A participating provider must submit filed fees that reflect the fees most frequently charged to and collected from their uninsured patients for the same procedures.
One of the provisions of the Delta Dental of New Jersey Participation Agreement is the dentist’s agreement not to charge a Delta Dental covered person more than the dentist’s “usual” fee.
The definition of “usual” fee is the fee for a specified procedure or series of procedures that the dentist most frequently accepts from his or her non-insured patients as payment in full, less any discount that is regularly offered to patients (other than a discount that reasonably reflects the time value of money).
This policy protects both Delta Dental and the patient from being charged more for procedures because there is dental coverage to pay the fee. It also protects the patient if Delta Dental does not pay the entire fee.
Submitting claims to Delta Dental that contain fees in excess of a provider’s “usual fee” can result in overpayments that are recoverable. Consequently, it is important that dentists periodically review their “usual” fees for procedures filed with Delta Dental and file revisions as needed.
For more information, please refer to:
The Delta Dental of New Jersey Participation Agreement.
The Delta Dental of New Jersey Rules and Regulations.
The Delta Dental of New Jersey Dentist Handbook for Participating Dentists, Chapter 2, Rules and Regulations and Chapter 11, Claim Verifications.
