Fee Filing Info
The topic of fee levels is probably the most significant aspect of dental prepayment. At Delta, we recognize that fees are an extremely sensitive issue, with a need for maximum understanding by the patient, the dentist and us. Below is an explanation of the percentile calculations which will hopefully make it easier to understand.
- The 80th Percentile
- Filed Fees and Maximum Plan Allowance
- The Fee Filing Process
- Contractual Obligations
- Non-Participating Dentists
- Helpful Hints
The 80th Percentile
The 80th percentile maximum allowable is calculated based on the filed fees of all participating dentists. Filed fees are those fees usually charged and collected for a given service by an individual dentist to all of his/her private patients. The maximum plan allowance is a determination of what should be a market rate fee for any dentist to charge.
Filed Fees and Maximum Plan Allowance
Participating dentists file their fees with Delta Dental for procedure codes performed by their office. A filed fee is your Delta Dental accepted fee charged to your patients for a given service. Fees that are filed at or below the Delta Dental Maximum Plan Allowance (MPA) are accepted. Fees filed at a rate higher than the Delta Dental MPA, must be adjusted.
The Delta Dental MPA for each procedure code is based on the fees filed by approximately eight out of ten Delta Dental participating dentists and various marketplace factors. The Delta Dental MPA is set up regionally. The maximums developed by this method are reviewed once a year. Any changes in the Maximum Plan Allowance will be effective January 1st. As a participating dentist, you may revise your fees annually.
Fees for Specialists
By definition, the 80th percentile assumes the filed fees are being compiled and compared with dentists of similar training and experience for the same service. It is important to understand the term "same service." If the service provided by the specialist is exactly the same as that provided by the general dentist, the maximum fee is the same for both (e.g. full mouth x-rays). However, if the procedures are specific to a specialist's training the specialist will be reimbursed at a higher Maximum Plan Allowance.
The Fee Filing Process
Fee Filing & Collection
The process begins with the individual dentist completing the DDIC Confidential Fee Listing and Participating Dentist Agreement, and submitting the form to ODS. The dentists individual fees and the Maximum Plan Allowance are kept completely confidential.
Provision for Fee Increases
Each dentist may submit a new fee for each procedure once every year. The fees are collected for a period of two years and then a new Maximum Plan Allowance is calculated.
Response to Fees
If a particular fee is within the Maximum Plan Allowance, a letter is sent advising the dentist that their fee is accepted. When filed fees exceed the Maximum Plan Allowance the dentist is advised that the fee needs to be adjusted. The effective date of your filed fees is the date signed on page 12 of the DDIC Confidential Fee Listing and Participating Dentist Agreement.
Contractual Obligations
The dentist, as part of his/her contract with DDIC , agrees that his/her reimbursement for covered services will not exceed their filed fee or the maximum allowable (80th percentile).
DDIC , as part of our contract with our subscribers, agrees to allow the full, actual accepted fee of the participating dentist. Therefore, if our program provides 80% payment, we pay 80% of the full, actual accepted fee.
The subscriber, as part of his/her contract with DDIC , has a guarantee that he/she will not receive any charges in addition to their co-payment percentage (e.g. 20%). The patient looks upon this as a "hold harmless" agreement, i.e. they will not have to pay any excess charges on services received that are part of the standard benefit contract.
Non-Participating Dentists
Claims received for treatment performed by non-participating dentists are paid differently if the Delta member is insured through an out of state control plan. In this case, the maximum allowable fee is established as the 51st percentile.
Helpful Hints
- Payments from Delta to participating dentists are based on their accepted fees with DDIC .
- A Confidential Fee Listing form must be submitted whenever a fee revision is requested.
- Dentists may submit a new fee for each procedure once every year.
- Do not list fees for procedures on the survey that you do not routinely perform in your office.
- When a given procedure has complications or extenuating circumstances, dentists may submit a narrative explanation which will be reviewed by our Dental Consultant.