Non-Covered Services
2024
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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.
2024