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Patient responsibility
Patient responsibility when a service is not covered
Is the participating Dentist limited to the approved fee?
A
- 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
- 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
- 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?
- 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
- 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
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
- 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
Connecticut
Age Limitation denial
- No for CT insured contracts where the CT law applies. 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.
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 for CT insured contracts where the CT law applies. 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
- No for CT insured contracts where the CT law applies. 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
- 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
- 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
- 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
- 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
- N/A
I
- 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
- Yes
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
- 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, effective 7/1/22
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, effective 7/1/22
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
- 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
- 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
- No
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
- 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
- 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
- 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
- Yes
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
- 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
- 8/1/2011
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
- 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
- 8/28/2013
- 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
- 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
- 7/15/2010
- 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 for NJ insured contracts. Yes, when NJ law doesn't apply as for example, for self-funded contracts.
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 for NJ insured contracts. Yes, when NJ law doesn't apply as for example, for self-funded contracts.
Member's plan does not include coverage for this service
- No for NJ insured contracts. Yes, when NJ law doesn't apply as for example, for self-funded contracts.
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
- 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
- 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 the current processing
Effective Date of noncovered services law
- N/A
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
- 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?
- Processing date
Effective Date of noncovered services law
- 8/1/2011
O
- 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
- 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
- N/A
- 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
- 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
- 9/1/2011
U
- 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
- 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
- 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
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
- 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)
- No
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
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
