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Do the primary dental insurance rules govern the allowed charges from the dentist?
Wiki User
∙ 14y ago
The answer to the question, is it depends. State laws on coordination of benefits (CoB) can impact the answer, but there is a general rule of thumb. If the dentist participates in a network that is connected to the patient's coverage--whether that coverage is primary or secondary, the participating network contractual relationship determines the amount that can be collected from the patient.
Here's a table that was developed by the National Association of Dental Plans outlining various CoB scenarios and what determines the charges to patients under each.
PATIENT COVERAGEWHAT THE DENTIST CHARGES THE PATIENTPrimary and secondary coverage are both DPPOs; Office participates in both network plans.The DPPO allowances of the primary plan.Primary coverage is a DPPO, and the secondary coverage is an indemnity plan.The DPPO allowances of the primary plan.Indemnity plan is primary, and the secondary coverage is a DPPO.The DPPO allowances of the secondary plan. Primary coverage is an DHMO, and the secondary is an indemnity plan.The DHMO patient co-payments. (The secondary indemnity plan may cover all or most of these co-payments.)Indemnity plan is primary, and the secondary coverage is an DHMO.The DHMO patient co-payments. (The primary indemnity plan may cover all or most of these co-payments.)Primary coverage is a DPPO, and an DHMO is the secondary plan.The DPPO allowances of the primary plan.Primary coverage is an DHMO, and the DPPO is the secondary plan.The DHMO patient co-payments. (The secondary DPPO plan may cover all or most of these co-payments.)
NOTE: Discount dental plans are not subject to COB laws and regulations as they are not insurance products.
Wiki User
∙ 14y ago
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What happens if primary insurance is PPO and secondary insurance is HMO?
When a DPPO is primary coverage, the charges paid by the patient are based on the agreed DPPO discounted fees--not the DHMO schedule of charges. The dentist would bill the DPPO for the procedures performed. If the dentist is in the DHMO network, he or she would also get his or her regular capitation payment for that patient.
When will secondary health insurance not pay?
if primary paid more than allowed amount or if patient has primary insurance
If you sign up for a discount dental plan do you have to find a dentist that accepts both your primary insurance and the discount plan?
Yes, if you want to get the value of both products, i.e. the payment from your primary insurance and the discounts on procedures that are not covered by primary insurance, you need to find a dentist that is covered by both products. If you are only using the discount product for just cosmetic procedures that are not covered by your insurance, you could go to a separate dentist, but depending on the procedures it could have an impact on other treatment planning. So it is best to discuss with your regular dentist. Also, you should also disclose that you have the discount coverage when filing a claim with the insurer.
Is primary insurance copays covered under secondary insurance?
Depending on your coverage, your primary insurance will cover 80% of your charges, minus your deductible (if not already met). Your secondary insurance will pick up the remaining 20% co-insurance and your co-pay, if you have one.
If the primary insurance allows more than the secondary insurance what would the secondary insurance pay?
Secondary insurance will not pay the claim but the remaining charges should not be billed to the member/patient. Provider of service should write off the patient responsibility that primary insurance applied.
If primary insurance pays more than what the secondary allowed?
The balance gets adjusted.
When a primary insurance payer pays 0 on a 1000 bill and a secondary pays 700 with a 700 contracted amount do you have to pay the difference 300?
With out a doubt...yes. Unless your dentist is a contracted provider through your insurance company, in that case they might have to adjust your account to what the contracted (allowed) fee is per the insurance company. If they are not a contracted provider they don't have to adjust one dime!
If Primary insurance paid more thatsecondary would allow. Is patient responsible for deductible and coinsurance?
Is the patient responsible for deductible and coinsurance if primary insurance paid more than secondary would have allowed.
What happens when one is covered by two insurance plans?
That is if the secondary does not have a clause in it that "they will not duplicate benefits" If so they will not always pay the difference. They will figure out the amount they would normally pay, subtract what the primary pays from that amount and pay the difference (which with mine is little to nothing and I end up paying the balance of the bill) Nothing really happens, one is the primary and the other is the secondary insurance for the patient. Primary insurance will pay up to 80% of allowed charges if the deductible is met, and the secondary insurance will pay the remaining 20% of the claim, again, if the deductible for the year has been met.
If the secondary insurance has a higher allowed amount than the primary insurance is the secondary required to pay the higher amount?
I need more details in order to answer this question.
Is it required to make a primary dental insurance adjustment if the dentist is a preferred provider before submitting a claim to secondary insurance?
You wait until both claims are received then write off the lesser of the two amounts
If parents are divorced which insurance is primary?
I think the wife's insurance is primary.
