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The United States Department of
Labor recently adopted regulations governing claim
adjudication and appeals for group health plans governed
by ERISA (Claim Procedure Regulations-Title 1 - 29 CFR
2560.503.1). The new claims and appeals procedures apply
to all ERISA plans, whether insured ("risk")
or self-funded ("ASO" or "ASC").
This process applied to all ERISA plans for which Delta
Dental provides coverage or administration. Delta Dental
is also applying a similar set of processes to non-ERISA
plans for which we provide coverage on a risk basis.
Some key points include:
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Predetermination of
benefits not required. However, patients and
their dentists may request a predetermination to
obtain advance information about the plan's possible
coverage of services before they are rendered.
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Patients and dentists will
usually be notified in writing within 30 days of
Delta Dental's claim determination. If special
circumstances require extra time (not to exceed 15
days), Delta Dental will inform them in writing.
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Explanation of Benefits
(EOB) forms (sometimes referred to as Adverse
Benefit Determinations) are the means used to inform
patients and dentists about why their claim was
denied. EOBs also contain information about
Delta Dental's informal and formal appeals
processes, as well as time limits applicable to the
processes. (To view a sample EOB, go to
www.deltadentalnj.com, click "Subscribers"
and then click "View an easy-to-read
description of our Explanation of Benefits
statement, PDF Format.") A summary of Delta
Dental's Benefit Determination and Appeal Process is
also available from our Web site; click
"Subscribers," then "Benefit
Determination & Appeal Process." This is
also available under the Home page "What's
New" section.
Our Web site also includes a
description of how subscribers or billing dentists can
request reviews of the Adverse Benefit Determination;
the timeline for such reviews; and the steps then taken
by Delta Dental during the reviews. The Web site also
includes special provisions applicable only to DeltaCare
programs.
You may obtain answers to
frequently asked questions from the U.S. Department of
Labor Web site at
www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html.
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