Maximizing Out of Network Insurance Reimbursement

This document is not meant in any way to dictate diagnosis or treatment of your patients, nor is it meant to take any position on the
“rightness” of any carrier’s reimbursement strategy.

This document, combined with the attached Out of Network (OON) grid and Dialogue Guide, will provide you with a tool to maximize
your patient’s insurance benefits and ensure that you are paid for the treatment they receive. Most PPO insurance carriers will pay for
out of network benefits, often at different fees or benefit levels. If a carrier will not pay for treatment while a provider is going through
the insurance credentialing process, your patient may be given the option to pay for the service at the estimated insurance rates for their
carrier.

What is the difference between “in network” and “out of network”?

A dentist is considered “in network” if they have completed a credentialing application and been approved with an effective date by the
carrier. Until the insurance carrier sends an approval, the dentist is considered “out of network.”

How does being an “out of network” dentist affect a patient’s benefits?

Some insurance carriers will have different maximums for out of network benefits, some will have different percentages on benefits, and
some insurance carriers will not pay for out of network providers. Refer to the grid for details.

Are we ever in network with a patient’s medical insurance?

No. We are always out of network with medical insurance.

Do federal or Medicaid plans have out of network benefits?

No. Federal and Medicaid plans will never pay if the provider is out of network.

How can I tell if a dentist in my office is credentialed with a specific insurance carrier?
Follow the link below, which will allow you to select your office and find out if your dentist(s) is credentialed with the carrier in question.
• On PDSConnect, go to the ROC homepage> Insurance Credentialing> Credentialing Grid.
• Click on the link and select your office from the dropdown list.
• Click “Find.” The credentialing status of all the providers in your office will be displayed.
In addition to displaying the in-network date, the grid also keeps you updated on the most recent status checks for a provider. If there
are any questions, or if you need help with the grid, please place a help ticket for the credentialing team.

How does a carrier determine the effective date for a dentist?

Most insurance carriers base the effective date on the date the credentialing application is approved and processed, as opposed to the
date it is received. Most carriers process and credential dentists within 90 days of receipt of the application; however, some carriers take
longer than this. Refer to the grid for details.

What does non-participating (non-par) mean with Delta Dental, and how does Delta Dental determine non-participating status for a
dentist?
• Non-par means a provider is registered in the National Provider File with Delta Dental, but not yet fully-credentialed as a
participating provider.
• Delta Dental requires that all dentists are added in the National Provider File before becoming in network (participating). A non-
par effective date is needed prior to processing claims. The claim may be processed if the patient has Out of Network benefits,
if no out-of-network benefits exist the claim will be denied.
• Enterprise states (CA, FL, GA, LA, NV, TX, UT) will typically backdate non-par status up to one year or to the date the provider’s
dental license became effective, whichever is most recent.
• Non-enterprise states (all other states) have different guidelines to determine non-par effective dates.

Will an insurance carrier backdate the dentist’s in-network effective date?

Most carriers will not backdate a dentist’s effective date. Therefore, any patients seen before the dentist is credentialed with a specific
insurance will be processed out of network if the patient has OON benefits. Refer to the grid for details.

What should I do if the insurance carrier processes and pays the claim out of network?
• If the PPO carrier pays for out-of-network benefits, or if a carrier backdates the effective date, the payment is sent either to the
National Support Center, the office, or the patient. Refer to the grid for details.
• If the payment is sent to the National Support Center/Lockbox, you do not need to do anything.
• If the payment is sent to the office, you will need to mail the check and EOB to the ROC Posting Team.
• If the payment is sent to the patient, you will need to contact and collect the payment from the patient. Refer to page 4.

Updated 03/11/2024
As with previous guidelines, there will certainly be exceptions to the carrier processes provided. Carriers often change their positions
regarding when they will or will not reimburse for treatment, thus affecting the payment of your claims. Please contact me with any
information you may have on existing or new discrepancies you find. Together, we will maximize your patient’s benefits for the treatment
he or she receives.

For clarification on how to discuss these guidelines with your patients, please refer to the Out of Network Dialogue below.

Stephanie Pearlman – (682) 321-4793

Director, ROC Field Partnerships

PPO OON Dialogue Guide

Patient Communication – Dentist is Out of Network:

When the dentist’s paperwork with an insurance carrier is still in progress:

1. Prior to discussing fees and benefits with the patient, utilize the OON Maximizer grid to determine if the insurance
check will be sent to the patient or the office, and note this on the careslip. Currently, Delta is the only major
carrier that will send the check to the patient, but this will need to be verified for other smaller/regional carriers.
2. Inform the patient that the dentist has recently chosen to participate in the insurance carrier’s network, but
his/her credentialing paperwork is still in process.
3. Let the patient know that this is only temporary, and services provided during this visit will be considered out of
network. However, the patient will not incur any additional charges related to out of network benefits.

Patient Communication – Insurance Check Will Be Sent to Patient:

When the dentist is out of network, insurance carriers may send checks directly to patients. (This is almost always the case
with Delta Dental, which is currently the only major carrier to do this.) Review the following alternatives with your owner
dentist and regional manager to determine the best course of action for new appointments when the insurance check will
go to the patient.

1. Ask the patient to pay the entire portion (patient and insurance) today. For example:
a. Mrs. Jones, the total portion for today’s services is $700. This includes your portion and the insurance
portion. Your insurance carrier will send their portion of $350 directly to you when the claim is processed.
This will be yours to spend.
2. Offer an FMP payment option. For example:
a. Ok, Mrs. Jones, we can set you up on a payment plan for the $700….
3. Ask the patient to pay their portion and once they receive the insurance payment, they can call the office to make
the payment over the phone.
a. Continue with the coordination process as usual, collect the patient portion, and explain that once they
receive the check from the insurance carrier, they should call the office to make the payment.
b. Provide the patient with an out-of-network letter by adding it in the Communications section in the Wrap
Up tab. This letter can be printed on the patient’s After Visit Summary and/or sent to their MyChart. This
letter further explains how to handle the check. (This is especially important for Delta Dental patients.)
c. Provide the patient with a self-addressed, stamped envelope. A colored envelope is recommended.

Patient Communication – Patient Received Check from Insurance Carrier:

When an account with an "Out-of-Network Collections" status is in your Guarantor - Unsecured Balances workqueue, call
the patient to obtain payment. Additionally, the office can utilize Guarantor Activities in the patient’s Guarantor Account to
send the patient an Account Letter – Insurance Payment Sent to Subscriber and/or a Balance Notification that will be sent
via their MyChart preferences. When you do this, you will encounter one of the three scenarios below:

1. The patient recognizes they have received the payment. In these cases:
a. Ask the patient to provide payment and a copy of their EOB to help adjudicate the claim properly.

Updated 03/11/2024
 NOTE: If the patient does not agree to provide payment, work with the patient to sort out any issues as
you would with any other outstanding balance.
b. Place a Help Ticket (ROC-Insurance Billing Operations>Audit> Adjustment Request) if you need help
adjusting the account.
2. The patient has not received an insurance check. In these cases:
a. Call the insurance carrier and confirm that the check has been cashed.
o If it was not cashed, ask for a stop and reissue of the payment. Call the patient and let them
know to expect the reissued check and ask them to provide payment and a copy of the EOB to
the office as soon as they receive the check.
o If it was cashed, call the patient and let them know the date the check was cashed, and ask the
patient to provide payment and a copy of their EOB immediately. If that patient does not have
the EOB, collect the payment, and place a Help Ticket (ROC-Insurance Billing Operations>
Insurance Collections (Trace)> Missing EOB/Obtain EOB) to help obtain a copy of the EOB.
3. The patient is not answering or returning office phone calls.
a. An account with a fully unsecured balance of over $60 that has reached 31 Patient Aging Days, the ROC –
Outsource team will manually review and send the account to an outside agency for outsourcing.
NOTE: In each of the above referenced scenarios, if an OON payment is sent to subscriber for Dental-Medical
claims, reference the Access and Work the Follow-Up – Claim Action Needed WQ SRG.

Communicating with a Patient who Received a Check and Notified the Office:

1. Explain that the patient can deposit the check into their personal account, and you can take the patient’s payment
over the phone for their convenience via a Debit or Credit Card. If they are uncomfortable making the payment
over the phone, they can also mail in a personal check using the stamped addressed envelope the office provided.
2. If the patient brings a personal check to the office:
a. Post the check as a patient payment.
3. If the patient brings in the insurance check as the form of payment:
a. Ensure the back of the check is endorsed to the office.
b. Post the signed check as a patient payment.
After posting a patient payment, a help ticket is also required (ROC-Insurance Billing Operations>Audit>Out of
Network Check Received) which must include an attached EOB. ROC will adjudicate the invoice, upload the EOB
to the Guarantor’s Invoice Docs, and resolve the help ticket.

When collecting any form of an Out of Network payment, complete the following fields in the
Payment Collections window:
• Comment Field = OON
• Reference Field = Check # or N/A if payment is a credit card

Document all conversations with insurance carriers or patients and any actions taken in the patient’s Guarantor Account
notes.

NOTE: There is an Out of Network letter that can be provided to the patient by adding it in the Communications section in
the Wrap Up tab. Once added, this letter can be printed on the patient’s After Visit Summary and/or sent to their MyChart.

Updated 03/11/2024
 Out Of Network (OON) Grid
How is doctor's effective date Will the carrier backdate the provider's effective Will a carrier process a claim for a provider that is Will the payment come to the office if
Carrier Name
determined? date? out of network? the provider is out of network?
Advantica Processed date Yes (30 days) Yes Yes
Aetna Processed date No Yes* Yes
Ameritas Start date Yes (90 days) Yes Yes
Anthem BCBS ^ Processed date No Yes* Yes
BCBS - Federal Processed date No No No
BCBS of AZ Processed date No Yes No
BCBS of CA Processed date No Yes Yes
BCBS of AZ Federal Processed date No No No
BCBS of Georgia Processed date No Yes Yes
BCBS of Kansas Processed date No Yes No
BCBS of Kansas City Processed date No No No
BCBS of MA Processed date No Yes No
BCBS of TX Federal Processed date No No No
BCBS of Washington/Premera Processed date No Yes No
BenefitSource/DentalSource Start date Yes (30 days) Yes Yes
Careington Processed date No Yes Yes
Cigna PPO Processed date No Yes Yes
Connection Processed date No Yes Yes
Delta Dental ^ Processed date No Refer to Note Delta Dental ^ Refer to Delta Dental OON Grid
Dentegra Processed date No Yes No
DenteMax Processed date No Yes Yes
DHA/Assurant/UHC Processed date No Yes Yes
Dina Dental ^ Processed date No Yes Yes
Diversified 1 ^ Processed date No Yes Yes
Diversified 2 ^ Processed date No Yes No
DNOA Processed date No Yes Yes
EMI Health Processed date No Yes Yes
Envolve Ambetter (UCCI Advantage Plus) ^ Processed date Yes (90 days) No Yes
Envolve Wellcare (UCCI Medicare Advantage) ^ Processed date Yes (90 days) No Yes
FDH EPO Received by carrier No No No
FDH PPO Received by carrier No Yes Yes
Guardian PPO/UMR Processed date No Yes Yes
HealthPartners Processed date No Yes Yes
HealthSmart Processed date No Yes Yes
Humana Federal^ Processed date No No No
Humana PPO^ Processed date No Yes* Yes
IEHP Processed date No No No
Liberty Processed date No Yes* Yes
Maverest Processed date No No No
MetLife Processed date No Yes Yes
OnceCall Care Processed date No Yes Yes
OperatingEngineers Processed date No Yes Yes
Premera Blue Cross Processed date No No No
Premier Access Processed date No Yes Yes
Premier Dental Processed date No Yes* Yes
Principal Processed date No Yes* Yes
Principal EPO Processed date No No No
Regence BCBS Processed date No No No
Sierra Health Plan/HPN Start date Yes Yes* Yes
Surrency Received by carrier No Yes* No
TDA Processed date No (new office); Yes (60 days existing) Yes Yes
Teacher's Health Trust Start date Yes Yes* Yes
UCCI Processed date No Yes Yes
UHC/DBP/PUD/Diversified Processed date No Yes Yes
UniCare Processed date No Yes Yes

* - Provided the patient's plan has out of network benefits

Anthem BCBS ^ - Includes states: CO, MO, NV
BCBS - If the patient is treated in an office located in another state, the payment will be sent to the patient.
Delta Dental ^ - Except in very rare circumstances, Delta Dental will pay all out of network claims. However, we must wait until the doctor is listed in Delta Dental's National Provider Data Bank before they will issue payment for a claim, including any
retroactive dates of service.
Dina Dental ^ - If the plan is Peoples Health (the member identification number begins with the letter G), please refer to UHC guidelines
Diversified 1 ^ - American General Life Company, Ameritas, Ben-E-Elect, Best Life Insurance Company, Dental Network of America, First Dental Health, Hometown Health Plan, Humana , Lincoln Financial, Principal Financial, SelectDent, UHC/DBP
Diversified 2 ^ - Anthem BCBS, Delta Health Systems, Empire, Federal Employee Plans, Golden West Dental & Vision, Missouri DenteMax, Prime and Complete, UniCare
Envolve Ambetter (UCCI Advantage Plus) ^ Only has OON benefits in TX, AR, OK, MI
Envolve Wellcare (UCCI Medicare Advantage) ^ Does not have OON benefits and requires a prior-authorization
Updated 03/11/2024
Humana Federal ^ - States: AZ, CA, CO, UT are automatically enrolled when credentialed with Humana PPO. States: ID, NM, OR, WA, NV, MN do not have Humana Federal Network. States: FL, GA, KS, MO, TN, TX are not contracted with Humana Federal
Humana PPO ^ - All offices are automatically enrolled with Humana Medicare when credentialed with Humana PPO; both networks utilize the Humana PPO Fee Schedule.
UniCare - Includes states: FL, KS, LA, AZ, MN, ID, NM, OR, TN, TX, UT , WA
EPO Networks will not provide OON benefits
Updated 03/11/2024
 Delta Dental Out Of Network (OON) Grid
What date is the provider considered in Will the carrier backdate the provider's in Will a carrier process claims for dates of Will the payment come to the office if the
Carrier Name
Network? Network effective date? service a provider is out of network? provider is out of network?
Delta Dental of Alabama Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Alaska Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Arizona Processed date No Refer to Note Delta Dental^ No
Delta Dental of Arkansas Processed date No Refer to Note Delta Dental^ No
Delta Dental of California Processed date No Refer to Note Delta Dental^ No
Delta Dental of Colorado^^ Processed date No Refer to Note Delta Dental^ No
Delta Dental of Delaware Processed date No Refer to Note Delta Dental^ No
Delta Dental of DC Processed date No Refer to Note Delta Dental^ No
Delta Dental of Florida Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Georgia Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Hawaii Processed date No Refer to Note Delta Dental^ No
Delta Dental of Idaho Processed date No Refer to Note Delta Dental^ No
Delta Dental of Illinois Processed date No Refer to Note Delta Dental^ No
Delta Dental of Indiana Processed date No Refer to Note Delta Dental^ No
Delta Dental of Iowa Processed date No Refer to Note Delta Dental^ No
Delta Dental of Kansas Processed date No Refer to Note Delta Dental^ No
Delta Dental of Kentucky Processed date No Refer to Note Delta Dental^ No
Delta Dental of Louisiana Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Maryland Processed date No Refer to Note Delta Dental^ No
Delta Dental of Massachusetts Processed date No Refer to Note Delta Dental^ No
Delta Dental of Michigan Processed date No Refer to Note Delta Dental^ No
Delta Dental of Minnesota^^^ Processed date No Refer to Note Delta Dental^ No
Delta Dental of Mississippi Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Missouri Processed date No Refer to Note Delta Dental^ No
Delta Dental of Montana Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Nebraska Processed date No Refer to Note Delta Dental^ No
Delta Dental of Nevada Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of New England^^^^ Processed date No Refer to Note Delta Dental^ No
Delta Dental of New Jersey^^^^^ Processed date No Refer to Note Delta Dental^ No
Delta Dental of New Mexico Processed date No Refer to Note Delta Dental^ No
Delta Dental of New York Processed date No Refer to Note Delta Dental^ No
Delta Dental of North Carolina Processed date No Refer to Note Delta Dental^ No
Delta Dental of Ohio Processed date No Refer to Note Delta Dental^ No
Delta Dental of Oklahoma Processed date No Refer to Note Delta Dental^ No
Delta Dental of Oregon Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Pennsylvania Processed date No Refer to Note Delta Dental^ No
Delta Dental of Rhode Island Processed date No Refer to Note Delta Dental^ No
Delta Dental of South Carolina Processed date No Refer to Note Delta Dental^ No
Delta Dental of South Dakota Processed date No Refer to Note Delta Dental^ No
Delta Dental of Tennessee Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Texas Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Utah Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of Virginia Processed date No Refer to Note Delta Dental^ No
Delta Dental of Washington Processed date No Refer to Note Delta Dental^ Yes
Delta Dental of West Virginia Processed date No Refer to Note Delta Dental^ No
Delta Dental of Wisconsin Processed date No Refer to Note Delta Dental^ No
Delta Dental of Wyoming Processed date No Refer to Note Delta Dental^ No

Delta Dental ^ - Except in very rare circumstances, Delta Dental will pay all out of network claims. However, we must wait until the doctor is listed in Delta Dental's National Provider Data Bank before they will issue payment for a claim, including
any retroactive dates of service.
Delta Dental of Colorado^^ - Delta Dental of Colorado EPO plans will not pay for any services performed by Out of Network providers.
Delta Dental of Minnesota^^^ - Includes states: MN and ND
Delta Dental of New England^^^^ - Includes states: ME,NH and VT
Delta Dental of New Jersey^^^^^ - Includes states: CT and NJ

Updated 03/11/2024
Updated 03/11/2024