Plan Administration | Dental Plan

The last item to be addressed is claims administration. The nature of dentistry and dental plan design suggests that claims administration is very important. While several years may lapse before an insured has occasion to file a medical claim, rarely does the year pass during which a family will not visit the dentist at least once. Therefore, claims administration capability is an extremely important consideration in selecting a plan carrier—and might very well be the most important consideration.

One key element of claims administration is "predetermination of benefits." This common plan feature requires the dentist to prepare a treatment plan that shows the work and cost before any services begin. This treatment plan generally is required only for nonemergency services and only if the cost is expected to exceed some specified level, such as $300. The carrier processes this information to determine exactly how much the dental plan will pay. Also, selected claims are referred to the carrier's dental consultants to assess the appropriateness of the recommended treatment. If there are any questions, the dental consultant discusses the treatment plan with the dentist prior to performing the services.

Predetermination is very important both in promoting better quality care and in reducing costs. These benefits are accomplished by spotting unnecessary expenses, treatments that cannot be expected to last, instances of coverage duplication, and charges higher than usual and customary before extensive and expensive work begins. Predetermination of benefits can be effective in reducing claim costs by as much as 5 percent. Predetermination also advises the covered individual of the exact amount of reimbursement under the plan prior to commencement of treatment.

Also important are alternate treatment provisions. These provisions enable the plan administrator either to approve the least costly, equally effective treatment option or to cover more expensive procedures only at the level of the less expensive alternative. Alternate treatment provisions, adopted by most plan sponsors, can reduce plan costs up to 5 percent.