Frequently Asked Questions

Most dentists already know the broad prompt payment requirements, but may not be aware of the details that could save time and money.  As a refresher, except for Personal Injury Protection (auto) and Worker’s Compensation claims, virtually all other types of health/dental plans must pay “clean claims” within 30 days of receipt if submitted electronically or 40 days for paper claims.  Overdue claims are subject to an interest penalty of 10 percent per annum.  The regulations, including amendments that took effect on July 7, 2003, provide necessary direction on the following issues.


·       What constitutes a “clean claim”?  A “clean” claim means: (1) the service or supply is covered; (2) the claim is accompanied by all of the information requested on the claim form or in other instructions previously provided to the patient or practitioner; (3) the patient was eligible on the date of service; (4) the carrier does not reasonably believe the claim was submitted fraudulently; and (5) the claim does not require special treatment.


·       What prevents carriers from asserting that they need further documentation or that a claim requires special treatment?  Carriers must notify participating health care practitioners at least annually, and must make available to covered persons on request, a listing of the type of information and documentation that must be submitted with the claim.  Random requests for additional information are not allowed.  For example, unless the listing specifically requires submission of x-rays for certain types of claims, carriers are not allowed to request them later.  Further, the Department was emphatic that requirements preclude carriers from asserting the “special treatment” exception for a claim on which it is not justified.  “Special treatment” is limited to situations in which unusual review is required to determine if a service or supply is covered, such as claims involving experimental treatments or newly approved medications.  Carriers must document in the claim file the circumstances requiring special treatment.


·       What about the “suspected fraud” excuse?  If a carrier reasonably believes that the claim has been submitted fraudulently, it must investigate the claim in accordance with its statutorily required fraud prevention plan, or refer the claim to the Office of Insurance Fraud Prosecutor.  If no fraud is found to have been committed, the carrier must pay the claim with the applicable interest.


·       When is a claim considered “received” by the carrier?  Prior to the July 7, 2003 amendments, paper claims were considered received based on the U.S. mail postmark date, but this requirement was deleted.  As currently written, however, carriers must acknowledge receipt of all claims.  Electronic claims must be acknowledged electronically within two days of receipt to the entity from which the carrier received the claim.  Paper claims must be acknowledged within 15 working days.  The “acknowledgement” requirement may be satisfied by a carrier’s web-based access to claims status information, or automated telephone system that includes the date of receipt, if offered.


·       How will denied or disputed claims be handled?  If a carrier denies or disputes payment of the claim as submitted, written notification must be provided within 30 or 40 calendar days of receipt.  This written notification must identify and explain all of the reasons why the claim is being denied or disputed.  Thereafter, a carrier may not deny or dispute a claim for reasons other than those contained in the first review after the claim was entered into the system.  (Examples of why a claim could not be entered in the first review include missing information or ineligibility of the patient.)  In imposing this requirement, the Department’s apparent intent is to eliminate, whenever possible, processing practices that result in a prolonged string of separate denials.  With regard to missing information or documentation, the required notice must identify with specificity what additional information or documentation is required and the carrier must engage in a good faith effort to expeditiously obtain it.  The Department’s comments provided examples of a “good faith effort” which included telephone, fax and e-mail.  It further stated that a letter sent to the practitioner by regular mail would not be considered a good faith attempt to expeditiously obtain the information.


·       May carriers just “pend” claims to avoid the prompt payment timelines?  No, claims may not be “pended”; they must be denied, disputed, or paid in full.  If only a portion of the claim is disputed or denied, the carrier must pay the uncontested portion within the required time period.


·       Are carriers allowed to change the procedure code submitted by the dentist?  If a carrier changes a procedure code (e.g., downcodes), it is considered a disputed claim, and a complete explanation must be provided.


·       What happens when carriers do not provide the required notice that a claim is disputed or denied?  Carriers that do not provide the required notice waive their right to contest the claim for any reason other than fraud.


·       Must a dentist request interest on overdue claims?  No.  For overdue claims on which the 10 percent interest payment is applicable, the carrier must either include the interest payment in the claim payment, or remit the interest by separate check within 14 days of the claim payment.  Effective July 7, 2003, carriers may aggregate interest amounts up to $25.00 with the consent of the practitioner.


·       How will the prompt payment requirements be enforced?  Carriers are required to submit to the Department detailed reports on the timeliness of claim payments.  The reports must include, for example, total claims, claims disputed or denied, claims paid late, interest paid, etc.  The carrier, at its own expense, shall have its annual report audited by a private auditing firm.  Upon review of the reports, the Department may require the carrier to implement a remedial action plan and/or have its claim processing procedures monitored by a private auditing firm.  If, following remediation measures, the Department determines that a disproportionate number of claims continue to be disputed, denied, paid late, or that the carrier is failing to pay required interest on claims, the Commissioner may impose a civil penalty up to $10,000.


These regulations appear to address many of the problems experienced by dentists.  Dental office staff can also play a part in securing prompt payment by verifying that all required documentation accompanies the initial submission of the claim.  Also remember that original x-rays should not leave the dental office for virtually any reason.  In fact, at least two dental plans have recently announced that x-rays required to be submitted with a claim will not be returned.




Q:            What are the time requirements for payment of insurance claims?


A:            With the exception of Personal Injury Protection (PIP) and Workers’ Compensation claims, carriers (including various types of managed care plans) must pay “clean” claims within 30 days (for electronic claims), 40 days (for paper claims), or in the case of capitation payments, within 5 days of the due date.  Overdue payments must include simple interest at the rate of 10% per year.  However, certain self-insured plans and union trust funds governed by ERISA are not subject to state regulation.  Federal regulations that govern “ERISA” plans state that decisions on post-service claims must be made within 30 days, but that does not mean claims must be paid within 30 days.



Q:            An insurance company is requesting a refund for a claim it states was paid in error.  Must I comply?


A:            Absent a specific contractual agreement related to this issue between a dentist and a third party payer, it is widely held that an insurance carrier is not entitled to recover an “overpayment” made to an innocent third-party creditor (e.g., dentist) when: (1) the payment was made due solely to the insurer’s mistake; (2) the mistake was not induced by a misrepresentation of the third-party creditor; (3) the third party creditor acted in good faith without prior knowledge of this mistake; and, (4) the amount is not greater than the sum that was owed to the third party creditor.  If you receive such a request, contact NJDA for assistance.



Q:            When can a claim be submitted for a multi-visit procedure, such as endodontic or prosthetic procedures?


A:            The short answer is that, if prominent disclosure is provided on the form, a dentist may legally submit a claim at the beginning of treatment.  But dentists would be prudent to consider the long answer that follows before making a decision.


State Board of Dentistry regulations (N.J.A.C. 13:30-8.10) prohibit a licensee from submitting a claim that contains “any description of a dental service or procedure which does not accurately reflect the actual work completed.”  A dentist may submit a claim following initial treatment as long as the actual status of treatment is accurately and non-deceptively disclosed on the form to avoid allegations of fraudulent billing.  Dentists who use older versions of the ADA Standard Claim Form should also alter the dentist’s certification statement.  (The Version 2000 ADA Claim Form no longer requires dentists to certify that the submitted procedures have been completed; the new certification now states “I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed…”).  However, dentists should be alert to the fact that some plans “incur liability” when a procedure begins, but others don’t consider their liability to incur until a procedure is complete.  This is especially significant at the end of a calendar year or if a patient loses coverage in the middle of treatment.  Further, some plan participation agreements specifically state that a dentist may not submit claims until the procedure is complete.


Q:            What if I prepare a tooth for a crown and have the crown fabricated, but the patient never returns to have the new crown cemented?


A.            You can submit a claim by report, with a complete narrative explaining the circumstances.  If the plan in question “incurs liability” at treatment onset, it may make an allowance for the work that has been completed.  The same would apply to situations in which the patient does not return to have endodontic therapy completed. 



Q:            An insurance company is requesting a radiograph before it will pay my claim.  Must I comply?


A:            If the requested radiographs are available, dentists should submit diagnostic copies (never the original).  However, if radiographs were not necessary for diagnosis or treatment and, therefore, not taken, the carrier cannot withhold payment solely on the basis that radiographs did not accompany the claim.  State law (N.J.S.A. 45:6-18.2) provides that radiographs may be used in the course of dental services only for diagnostic or treatment purposes, not to verify the performance of dental services.  Further, New Jersey’s prompt payment regulations require plans to provide to participating dentists (or enrollees as the situation dictates) a list of their documentation requirements for various services.  This provision was intended to avoid situations in which payment was delayed due to the plan’s need for “further information”.  The Department of Banking and Insurance has stated that it is not acceptable for a plan to make “random” requests for information on submitted claims.



Q:            I do not accept insurance assignment in my office, but I do complete the claim form for the patient.  May I charge for this service?


A:            No.  State law (N.J.S.A. 45:6-18.1) prohibits dentists from charging for the completion of claim forms.  However, no law or regulation prevents dentists from charging a fee for the completion of pre-authorizations submitted at the patient’s request.  Further, effective October 1, 2002, state law (“HINT”) requires all practitioners to submit claims on behalf of patients unless the patient makes a specific request to submit the claim himself.  If benefits are not assigned, claims must be submitted within 60 days of the last date of service for a course of treatment.  On claims with a valid assignment of benefits, dentists have 180 days to submit the claim.  If these deadlines are not met, third party payers have the right to deny payment of the claim, and practitioners would be prohibited from collecting the payment from the patient.



Q:            If plans cover crowns, why do they deny claims for crowns placed on implants?


A:            Coverage for implant crowns is largely decided by the language contained in the plan’s master policy document.  Most dental plans exclude implants and anything attached to them.  However, some plans cover implants as well as the attached prosthetics, while others exclude implant surgery but do provide some alternate benefit for the crown or prosthetic.  Always pre-authorize any type of implant-related service.


Q:            I received payment from my patient’s dental plan based upon the plan’s determination of UCR, which is considerably less than my actual fee.    There is a statement on the check that the payment is considered “payment in full”.  Is this binding or may I deposit the check and bill the patient for the balance?


A:            This type of restriction is enforceable so, if you accept the check, you accept the payment as “payment in full”.  Some self-insured plans adopted this technique to hold down their costs but prevent them from being passed on to their employees.  This also occurs when an insurance company is impaired or becomes insolvent and payments are made from the “Insurance Guaranty Association”.  The law which created the association requires a “provider of health care services”, in order to receive payment, to forgive 20% of the obligation which would otherwise be paid by the insurer had it not been insolvent.



Q:            How can I legally waive the copayment for certain patients (e.g., clergy)?


A:            A dentist must “conspicuously disclose” on the face of the claim form that all or a portion of the copayment will not be collected from the patient.  Based on information reported to NJDA, it appears that the result of this disclosure may be that the plan will reduce its payment accordingly.  For example, if the plan normally covers 80% of the fee, but a dentist indicates that the 20% copayment will not be collected, the plan may only pay 80% of the amount that the dentist intends to collect (80% of 80%).  Failure to disclose waiver of copayment is considered insurance fraud.



Q:            I have a problem with a plan that my office has not been able to resolve.  What is my recourse?


A.            Member dentists can always turn to NJDA’s Claim Resolution Program (CRP) for assistance with a variety of non-payment issues, but only if the administrative remedies of the plan (e.g., appeal process) have been exhausted.  NJDA has been very successful in resolving problems.  In 2004, NJDA received a total 151 complaints; of this number, only three were not resolvable because of a specific policy limitation not previously communicated.  Thirty-three complaints were submitted for “data purposes only” after the dental office resolved the problem; this information is helpful in alerting NJDA to patterns of poor performance on the part of specific plans.  Contact NJDA’s Department of Dental Care Programs for a copy of the CRP form, which you should have the patient sign to authorize release of information to NJDA.