Let’s face it, insurance reimbursements can get complicated.
Before you begin to contract with any Carrier, make sure you understand how the 3 different kinds of relationships a Provider can have with a Carrier (dental insurance) and their associated Payor Lists (Network Partner/Payor List/Third Party Administrator ‘TPA’) may affect how a Provider is reimbursed.
Understand Your Carrier Relationship:
- Direct Contract – If a Provider is directly contracted with a Carrier, they will be reimbursed at that contracted fee schedule. A direct contract supersedes any relationships and fee schedules that may exist with Carriers listed in Payor Lists.
- Carrier listed in only 1 contracted Payor List – If the Provider is not directly contracted with the Carrier (See #1), and the Carrier is listed in only 1 of the Provider’s contracted Payor Lists, call the Carrier to verify the patient’s eligibility and to verify their plan is covered under the associated Payor List. The Provider should be reimbursed at the contracted fees associated with the Payor List.
- Carrier listed in multiple contracted Payor Lists – If the Provider is not directly contracted with the Carrier (See #1), and the Carrier is listed on multiple of the Provider’s contracted Payor Lists, call the Carrier to verify the patient’s eligibility and to verify their plan is covered under the associated Payor Lists. The Provider may be reimbursed at the lowest of the Carrier’s associated Payor List fee schedules with whom the Provider is contracted.
Important – It is the sole responsibility of the Practice to verify benefits and eligibility with the Carrier prior to performing services. Not all Carrier plans may be included in the associated Payor Lists and participating Carriers may change at any time without notice.