Delta Dental recently revised its Article XIV, Sections 5-8 of its Bylaws and Sections 1, 4, 8 and 16 of the Rules and Regulations. The revisions are effective as of February 1, 2007. The changes are important and we urge you to read them carefully. You may print out replacement pages from our Web site (www.deltadentalnj.com; log into Benefits Connection from the Dentists home page; click “Participating Handbook” from the left navigation bar and then “Participation Fees” from the Table of Contents) for insertion in your Dentist Handbook. You may call (877) 837-3787 to request hard copies of these pages.
The Bylaw revisions address requests by Delta Dental for information and documentation from you as a participating dentist as well as the substance and timing of your response to such a request. They also address the circumstances which may result in cancellation of a participation agreement and authorize the President of Delta Dental to terminate a participation agreement when the Participating Dentist has breached the participation agreement or the Rules and Regulations. In addition, they now expressly prohibit a dentist from collecting any fee for services submitted to Delta Dental in a claim in which the Participating Dentist provides false information to Delta Dental (there is an exception relating to certain typographical errors). You will also note that they eliminate the "UCR" terminology in favor of "approved fee" terminology.
The revisions to the Rules and Regulations include a provision which authorizes Delta Dental to require that Participating Dentists record specific types of information for procedures which they perform and submit to Delta Dental for payment and to provide that a Participating Dentist is not entitled to receive payment for such services where the required information has not been recorded and preserved. Should Delta Dental proceed to implement this requirement, it would issue a notice to you which identifies the procedure(s) involved and the detailed information which you must record when you perform that procedure. By way of example, Delta Dental may determine that a Participating Dentist should record the reason for needing to perform a surgical extraction as well as suturing and any prescription written to the patient. If Delta Dental did so and provided written notice to you to that effect in accordance with the notice provision of the Rules and Regulations, you would be obligated to record that information whenever you performed surgical extractions on Delta Dental patients or forego charging for the surgical extraction.
Other revisions to the Participating Dentist Rules and Regulations include a detailed process for responding to Delta Dental's requests for information and documentation and addressing objections to Delta Dental's requests. The Revised Rule provides for reimbursement to the Participating Dentist for certain costs incurred in photocopying records at Delta Dental's request and/or out of pocket expenses incurred in obtaining other records at Delta Dental's request. In addition, the revisions eliminate the "UCR" terminology as discussed above.
Please also note that the Revised Rules address the imposition of service fees which Participating Dentists may impose upon Delta Dental patients. In the past, the Rules and Regulations prohibited Participating Dentists from imposing a fee for completing requests for preestimates of payment. The Rules and Regulations now also address other types of service fees. They permit certain fees under certain circumstances and prohibit others. They are designed to protect Delta Dental patients while simultaneously allowing Participating Dentists to charge reasonable fees when the Delta Dental patient has not acted appropriately (e.g. issuing a "bad check" to the Participating Dentist.)
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Bylaws Changes: Article XIV Participating Dentists (Revised Sections Only)
SECTION 5. Participating Dentists shall furnish to the corporation all information, documentation, and reports and produce patients’ files (including billing records) required by action of the President or his designee or the Board of Trustees or a committee thereof and shall cooperate with the President or his designee, and the Board of Trustees or any committee thereof, in any compliance review and any investigation pertaining to the dentist’s action as a Participating Dentist provided that the dentist is not required to produce any information and/or documentation which is not relevant to the issue as to whether or not dentist has either breached the participation agreement and/or overbilled or attempted to overbill Delta. If a Participating Dentist disputes the relevancy of information and/or documentation requested by Delta, the Participating Dentist must timely follow the procedures set forth in the Rules and Regulations and the dispute shall be resolved pursuant to such procedures. The President is authorized to terminate the Participation Agreement of any Participating Dentist who fails to fully and/or timely comply with this section and/or any determination issued pursuant to the procedures set forth in the Rules and Regulations.
SECTION 6. The President may terminate the participation contract with any dentist or impose conditions upon its continuation, (including but not limited to mandating preauthorization of claims, specific fee verifications and /or offsetting the cost of fee verifications conducted by Delta) for any breach by the Dentist of his/her Participation Agreement. This includes without limitation any knowing violation of any provision of the Article XIV or the Participating Dentist Rules and Regulations.
SECTION 7(a). A Participating Dentist shall have no right to payment for any claims submitted to the Corporation which contained false information concerning the claim, including but not limited to the service performed, the date of service, the fee, or non-disclosure of other coverage unless the error was typographical in nature and not part of a pattern. A "pattern" for purposes of this section means five or more misrepresentations of the same type (e.g. five or more claims with misrepresented services, whether or not the services were the same CDT code or category).
(b). The Participating Dentist shall refund all payments received from the Corporation or groups for which the Corporation directly issued a benefit check to the Participating Dentist for any claims of the type referred to in Section 7(a) within thirty (30) days of the Corporation's request therefor and shall have no right to payment or offset from the Corporation or the covered person as a result of returning such payment.
SECTION 8. APPROVED FEE, USUAL FEE
(a). The Participating Dentist shall not be entitled to accept or receive from Delta and/or the covered person a fee greater than the "approved fee" for the respective procedure.
(b). "Approved fee" means the fee amount for the respective procedure which Delta has approved. It is the lowest of (i) the Dentist's actual fee charged and intended to be collected for the procedure, (ii) the Dentist's "usual" fee for the respective procedure as filed with Delta in accordance with these Bylaws and the Participating Dentist Rules and Regulations, and (iii) the fee level for the procedure that Delta Dental has established based on its dentists' filed and/or submitted fees as well as other data designed to produce a competitive and attractive fee level.
(c). "Usual" Fee. A Dentist's "usual" fee is the fee for a specified procedure or series of procedures which the Dentist most frequently accepts from his or her non-covered patients as payment in full, less any discount which is regularly offered to patients, other than a discount which reasonably reflects the time value of money.
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Delta Dental of New Jersey, Inc. Participating Dentist Rules and Regulations (Revised and Restated as of February 1, 2007) (Revised Provisions Only)
These rules and regulations apply to all Participating Dentists. These regulations are revised and restated effective as of February 1, 2007:
- (a) Participating Dentists shall prepare and maintain legible records concerning the services rendered to patients covered by the Corporation (as defined in No. 14 below) and the amounts billed and collected for such services in accordance with state law. The Corporation may, on due notice, require that Participating Dentists record specific detailed information for one or more dental procedures performed on persons covered by the Corporation. If the Participating Dentist fails to promptly record all of the required information and preserve it for the time period required by this section, the Participating Dentist shall be deemed not to have performed the procedure and shall have no right to collect any payment therefor from the Corporation and/or the patient. Such records shall be maintained for at least seven years from the date of the respective rendition of such service, the issuance of such bill, and the receipt of such payment. In the event that the record is not readily readable, the Participating Dentist shall promptly provide a transcription of such record upon request by the Corporation. Participating Dentist shall make all such records available to the Corporation or its designee for review and/or copying during normal business hours upon request. Participating Dentist shall comply with all applicable laws and regulations regarding the privacy and confidentiality of all records maintained pursuant to the Participation Agreement and/or the Rules and Regulations.
(b) Participating Dentists shall provide to the Corporation any information or documentation that the Corporation requests in order to determine: (i) whether the Participating Dentist has misrepresented information to the Corporation (e.g. submitted claims, requests for estimates of benefits or fee filings that contained inaccurate information and/or incomplete information); (ii) the genuineness and/or completeness of documents produced by the Participating Dentist; and/or (iii) whether documentation or information requested by the Corporation has been withheld and/or disposed of. Participating Dentists shall provide such information and/or documentation within the timeframe requested by the Corporation. If the Participating Dentist believes that the period of time provided by the Corporation is insufficient, the Participating Dentist shall notify the Corporation in writing within ten (10) days of receipt of the Corporation’s request that the Participating Dentist objects to the Corporation’s request and further specify the time period that the Participating Dentist believes is reasonably necessary to retrieve and produce the requested information and documentation and the reason(s) therefor. If the Participating Dentist believes that any of the information and/or documentation requested by the Corporation is not pertinent to (i), (ii), or (iii) of this section, Participating Dentist shall notify the Corporation in writing and in detail within the same ten (10) day period as to the information and/or documentation which the Participating Dentist asserts is not pertinent and the reason(s) why it is not pertinent and simultaneously provide the remainder of the requested information and/or documentation. If the Corporation notifies the Participating Dentist that it agrees with the Participating Dentist’s request for additional time, the Participating Dentist shall produce the requested information and documentation within the time period requested by the Participating Dentist. If the Corporation objects to the additional time period and/or to the extent and/or limitation on the information and/or documentation to be produced, it shall so advise the Participating Dentist and the Participating Dentist must fully comply with that decision. Every rejection by the Corporation of a Participating Dentist’s request to extend the time to provide information and/or documentation or to limit the amount of information and/or documentation to be provided to the Corporation shall be reviewed and approved in advance by the President of the Corporation or his designee.
(c) The Corporation shall pay Participating Dentists for copies of documents produced by Participating Dentists at the Corporation's request. The fee shall be $.15 per page when copied by the Participating Dentist. The Participating Dentist shall not be entitled to compensation for any expenses incurred in connection with the review and/or redaction of records for production to the Corporation or for the retrieval of information within the possession or control of the Participating Dentist. The Corporation shall reimburse the Participating Dentist for any out-of-pocket expenses incurred in obtaining information or documentation (e.g. bank charges).
- Participating Dentists shall not collect from a patient covered by the Corporation a fee which exceeds the approved fee for that procedure as determined by the Corporation. Nor shall Participating Dentists collect from a patient covered by the Corporation a fee for a component part of a service which exceeds the approved fee for the more comprehensive service as determined by the Corporation.
- (a) Participating Dentist shall not impose any fee on a subscriber or covered person for preparing or completing any claim form or request for predetermination of benefits (including preparation of necessary charting or narrative) to be submitted to the Corporation. Participating Dentists shall not impose any service fee or similar charge upon the Corporation or upon a subscriber or covered person arising out of claims which were and/or should have been submitted to the Corporation which fee or charge relates to the processing, payment, or adjustment of claims by the Corporation or the return of funds received from the Corporation for claims paid to the Participating Dentist. Nor shall a Participating Dentist impose any other service fee upon a subscriber or covered person unless: (i) the subscriber or covered person has agreed to the fee in writing; (ii) the amount of the fee is reasonable; and (iii) the fee is imposed for services requested by and/or caused by the subscriber and/or covered person.
(b) The Participating Dentists shall submit claims to the Corporation within one year from the date of service or their receipt of payment therefor from a primary plan (where there is coordination of benefits), whichever is later, and shall not collect the charge therefor from the Corporation and/or the patient should the Participating Dentist fail to file claims within this time period.
- Delta Dental may revise and/or supplement these regulations from time to time, such revision(s) and/or supplement(s) to be effective and binding upon Participating Dentists at the later of: (a) The effective date specified by Delta Dental or (b) The earlier of: (i) Ten (10) days following the Participating Dentist's receipt of the revised and/or the supplemental regulations(s); or (ii) Thirty days following the Participating Dentist's receipt of notice from Delta Dental that the revised and/or supplemental regulation(s) are posted on Delta Dental's website and available in hard copy upon request by the Participating Dentist. For purposes of this subsection, Delta Dental may give such notice in Delta Dental publications (such as the Dental News) or in transmissions it makes in the ordinary course of business (such as with payments and/or related communications)."
