Insurance Connection
Third-Party Complaints
Experiencing problems with thirdparty insurance ? Let PDA know with this easy to use Third-Party Complaint form . This form gives dentist and dental staff the opportunity to provide PDA and ADA with basic information regarding payer concerns . The information received will be used to keep a close watch on carrier trends and problems .
PDA ’ s Dental Benefits Committee ( DBC ) meets regularly with third-party insurance representatives to discuss issues raised by members . This ongoing dialogue has resulted in greater cooperation in billing procedures , faster reimbursement timelines and network referrals . Dentists throughout Pennsylvania need to report the problems they are having with thirdparty payers so PDA may advocate effectively during these meetings .
PDA is a dedicated advocate for the dental profession regarding insurance issues . Members can assist PDA in this effort by keeping DBC informed of the insurance problems encountered in daily interactions . Questions may be addressed to our new government relations coordinator Ivan Orlovic , at iio @ padental . org or by phone at ( 800 ) 223-0016 , ext . 105 .
Ivan comes to us from Delta Dental of Pennsylvania , where he has worked in several insurance-related departments over the span of five years . His knowledge of the dental industry will help serve members with insurance-related problems . Please contact him for his assistance in handling any issue you may have with an insurance company . Ivan is also available to
THIRD-PARTY COMPLAINT FORM
attend district and local dental society meetings to hear from you firsthand and to inform you about PDA ’ s initiatives to improve insurance practices in Pennsylvania .
1 . Date : 2 . Dentist Name : 3 . County : 4 . Third-Party Name : 5 . Dentist contracted with plan 6 . How was the claim filed , paper or electronic : 7 . What type of complaint or problem applies to you ?
❑ Coordination of benefits
❑ EOB language
❑ Downcoding ( changed code to a less complex or lower cost procedure )
❑ Bundling ( combining procedures that results in a reduced benefit )
❑ Review by a non-dentist
8 . Utilization review ( a system to evaluate procedure utilization frequency / plan abuse )
❑ Delayed payment
❑ Denial of claim or pre-authorization
❑ No direct pay to non-participating provider
❑ Denial of payment after pre-authorization
❑ Lost claims , x-rays or other documentation by carrier
❑ Extensive or additional documentation requested
❑ Interference with the doctor-patient relationship
❑ Other
Please give a brief description of the problem and the actual or proposed solution :
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