Transparency of Coverage
Out-of-Network Liability and Balance Billing
Balance billing occurs when an out-of-network provider bills an enrollee for charges, other than copayments, coinsurance, deductibles, or any other amount that may exceed the maximum allowable charge for the benefit, where applicable. If a Subscriber uses an out-of-network provider for services, the provider may balance bill for the difference between the Maximum Plan Allowance, and the billed charges. If a Subscriber uses an in-network provider (PPO or Premier Provider), the provider has contracted with DDKS as a participating provider and has agreed not to balance bill the Subscriber for services. The Subscriber is only responsible for applicable coinsurance, deductibles, amounts that exceed the benefit maximum (for adults only) and for non-covered services.
Enrollee Claims Submission
Claims will be submitted on a Subscriber’s behalf from a in-network provider. However, if a Subscriber obtains services from an out-of-network provider, the provider may file a claim on the Subscriber’s behalf. However, if the provider does not file a claim on the Subscriber’s behalf, the Subscriber must submit a claim to DDKS at 1619 N. Waterfront Parkway, Wichita, Kansas 67206, or to any authorized agent of DDKS, with information sufficient to identify the Subscriber. Claims must be submitted to DDKS within six (6) months of the date the service was provided. Failure to submit a claim within six (6) months of the date that the service was provided will not invalidate or reduce the claim if it was not reasonably possible to submit the claim within such time, provided that such claim is submitted as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one (1) year from the date the service was provided.
Grace Periods and Claims Pending Policies During Grace Periods for Subscribers with Advanced Premium Tax Credit
Subscribers may qualify for Advanced Premium Tax Credit (APTC) as part of the Affordable Care Act in order to subsidize the cost of their dental coverage. Subscribers must be provided a grace period of three consecutive months if an enrollee is receiving APTC and has paid the initial premium charged. The policy may be cancelled if an initial payment is never received, and the effective date of the cancellation will be the same day as the effective date of the policy.
After the initial payment is received, Subscribers are given until the last day of the month to pay for subsequent months during the plan year. If a payment is not received as of the last day of the month, the 90-day grace period will begin and the Subscriber will receive notification of such delinquent payment. During the first month of the grace period, claims will be paid; however, during the second and third months of coverage, claims may be suspended for services rendered to the Subscriber. Additionally, during the grace period, notification must be made to the Department of Health and Human Services (HHS) and notification must be made to providers regarding the potential for claims to be denied during the second and third months of the grace period. If the Subscriber pays the premium in full at any time during the 90-day grace period, the grace period would no longer apply. The grace period would then start over for any future missed premium payments.
If at the end of the 90-day grace period either no or only partial premium payments have been made, the Subscriber’s policy will be cancelled and the cancellation will be effective either at the end of the first month of the grace period or at the end of the last month the premium was paid in full, whichever is most current. If cancelled at the end of the first month of the grace period, the Subscriber will be responsible for full payment of any claims.
A retroactive denial is the reversal of a previously paid claim, through which the Subscriber becomes responsible for payment. Claims may be denied retroactively, even after the Subscriber has obtained services from the provider, where applicable. As a safeguard, payment of premiums in a timely manner by the Subscriber is suggested.
Claims may be retroactively denied if DDKS is informed that a provider has submitted a claim for services not rendered or using incorrect treatment codes causing benefits to be paid incorrectly.
Enrollee Recoupment of Overpayments
Enrollee recoupment of overpayments is the refund of a premium overpayment by the enrollee due to the over-billing by the issuer. If the Subscriber believes there has been an overpayment toward their DDKS policy premium, the Subscriber may request a refund by contacting DDKS at 1-800-234-9462.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Medical necessity is used to describe care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is a process through which DDKS approves a request to access a covered benefit before the insured accesses the benefit. Some services may require prior authorization and/or be subject to review for medical necessity.
Treatment plan that involve Covered Services which include prosthodontic services, individual crowns (except stainless steel), surgical periodontics, endodontics, and oral surgery except for simple extraction of a single tooth, should be submitted to DDKS for predetermination of benefits. Failure to do so may result in a loss of benefits if, in the professional judgment of DDKS, such treatment is not necessary or a lesser procedure could have restored the tooth or dental arch to a reasonable degree of functionality. A predetermination of benefits does not obligate DDKS to provide any benefits associated therewith if the Subscriber is no longer eligible to receive such benefits at the time the Covered Services are performed. A predetermination of benefits is only effective with respect to Covered Services which commence within ninety (90) days of the date the treatment plan is submitted to DDKS by the treating Dentist. Otherwise a new predetermination of benefits must be sought.
Information on Explanations of Benefits (EOBs)
An Explanation of Benefits (EOB) is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy. If a claim for benefits is denied in whole or in part, written notification called an EOB will be provided by DDKS within thirty (30) days after a claim is received, unless special circumstances require an extension of time for processing. If additional time is necessary, DDKS will notify the Subscriber and/or the treating Dentist of the reason for the additional time, including a description of additional information that is necessary to process the claim if information is missing. If additional information is necessary, the Subscriber will have forty-five (45) days to provide the additional information or else the claim will be decided based upon the information then available to DDKS.
Coordination of Benefits (COB)
Coordination of benefits exists when an enrollee is also covered by another plan and determines which plan pays first. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans does not exceed 100% of the total allowable expense. A plan includes group and non-group insurance contracts.