Coordination of Benefits – Medical vs. Dental

It’s something we are familiar with in dentistry, coordination of benefits between carriers. Often times when you have a primary and a secondary dental carrier the secondary will not duplicate benefits paid by the primary. Legally you should only be collecting up to your usual and customary office fees for procedures but often times you will be limited to one carrier’s fee schedule if you are a contracted provider.

We strongly encourage offices to not file concurrent claims with the medical and dental insurances. There are many reasons for this. The first being that the dental may require the medical carrier’s explanation of benefits to make payment so you will just need to wait for the medical claim to adjudicate anyways while the dental claim sits tied up with the dental carrier.

Secondly, if your patient has met their deductible and their out of pocket maximums and their services are payable under their medical then you stand to collect 100% of your billed charges. This would eliminate the need to file with the patient’s dental carrier. Legally, if you have collected 100% of your usual and customary fee from the medical carrier you cannot seek reimbursement from the patient’s dental carrier unless permitted by your state laws. Any payment received over the full usual and customary fees should be returned to the carrier as an overpayment.

If you receive payment from the medical and you have not collected 100% of your usual and customary fees then go forward with filing your claim to the patient’s dental carrier with a copy of the medical EOB for reference. Most dental carriers will make the remainder of the payment up to your contracted allowable.

Jamie King

Marketing Manager