremier
program and DeltaPreferred Option (DPO - Delta's
PPO program), submit only one claim form to
Delta. Include both subscribers' names
and social security or identification numbers
on the claim. If
the DeltaPremier group is primary, Delta's initial
payment will usually be based on the dentist's
filed fees for services covered under the DeltaPremier
group. Secondary payment will be calculated on
the DPO allowances. If DPO is primary, payment
will be based on the DPO allowances for both coverages.
DeltaPremier and PPO (with another
carrier)
When the PPO program is
provided by a carrier other than Delta, and this
coverage is primary, send the claim to the other
carrier first. Then, submit the claim, including
the amount paid by the primary carrier, to Delta.
The PPO fees agreed upon with the other carrier
are the fees that should be entered on the claim that is submitted to Delta.
DeltaPremier or DPO and HMO/capitation
A patient may be covered
by both DeltaPremier or DPO and a prepaid dental
plan. Determine which coverage is prime and which
is secondary using the same guidelines as for
all other dual coverage cases. If DeltaPremier
or DPO is primary, enter the dual coverage information
and your fees on the claim and submit it to Delta.
If you are a participating dentist in the HMO/capitation
plan, and if the prepaid dental plan is primary,
the portion of your usual fees covered by the
HMO must be entered on the claim you submit to
Delta for secondary payment. To calculate this,
follow these steps:
- Enter your fees on the
claim.
- Determine the total copayment
for which the patient is responsible under the
terms of the prepaid dental plan agreement.
- Subtract the total copayments
from your total fee.
- Enter the difference on
the claim as "Amount paid by prime: $________."
This allows Delta to correctly coordinate its
payment with the prepaid dental plan.
What to include when submitting
dual coverage claims
Please do the following
so Delta can pay the claim correctly, without having
to return it for more information:
- List social security numbers
for both covered subscribers
- Indicate the patient's
relationship to each subscriber
- Provide the birthdate of
each parent
- For a divorce situation,
indicate the parent with whom the child lives
Be sure
to advise Delta of any change in dual coverage status
When submitting claims,
be sure to review and update your patients' dual
coverage status. Many patients change their coverage
in the fall when a large number of groups conduct
open enrollment.
If a patient no longer
has dual coverage, writing "patient no longer
covered by another program" on the treatment
form will help ensure correct payment and updating
of Delta's records.
When Delta is the secondary carrier
When Delta is secondary,
the dentist's Delta fees apply, even if the primary
coverage allowed higher fees. The patient cannot
be charged a fee that is higher than the amount
Delta calculates to be the patient portion.
Please indicate the total
amount paid by the primary carrier on the face
of the claim. Do not itemize by service
or otherwise separate the amount paid by the primary
carrier.
The combined payments by
all programs may not exceed the total fee for
the treatment. If you or the patient receives
more than 100% of the fee, the amount in excess
should be refunded to the secondary carrier.
When a patient is covered by
two Delta programs
Please submit only one claim.
Delta will process the primary benefits, even
if processing the secondary coverage must be delayed
(for lack of eligibility data, for example). There
is no need to resubmit the claim. You will be
notified separately when processing of secondary
coverage is completed.
When a patient is covered by
two Delta programs and a treatment plan is submitted
for predetermination
You will receive two Notices
of Predetermination. When submitting for payment,
please return both notices together. Please do
not attach a claim. To ensure correct processing
if the two notices become separated, write the
social security number for the other Delta program
on each notice.
In cases of dual coverage, groups
follow the birthdate rule, not the gender rule
The birthdate rule states
that the parent whose birthdate falls earlier
in the year holds the primary coverage for dependent
children. The year is not relevant. For example,
if the father's birthdate is 5/10/57 and the mother's
birthdate is 4/13/58, the mother's coverage is
primary. These rules may be superseded by a court
order that establishes the responsible party for
the child's coverage.
To ensure timely processing of
dual coverage for dependent children whose parents
are divorced and possibly remarried
Please use the following
general processing guidelines (unless there are
other circumstances, such as a court order that
specifies primary coverage):
- Primary coverage -- natural
parent with custody
- Secondary coverage --
step parent with custody
- Third coverage -- natural
parent without custody
- Fourth coverage -- step
parent without custody
Orthodontic services
Dental offices that provide
orthodontic services should be sure to submit
dual coverage information on any claims for orthodontic
procedures, even when the other insurance does
not cover orthodontics.
Some Delta groups have a non-duplication
of benefits clause in their contract
In cases where the non-duplication
of benefits rule applies, the secondary carrier
pays only the difference between what the first
carrier actually paid and what the secondary carrier
would have paid if it had been the prime carrier.
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