Articles
Submitting Every Claim Electronically Saves You Time, Money
NJ Credentialing Update
Filing Electronic COB Claims
Who Can a Young Dentist Turn to for Advice?
Claims Processing Tip
SO, WHO WANTS TO BE A MILLIONAIRE?
Professional Services Adds New Connecticut Coordinator
Delta Dental Alliance Expands Network to Smaller Employers
Handbook Revisions
Congratulations, Convention Raffle Winners!
Change in Benefit Categories

Submitting Every Claim Electronically Saves You Time, Money

One of the most frequently asked questions EDI Coordinator Beth DeCapio hears when she visits dental offices is: What types of claims can be submitted electronically to Delta Dental? "All types, including coordination of benefits, pre-treatment estimates and orthodontics," she answers. Even student documentation can be sent to Delta Dental electronically.

In some cases Delta Dental may require x-rays. When x-rays are needed, dental offices are notified the next day via their electronic claims status report. X-rays should be sent in the yellow envelopes specially designated for electronic claims submissions. These envelopes are sent to a special post office box for expedited processing.

To find out more about how to make the most of electronic claims submission in your practice, contact Beth DeCapio at (973) 285-4035 or bdecapio@deltadentalnj.com. She is available to meet with you and your staff at your office.

NJ Credentialing Update

Credentialing surveys are now due for participating dentists in New Jersey. If you have not received a credentialing packet and are a participating dentist in New Jersey, please contact our Credentialing Department at (888) 203-6993. For assistance completing the credentialing paperwork, please contact our dental network coordinators at (888) 396-6641.

Filing Electronic COB Claims

When patients have Delta Dental Plan of New Jersey as both their primary and secondary carrier:

1. Submit one electronic claim to Delta Dental.
2. If you wish, use the Remarks or Notes section in your practice management software to alert us that Delta Dental is both primary and secondary.

When patients have Delta Dental Plan of New Jersey as their secondary carrier:

1. Submit the insurance claim to the primary carrier.
2. When you receive the primary benefit payment, enter the amount in your practice management software.
3. Generate the electronic claim to Delta Dental, the secondary carrier. (Your software may be coded to forward that primary amount to us electronically when the secondary claim is created. If not, use the Remarks or Notes section in your software to tell us the primary carrier's name and the amount received.)

We will usually not request a copy of the primary carrier's statement to process the claim; however please retain it for future reference.

For more information about entering COB information into your practice management software, please contact your software vendor.

Who Can a Young Dentist Turn to for Advice?

This article originally appeared in the January/ February 2000 issue of the SAFECO Dental News. Permission to reprint this article was granted by SAFECO.

Recent graduates are especially vulnerable to mishaps and malpractice claims because of their inexperience. Following graduation, every dentist confronts a variety of problems not faced in school. These problems are more complex, and numerous practice-management decisions need to be made on a daily basis. Even dentists who become associates in an established practice quickly sense the aloneness associated with the profession. SAFECO, therefore, advises young dentists to avail themselves of the opportunities for continuing education, membership in professional organizations, and Internet access to current scientific literature. Unfortunately, recent graduates often feel they are too busy and fail to take advantage of educational options.

Every young dentist should have a mentor, a dentist with good judgment and the wisdom that comes from experience. In dental school, one learns the "ideal" treatment for a problem and always has an instructor to turn to when difficulties arise. In practice, however, other factors influence what treatment is most appropriate for a particular patient. Should you, for example, recommend extractions and a full denture for a patient with limited finances, even though a number of teeth could theoretically be saved? What is your liability if a patient delays or is unable to proceed with needed treatment and you continue to provide only limited care? In addition, for answers to certain everyday questions (such as how to deal with a patient dissatisfied with the feel and function of a newly placed partial denture, or how to handle a nonspecific pain complaint), access to an experienced colleague is essential.

Creating a network of colleagues to turn to for informal advice and counsel is an important part of dental practice. Local courses and society meetings are good places to meet experienced general practitioners as well as specialists to whom you will feel comfortable referring patients. Every dentist has been a beginner. Most are willing and eager to share the lessons learned from years of experience and help you avoid the many treatment and liability risks of a newly established practice.

SAFECO offers participating dentists who have completed Delta Dental Plan of New Jersey's credentialing requirements a special 10% premium discount (over and above other available discounts) for qualified dentists insured under the SAFECO Insurance Company Preferred Dental Professional Liability Program. For a no-obligation estimate, call (800) JAMISON (526-4766), ext. 352, or e-mail lbarbero@jamisongroup.com.

Claims Processing Tip

Here's a tip that will not only simplify your electronic claims submissions, but also help prevent processing and payment delays. When you send a Coordination of Benefits (COB) electronic claim in which Delta Dental is the secondary carrier, all Delta Dental needs to issue a secondary payment is the primary carrier's payment amount. This information can be entered into the area of the electronic format designated for COB payments or, if that is not available, in the "Remarks" section.

SO, WHO WANTS TO BE A MILLIONAIRE?

You may or may not be aware that the State of New Jersey has become much more aggressive in fighting fraud. On January 15, 1998, Governor Whitman signed into law Chapter 353 of the Laws of 1997, establishing "Health Care Fraud" as a separate crime, which carries enhanced penalties. The Office of Insurance Fraud Prosecutor was recently established to enforce the New Jersey Insurance Fraud Prevention Act.

These new laws can be imposing and stringent. Delta Dental Plan of New Jersey can help. Let us work with you to avoid some of the areas that cause confusion. Although you are the only one responsible for making yourself a millionaire, Delta Dental would like to help you avoid losing money. The new regulations have imposed some very stiff fines. Play this game with us. It will address most common issues we have found to be problems.

ARE YOU READY?

100 Points

Which of the following are part of New Jersey's renewed commitment against insurance fraud?

1. The state now requires health and dental insurance companies to maintain Special Investigative Units
2. The state requires mandatory minimum anti-fraud training for the entire claims processing staff
3. All suspected fraud must be reported to the Office of Insurance Fraud
4. The establishment of health care claims fraud as a civil offense

- Correct answer: ALL of the above

200 Points

All claims must be received within what time frame, or Delta Dental will not process for payment, and your charges are not collectable from the patient?

1. One day
2. One week
3. One month
4. One year

You could call a friend, or you could call Delta Dental's Customer Service area.

- Correct answer: D. One year from the date of service

300 Points

What is the correct date to submit to Delta Dental for removable prosthetics?

1. The date of the treatment plan
2. The date of the impression
3. The date it was sent to the lab
4. The date it was delivered to the patient (insertion date)

You could use your 50/50…or you could check your Participating Dentist Handbook.

- Correct answer: D. The insertion date

500 Points

What is the correct date to submit to Delta Dental for a root canal therapy?

1. The date the patient calls for an appointment
2. The date the canals are permanently filled
3. The start of the root canal
4. The date of the treatment plan

That's right, the answer is in your Handbook…Chapter 9.

- Correct answer: B. The date the canals are permanently filled

1,000 Points

What is the correct date to submit to Delta Dental for fixed bridgework or crowns?

1. The date of the lab bill
2. The date of the treatment plan
3. The cementation date regardless of the type of cement used
4. The preparation date

- Correct answer: C. The cementation date regardless of the type of cement used

Hopefully, you have a THOUSAND points…you're on your way!
Do you wish to continue?
Are you sure?

2,000 Points

Some minimum requirements for patient records (which must be kept for 7 years) are:

1. Patients' name, address and date of birth
2. A date and description of each visit including all radiographs taken
3. Complete financial data, including the date and amount billed to or received from the patient or third party. This includes copies of claim forms and EOBs
4. Legible entries Instead of using a 50/50, check the NJ State Board of Dentistry Regulations (13;30-8.7).

- Correct answer: ALL of the above

4,000 Points

Claim verifications are done for cost containment purposes and to check the correctness of claim payments. What does the claim verification procedure consist of?

1. Completion of a questionnaire
2. In-office photocopying of treatment and financial records for both Delta Dental and uninsured patients
3. Provision of additional information and/or documents as needed
4. Conference call or in-person meeting as needed

- Correct answer: ALL of the above

There is some additional information in the Handbook, Chapter 11

8,000 Points

What are some of the more common discrepancies found during a claim verification?

1. Undisclosed waiver of copayment and unreported discounts
2. Filed fees which exceed those fees most frequently charged to uninsured patients
3. Failure to report other coverage for dental services
4. Incorrect dates of service or billing for services different than those performed
5. Billing for incomplete services

- Correct answer: ALL of the above

16,000 Points

What can be considered fraud?

1. All of the answers to the 8,000 Points question above
2. Preparing or presenting false information to an insurance company
3. Failing to disclose or concealing material information
4. Knowingly benefiting from someone else's insurance fraud

- Correct answer: ALL of the above

32,000 Points

Which of the following are true for coordination of benefits with Delta Dental?

1. Medical coverage is usually primary
2. Most policies use the Birthday Rule, but some are still gender specific
3. Combined payments may not exceed 100% of your approved fee
4. Payment by any primary carrier must be reported

You could ask the audience, but it would be better to check with your Participating Dentist Handbook or a member of the Delta Dental staff.

- Correct answer: Once again it is ALL of the above

64,000 Points

The fee reported to Delta Dental by the attending dentist on the Fee Filing Form should be:

1. The fee actually charged and intended to be collected
2. The fee most frequently accepted from non-covered patients as payment in full (Usual Fee)
3. Kept up to date
4. For a service the dentist commonly performs

- Correct answer: ALL of the above

125,000 Points

Undisclosed forgiveness of a patient's copayment is a form of over-billing. Undisclosed waiver of copay is:

1. Prohibited by the Delta Dental Participating Dentist Agreement
2. Considered "an ethical impropriety" by the American Dental Association
3. A potential basis for State Board disciplinary action
4. Prohibited by the New Jersey State Board of Dentistry. Their Regulations (13:30-8.10 c) state that all discounts must be disclosed "conspicuously" and legibly on the face of the claim Instead of using a 50/50, check the NJ State Regulations or the Participating Dentist Handbook.

- Correct answer: ALL of the above

250,000 Points

According to NJ State Board of Dentistry Regulations, the accuracy of all information contained in submissions is the personal responsibility of the licensee whose name, license number or signature appears on the claim. Which of the following inaccuracies submitted by the office can be damaging for the dentist?

1. Inaccurately submitting a date of a service to help the patient and gain insurance benefits
2. Submitting a fictitious service in order to collect for a previously denied service
3. Billing under another patient's name in order to collect benefits
4. Submitting for a dental service or procedure which does not accurately reflect the actual work completed

Are you unsure what code you should use for a seldom performed service? You could check with one of Delta Dental's consultants.

- Correct answer: ALL of the above

500,000 Points

Which of the following statements are true with respect to "patterns" of fraud?

1. They constitute five or more violations of the New Jersey Insurance Fraud Protection Act, which are the same or similar types of actions or involve the same victim
2. They entitle the insurance carrier to recover triple damages
3. They must be referred to the Office of Insurance Fraud Prosecutor
4. The fine for patterns can be up to $250,000 to $500,000 plus 10 years prison time (per incident) under the Federal Health Care Claim Fraud Act

- Correct answer: ALL of the above

1,000,000 Points

Some consequences under the New Jersey Health Care Claims Fraud Act are:

1. Increased ability to prosecute for claims
2. Possible loss of license
3. Increased fines and increased severity of the offense
4. Disclosure to others such as State Board of Dentistry and The Federal Health Care Integrity Data Bank

Is that your FINAL answer?

ARE YOU SURE?

You can lose more that just the amount of your claim. In 1999 alone, the Office of Insurance Fraud Prosecutor had 78 criminal insurance fraud convictions, with one in five receiving jail time. They collected more than $5 million in restitution. They also collected close to $6 million in restitution under civil convictions. Disciplinary action was taken against 26 licensed health care professionals.

- The correct answer is: ALL OF THE ABOVE

You should be aware, that in addition to the increased penalties being awarded, there is increased dedication of resources on the local, state, federal, corporate and professional levels. There is a cooperative effort among state law enforcement agencies, the insurance industry, and the Department of Consumer Affairs. There has also been renewed coordination of the New Jersey State Office of Insurance Fraud Prosecutor and professional boards.

New endeavors include a campaign for consumer education. This incorporates increasing patient awareness of fraud, with an advertising campaign that offers a toll-free number for reporting insurance fraud. New advanced "fraud-finding" computer software is also being used in an effort to detect and eliminate insurance fraud.

In addition to the increased state efforts, there has been successful pursuit of fraud by other dental coverage providers as well. Our reviews are constantly increasing due to patient generated leads, dental staff referral, and detection by both Delta Dental's computer systems and Delta Dental's own professional staff. This persistence and dedication are increasing the effectiveness of our pursuit of fraudulent claims submissions.

Take the time to protect your practice, your profit and your professional reputation.

Written by Patricia Hull, representative, Claim Verification Department.

Professional Services Adds New Connecticut Coordinator

Delta Dental is pleased to introduce the newest member of our Professional Services staff. Desiree Fusco, dental network coordinator, serves dental offices throughout Connecticut, except Fairfield County.

Desiree's background includes six years as a dental/office assistant with an oral surgeon. She has also worked in a law firm and holds a bachelor's degree in legal studies. Delta Dental's Professional Services professionals are often the first point of contact between dental offices and Delta Dental. Dental network coordinators are available to provide answers and assistance about Delta Dental's policies and programs, including electronic claims processing, credentialing and our new In-Net program, which offers discounts on products and services for dental practices.

"I look forward to meeting the doctors in my territory and helping them in any way I can," says Desiree. She plans to become a familiar face to the Connecticut dental community. Desiree will be attending the Connecticut State Dental Association monthly meetings, including the all-day meeting September 13 at Aqua Turf in Plantsville, Connecticut. She also welcomes the opportunity to visit dental staffs at their offices. You may contact Desiree at (860) 585-9896.

Delta Dental Alliance Expands Network to Smaller Employers

A recent marketing alliance between Delta Dental Plan of New Jersey and the American General Financial Group/United States Life Insurance Company opens Delta Dental's network of dentists to more small-employer groups.

U.S. Life offers DeltaPreferred Option (which it calls New Jersey TruDent Preferred Dental Plan) to employers with 2-99 employees and DeltaPremier (which it calls the New Jersey TruDent Premier Dental Plan) to employers with 10-99 employees.

The program is marketed by U.S. Life and administered by Delta Dental. The Delta Dental logo is prominently displayed on patient ID cards. Patients in this program receive full DeltaPremier or DeltaPreferred Option benefits, including access and referrals to their plan's participating dentists. As with all our dental programs, Delta Dental's Customer Service Department handles all claim and benefit inquiries; call (800) 452-9310.

Handbook Revisions

In July, dentists in New Jersey and Connecticut were mailed revisions to the Participating Dentist Handbook.

These revisions include new coding information, including associated DeltaUSA processing policies, updated addresses of Delta Dental Plans in other states, new bylaws for New Jersey dentists, an updated diagnostic materials chart and new information about coordination of benefits.

If you did not receive the handbook or have questions, please contact your dental network coordinator at (888) 396-6641.

Congratulations, Convention Raffle Winners!

Hundreds of dentists visited the Delta Dental and DeltaLink booths at the annual New Jersey and Connecticut dental conventions, held last May.

Winners of the raffle drawings at the Connecticut State Dental Association Convention included:

Delta Dental

• Dr. Gregory Arnold, Torrington, Connecticut
• Dr. John Latvis, Bristol, Connecticut

DeltaLink

• Dr. Edward Fournier, Bristol, Connecticut
• Dr. John Wakim, Groton, Connecticut

Winners of the raffle drawings at the Mid-Atlantic Dental Expo (formerly the New Jersey Dental Association Annual Conference) were:

Delta Dental

• Dr. Richard Genung, Denville, New Jersey
• Dr. Karen Rosen, North Brunswick, New Jersey
• Susan Wyszynski, Ocean City, New Jersey

DeltaLink

• Dr. Mark Lefelt, Riverdale, New Jersey
• Dr. Harvey Rein, Aberdeen, New Jersey

Delta Dental raffle winners received duffel bags and golf paraphernalia. DeltaLink raffle winners received beach tote bags filled with a DeltaLink beach towel, beach ball, splash balls, key cases and other items.

Change in Benefit Categories

Effective July 15, 2000, unless otherwise specified by the group contract, the following services will be paid under the Basic Benefits Category and applied to the individual's annual maximum (if applicable). These services will no longer be paid under the Orthodontic Benefits category.

7280 Surgical Exposure of Tooth for Orthodontic Reasons
7290 Surgical Repositioning of Teeth
7291 Transseptal Fiberotomy, by Report