Claims Payment Policy and Practices for Qualified Dental Plans (QDP)

Information provided here on our policies:

• Out-of-network liability and balance billing
• Enrollee claim submission
• Grace periods and claims pending
• Retroactive denials
• Recoupment of premium overpayments
• Medical necessity and prior authorization: enrollee responsibilities
• Explanation of benefits (EOB)
• Coordination of benefits (COB)

Out-of-network liability and balance billing

DPPO:
When you receive covered services from a non-participating dentist, you will be reimbursed up to a specified maximum amount as outlined in the section of your Evidence of Coverage (EOC) booklet entitled “Summary of Benefits and Member Copayments”. You will be responsible for the remainder of the dentist’s billed charges. You should discuss this beforehand with your dentist if he is not a participating dentist. Any difference between a dental plan administrator’s or Blue Shield of California’s payment and the non-participating dentist's charges are your responsibility.

DHMO:
With an DHMO plan, there is generally no coverage for services provided by non-participating dentists.

Enrollee claim submission

When you receive health care services, a claim must be submitted to request payment for covered services. A claim must be submitted, even if you have not yet met your deductible. Blue Shield uses claims information to track dollar amounts that count towards your deductible.

When you see a participating dentist, your provider submits the claim to Blue Shield. When you see a non-participating dentist, you may have to submit the claim to Blue Shield. Claim forms are available by logging into the member website at blueshieldca.com. Please submit your claim form and medical records within one year of the service date.

How to submit a claim

Grace periods and claims pending

Premium grace period if you do not receive advance payments of premium tax credits

The subscriber has a 30-day grace period from the due date to pay all outstanding premiums before coverage is canceled due to nonpayment of premiums. Coverage will continue during the grace period. If the subscriber does not pay all outstanding premiums within the grace period, coverage will end 30 days after the last day of paid coverage. The subscriber will be liable for all premiums owed, even if coverage is canceled. This includes premiums owed for coverage during the 30-day grace period.

Retroactive denials

Whenever payment on a claim is made in error, Blue Shield has the right to recover such payment from the subscriber or, if applicable, the provider or another health benefit plan, in accordance with applicable laws and regulations. With notice, Blue Shield reserves the right to deduct or offset any amounts paid in error from any pending or future claim to the extent permitted by law. Circumstances that might result in payment of a claim in error include, but are not limited to, payment of benefits in excess of the benefits provided by the health plan, payment of amounts that are the responsibility of the subscriber (cost share or similar charges), payment of amounts that are the responsibility of another payor, payments made after termination of the subscriber’s coverage, or payments made on fraudulent claims.

To prevent retroactive denials:

• Make sure your providers have your current ID card;
  
• Know how you can access care;
• Know which services are covered under your plan;
• Know which services are not covered under your plan;
• Know how you must get prior authorization for certain services; and
• Pay your premiums on time.

Recoupment of premium overpayments

If the subscriber pays premiums beyond the date coverage ends, those premiums are unearned. Blue Shield will refund unearned premiums to the subscriber who are billed directly or to the group administrator/group for the subscribers who are covered and billed through their employer, minus any amount Blue Shield pays for benefits received after the date coverage ends. Blue Shield will only issue a refund to the Subscriber if the amount the subscriber/group administrator paid in unearned premiums is more than the amount Blue Shield pays for benefits after coverage ends.

To obtain a refund of a premium overpayment, call the Customer Service phone number: (510) 607-2000.

Medical necessity and prior authorization time

All services must be medically necessary. The fact that a participating dentist may prescribe, order, recommend, or approve a service or supply does not, in itself, determine medical necessity

Enrollee responsibilities

Services which are of medical necessity include only those which have been established as safe and effective and are furnished in accordance with generally accepted national and California dental standards which, as determined by a contracted Dental Plan Administrator, are: a. Consistent with the symptoms or diagnosis of the condition; and b. Not furnished primarily for the convenience of the member, the attending dentist or other provider; and c. Furnished in a setting appropriate for delivery of the service (e.g., a dentist’s office).

You are responsible for assuring that the dentist you choose is a participating dentist. Note: A participating dentist’s status may change. It is your obligation to verify whether the dentist you choose is currently a participating dentist in case there have been any changes to the list of participating dentists. A list of participating dentists located in your area, can be obtained by contacting a Dental Plan Administrator at 1-877-885-0254. You may also access a list of participating dentists at blueshieldca.com. You are also responsible for following the Precertification of Dental Benefits Program which includes obtaining or assuring that the dentist obtains precertification of benefits.

When a decision will be made about your prior authorization request:

Failure to meet these responsibilities may result in the denial of benefits. However, by following the precertification process, both you and the dentist will know in advance which services are covered and the benefits that are payable.

Explanation of benefits (EOB)

Blue Shield or the Benefit Administrator will process your claim within 30 business days of receipt if it is not missing any required information. If your claim is missing any required information, you or your provider will be notified, and asked to submit the missing information. Blue Shield cannot process your claim until we receive the missing information.

Once the claim is processed, you may receive an Explanation of Benefits (EOB). The EOB will include valuable information including the provider and date of each service, a description of each service, patient responsibility, deductible status (if applicable) and the amount paid.

Coordination of benefits (COB)

Per DHMO/PPO Family Dental Plan Evidence of Coverage (EOC), all individual and family medical plans include an embedded pediatric dental benefit on the health benefits exchange. For purposes of coordinating pediatric benefits, the medical plan is the primary dental benefit plan and the Family Dental PPO Plan is the secondary dental benefit plan.