Quick Tips September 2023 | Page 27

Non-Covered Services

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Quick Tips for the Dental Office

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Non-Covered Services

In 2012 , Act 186 ( non-covered services ) was signed into law . This law allows dental providers the ability to charge their full and customary fee for services that are not covered under the terms of a patient ’ s insurance contract , even if the dentist is a participating provider with the insurance carrier .
Act 186 stipulates that insurance companies may not require a participating provider to limit their charge to patients for non-covered services . Rather , dentists are given the option to do so . If you choose not to participate in the non-covered services provision , yet remain participating with the insurer , notify the insurer in writing of your intent .
Example :
If a patient has coverage for basic , diagnostic and preventative services , but does not have coverage for prosthetics , a dentist is able to bill their full fee for services that are not covered under the terms of a patient ’ s contract , even if the dentist has signed a contract with the insurance carrier . A dentist is not required to accept the insurance carrier ’ s fee allowance .
Are there any scenarios in which I cannot bill my full fee ?
The Act does stipulate that there are scenarios in which a provider must accept the insurance carrier ’ s allowance for non-covered services , if non-payment is due to any of the following instances :
• Patient ’ s deductible has not yet been satisfied
• Co-payment or Co-insurance is applicable
• Waiting periods
• Patient has reached a lifetime or annual maximum
• Service is limited by frequency
• Payment was made for an alternate form of treatment
Examples :
If a patient has coverage for only one prophylaxis per year and the patient has two , even though the carrier will not pay for the second , the dentist is limited to collecting the amount of the carrier ’ s allowance from the patient because the service was limited by frequency .
If a dentist places a composite restoration and the patient has coverage for both amalgam and composite restorations , the insurance carrier may make an allowance for an amalgam under the alternate treatment provision , and the dentist may bill up to the carrier ’ s allowance for a composite . 2022