Dental Insurance Resources

The ADA Contract Analysis Service (CAS) was developed based on the common-sense premise that one should always read and understand an agreement before signing it.

This is where CAS comes in handy to educate members, in clear language, on issues concerning contract provisions—thus helping dentists make informed decisions about participating in provider contracts offered. Understanding the contractual relationship before signing helps prevent dentists from later being blindsided by contract provisions. CAS highlights areas that a dentist may wish to request further clarification from the company. Such as:

• Does the provider agreement limit how much the dentist can charge an insured patient for non-covered services?
• Or, what type of decisions may result from the company's utilization review programs?
• How does the contract define the dentist's "Usual" and "Customary" fee?
• Or, what is the dentist's obligation to his or her patients after the agreement with the dental benefit company is terminated?

In Missouri, Assignment of Benefits (AOB) laws are in place that authorize a beneficiary/patient to direct the insurer to forward payment for a covered service directly to the treating dentist.

In 2022, legislation passed to include pre-paid dental plans into this statute. Unfortunately, there were still issues with pre-paid dental plans not complying with this law, due to claims of ERISA exemptions for self-funded and federally funded dental insurance plans.

In 2024, legislation was passed to include Missouri’s prompt-pay law, which would require payment from an insurance carrier be made to either the doctor or the patient within 45 days of receiving the claim.

• If you are experiencing issues with assignment of benefits, please contact Halie Payne.
• Section 376.427 RSMo
  

Systematic combining of procedures (codes) resulting in a reduced benefit for the patient or beneficiary.

Health carriers often collect refunds on claim overpayments by reducing legitimate claim payments made to providers who did not receive the overpayment or by taking the overpayment amount out of the next insurance payment they send the provider, even if it is for a totally different patient.

Additionally, there have been instances of a provider returning an overpayment, but the insurance company does not credit it back to the correct patient from whose account it was taken.

In 2020, legislation was passed that requires an insurance company must collect an overpayment from the provider or the third-party the carrier made the overpayment to. Also requires that the health carrier must inform the provider of the date, service and claim that they are collecting the overpayment for.

• Section 376.1345 RSMo

Occurs when a patient is entitled to benefits from more than one dental plan. It is ADA policy that the patient should get the maximum allowable benefit from each plan.

The ADA Practical Guide to Dental Letters Book features customizable dental office correspondence including insurance letters explaining how insurance works, UCR and coordination of benefits.

Credentialing Service

The ADA credentialing service, powered by CAQH ProView, is making it easier to submit and maintain your credentials in one central place. Your information will be accessible to you, and the participating organizations you choose. Learn more. more.

HMO Credentialing Form

Question: Is there a standard HMO Standardized Credentialing Form dentists should use?

Yes, Missouri has adopted the CAQH Form UCDS for credentialing purposes, effective January 30, 2009. You can download it and learn more at the Missouri Department Missouri Department of Insurance Insurance website.

Dental Loss Ratio (DLR) is a topic and advocacy issue gaining traction across the nation, and one of which is on the MDA agenda. Enacting dental loss ratio (DLR) legislation in states is a critical step to tempering the influence insurance companies have over how dentists serve their patients and run their practices. Setting minimum standards of transparency and consumer protection regarding how dental insurers spend patient premiums, as is standard in the medical industry, would go a long way toward improving patient access to the care they need from their dental provider.

• ADA Dental Loss Ratio

When dental plans use a procedure code different from the one submitted to determine a benefit in an amount less than that which would be allowed for the submitted code.

Insurance carriers can lease or rent the "in-network" relationship they have established with a provider without the provider's consent or knowledge. This erodes patient-provider trust, which can lead to assumptions in treatment plans and costs when the provider has no idea a patient is moving in or out of network.

Missouri passed legislation requiring providers check a separate box on a contract allowing the insurance carrier to lease out their "in-network" status to other plans. If the box is not checked, then the insurance carrier may not lease out the provider's "in-network" status to other plans.

• Section 376.1060 RSMo

Non-Covered Services

Prohibits capped fees on non-covered services. This law prohibits a contract between a health carrier (or a health benefit plan) and a dentist from requiring the dentist to provide services to an insured at a fee established by that plan if the services are not covered under the plan. See Section 376.1226 RSMo.

Silent PPOs

A Silent PPO is a situation in which an insurance company leases the services of a contracted provider to another insurance company and fails to notify the provider, or the provider is otherwise unaware the leasing has occurred. Your contracts likely allow for the leasing of your services to a third party insurance company, with your consent. However, silent leasing, done without the provider being notified, creates confusion on behalf of the doctor and the patient. See Section 376.1060 RSMo.

Out-of-Network for Emergency

There is language in Section 376.1367 RSMo pertaining to emergency services benefit determination (coverage required, when).

Related Resources

• The ADA Practical Guide to Dental Letters Book features customizable dental office correspondence including insurance letters explaining how insurance works, UCR and coordination of benefits.

Required by Missouri law; if a person with health insurance assigns their benefits to a healthcare provider, the insurance company must make the payment for healthcare services directly to that provider within 30 days.

If a person’s insurance doesn’t cover payment to out-of-network providers, and the insurance company approves the services from an out-of-network provider, payments will be made directly to that provider.

Question: The insurance company has not paid me on a claim. What can I do to further this process?

Under the 'Prompt Pay' law (Section 376.383 RSMo), an insurance company is required to pay the claim within 30 days. If after 45 days of receipt of the claim it has not been paid, the health carrier shall pay the claimant one percent interest per month. The interest shall be calculated based upon the unpaid balance of the claim. Read the entire statute for specifications.

In 2019, legislation passed to hold insurance carriers accountable for the payment of prior authorization they have issued in the state of Missouri. 

• Section 376.1364 RSMo

Legislation passed in 2024 requires explicit written consent from providers to health insurance carriers to receive payment via virtual credit card. This additional clarification of the language was a result of legislation passed in 2019, which only required an opt-out from providers. As a result, many providers were having to opt-out for every single claim creating more administrative burdens.

• Section 376.1345 RSMo
• ADA Electronic Transactions