Cost Control Measures
Bundling -This is the systematic combining of distinct dental procedures by third-party payers that result in a reduced benefit for the patient/beneficiary.
Downcoding -This is the practice of third-party payers in which the procedure code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.
Least Expensive Alternative Treatment – The dental plan may only allow benefits for the least expensive treatment for a condition. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on their dental benefit coverage. In many instances, the least expensive alternative is not always the best option, You should consult with your dentist on the best treatment option for you.
Explanation of Benefits (EOB) - An EOB is a written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan. In those instances where the plan makes partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the EOB. Any difference between the fee charged and the benefit paid may be due to limitations in the dental plan contract. Typical information reported on an EOB includes:
- the treatment reported on the submitted claim by ADA procedure code numbers and nomenclature; and
- the ADA procedure code numbers and nomenclature on which benefits were determined.