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Patient Responsibility

Patient responsibility when a service is not covered

Is the Participating Dentist Limited to the Approved Fee?

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Choose your state


A C D F G H I K L M N O P R S T U V W

A


Alabama
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of Service

Effective Date of noncovered services law

  • N/A

Alaska
Age Limitation denial

  • No; if a service is not covered under the contract, Alaska does not hold dentists to their filed fees.

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes; it does not make a difference if Alaska paid part or nothing.

Service rendered on a tooth that is not eligible (Ex - sealants)

  • If the service is not covered under the contract, then AK does not hold the dentist to the MPA/filed fee. If the service is covered and only being denied for frequency or maximum, then AK does hold the dentist to their filed fee.

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing Date


Effective Date of noncovered services law

  • 9/13/2010

Arizona
Age Limitation denial

  • Yes

Yes

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing Date

Effective Date of noncovered services law

  • 1/1/2011

Arkansas
Age Limitation denial

  • No for age limitations. Yes for time limitations

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes - It does not make a difference.

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes - Including composites to amalgams effective 9/9/15

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A due to no change in current processing

Effective Date of noncovered services law

  • 3/22/2011

C


California
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 1/1/2011

Colorado
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Connecticut
Age Limitation denial

  • Yes, where the Connecticut law (PA 11-58, Section 19) does not apply. The Connecticut law does NOT apply to self-funded contracts or to insured coverage contracts that are incorporated in or derived from a collective bargaining agreement.

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes, where the CT law (PA 11-58, Section 19) does not apply. The CT law does NOT apply to self-funded contracts or to insured coverage contracts that are incorporated in or derived from a collective bargaining agreement.

Member's plan does not include coverage for this service

  • Yes, where the CT law (PA 11-58, Section 19) does not apply. The CT law does NOT apply to self-funded contracts or to insured coverage contracts that are incorporated in or derived from a collective bargaining agreement.

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • As of processing date 01/01/2012: CT law (PA 11-58, Section 19) does not allow holding DDS to maximum approved fee for non-covered services. The CT law does NOT apply to self funded contracts or to insured coverage contracts that are incorporated in or derived from a collective bargaining agreement.

Effective Date of noncovered services law

  • 1/1/2012

D


Delaware
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of Service

Effective Date of noncovered services law

  • N/A

District of Columbia
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of Service

Effective Date of noncovered services law

  • N/A

F


Florida
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of Service

Effective Date of noncovered services law

  • 7/1/2014

G


Georgia
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes 

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of Service

Effective Date of noncovered services law

  • 7/1/2011

H


Hawaii
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A

Effective Date of noncovered services law

  • N/A

I


Idaho
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Effective 1/1/2013

Effective Date of noncovered services law

  • 1/1/2013

Illinois
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Only if the original submitted code is included in the group's benefit plan. If not, we do not hold

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Claims processed for an Illinois dentist cannot hold that dentist to the MPA for a service not included in the group benefit plan

Effective Date of noncovered services law

  • 1/1/2013

Indiana
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Iowa
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • No

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing date

Effective Date of noncovered services law

  • 7/1/2010

K


Kansas
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/1/2010

Kentucky
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Legislation prohibiting dental insurers from holding providers to allowed fees for non covered services KRS 304.17C-085

Effective Date of noncovered services law

  • 7/1/2012

L


Louisiana
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 1/1/2011

M


Maine
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Maryland
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 10/1/2011

Massachusetts
Age Limitation denial

  • Yes, but not for orthodontic services if it has a specific age limit

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • We are in the process of implementation until pending legislation in Massachusetts  is finalized.

Effective Date of noncovered services law

  • Pending

Michigan
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Minnesota
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes, payment makes no difference

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing date

Effective Date of noncovered services law

  • 8/1/2011

Mississippi
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/1/2012

Missouri
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing date

Effective Date of noncovered services law

  • 8/28/2013

Montana
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing date

Effective Date of noncovered services law

  • 7/2/2013

N


Nebraska
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/15/2010

Nevada
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

New Jersey
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Effective for contracts issued or renewed on 11- 28-14 or thereafter. It is unclear as to whether “contracts” refers to participation agreements or coverage contracts. DDNJ intends to automatically apply the law to all dentists and to all fully insured contracts for dates of service 7-1- 15 and thereafter

Effective Date of noncovered services law

  • 11/28/2014

New Mexico
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 4/7/2011

New York
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

North Carolina
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/21/2010

North Dakota
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A due to no change in current processing.

Effective Date of noncovered services law

  • N/A

O


Ohio
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Oklahoma
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Oregon
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • If the service is not covered under the contract, then OR does not hold the dentist to the MPA/filed fee. If the service is covered and only being denied for frequency or maximum, then OR does hold the dentist to their filed fee.

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 3/18/2010

P


Pennsylvania
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A

Effective Date of noncovered services law

  • 12/24/2012

Puerto Rico
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A

Effective Date of noncovered services law

  • N/A

R


Rhode Island
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • No, unless $1 or more paid

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • No

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A

Effective Date of noncovered services law

  • 6/18/2009

S


South Carolina
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • N/A

Effective Date of noncovered services law

  • N/A

South Dakota
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/1/2010

T


Tennessee
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 5/23/2011

Texas
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 9/1/2011

U


Utah
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

V


Vermont
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • Yes

Eligibility denial

  • No

Waiting Period denial

  • No

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Virginia
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • N/A

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • VA's contracts have been written to pay this way all along; nothing will be changing.

Effective Date of noncovered services law

  • 7/1/2010

W


Washington
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • We cannot implement per WA state Substitute House Bill 2686

Effective Date of noncovered services law

  • 6/10/2010

West Virginia
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • Yes

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • N/A

Wisconsin
Age Limitation denial

  • No

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • No

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Processing date

Effective Date of noncovered services law

  • 1/1/2014

Wyoming
Age Limitation denial

  • Yes

No payment on procedure due to patient and/or family maximum reached or frequency denials

  • Yes

Service rendered on a tooth that is not eligible (Ex - sealants)

  • Yes

Member's plan does not include coverage for this service

  • No

Eligibility denial

  • No

Waiting Period denial

  • Yes

Alternate Benefit provided (Ex - composite filling submitted and an alternate benefit of an amalgam is provided)

  • Yes

Service denied due to clinical review

  • No

When you implemented the noncovered services policy, was it based on the claim's date of service or the processing date?

  • Date of service

Effective Date of noncovered services law

  • 7/1/2011