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Aetna Life & Casualty Statement of Claim Practices and Procedures with Respect to Dental Expense Benefits
During recent months, the Council on Dental Care Programs has met with representatives of Aetna Life & Casualty regarding that company’s philosophy and administrative procedures with respect to its dental expense benefit programs. The discussions have been cordial and helpful in working toward the resolution of mutual prob lems. Aetna has now prepared a formal statement of claim prac tices and procedures. In addition to further discussions with the Council, Aetna will be contacting every component dental society to further clarify and explain its method of dental benefit adminis tration. Because the Council believes the Aetna statement to be of significant interest to all dentists, it is presented herewith. Council on Dental Care Programs
A e t n a L ife & C a s u a lt y s t a t e m e n t o f c la im p r a c tic e s a n d p r o c e d u r e s w ith r e s p e c t to d e n ta l e x p e n s e b e n e fits
The intent of Aetna Life & Casualty is to deter mine for each claim the proper liability o f the dental benefit plan under which the claimant is covered in order to assure full and equitable payment to all claimants, and its claim prac tices and procedures are designed to achieve that intent. Each claim is reviewed and evaluated in terms o f the coverage provided by the plan. Informa tion pertaining to the claimant, and the nature and cost of treatment and services is obtained from the claimant, the attending dentist, and the policyholder. The claim information is screened by claim processors and additional information is obtained, or clarified as necessary. Where there are questions concerning the professional aspects o f the treatment or services, the claim is referred to experienced consulting dentists for review and evaluation. The calculation of
the benefit payment is described to the claim ant, and for those claims where pretreatment review (predetermination) takes place, explana tion of the benefits payable is usually provided to the claimant and his attending dentist. Sub mission for pretreatment review is encouraged. The information required for each claim must be sufficient to determine the disease or injury present, the nature and extent o f treatment and services, and the charges for each service. Pre treatment X-rays are required in connection with certain services for review with other avail able information by the consulting dentist. For some claims, in-mouth examinations are con ducted by an examining dentist on a pretreat ment or posttreatment basis. Aetna is fully in accord with the “ Guidelines on U se of Radiographs in Dental Care Pro grams” of the American Dental Association,
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 87, September 1973 ■ 671
and our practices and procedures are designed to be consistent with them. When, in the process of reviewing a claim, questions as to fact or interpretation arise con cerning the professional aspects o f treatment services, the attending dentist is contacted di rectly by the consulting dentist. A lso, the bene fit provisions may require discussion of treat ment or services alternatives with the attending dentist in order to determine the benefits pay able. In those few instances where this contact does not lead to sufficient clarification to allow Aetna to determine the benefits of the plan, the claim is considered for referral to a review com mittee. The professional aspects o f treatment services are not discussed with the claimant by Aetna; however, the claimant is advised of the services or charges which are not covered by the benefit provisions o f the plan. For dental plans where the benefits are based upon the “ usual and customary” charge, rath er than being determined in accordance with a schedule o f specific dollar allowances, Aetna compares the actual charge with data it has col lected on charges made by other dentists in the area for the same procedure. Under these plans, A etna’s liability is limited to the prevailing fee for the procedure performed, and this is de scribed in employee plan descriptions as well as in communicating our benefit determination to the claimant. H owever, in the event a charge exceeds in a significant amount Aetna’s cal culation of the prevailing fee for the procedure performed, Aetna will contact the dentist prior to communicating its benefit determination to the claimant; however, contact will not neces sarily be made when an individual dentist’s usu
al charge has been documented through past experience as routinely above the prevailing range as calculated by Aetna. A copy o f any correspondence advising a claimant of A etna’s fee calculation which is less than the dentist’s actual charge will be sent to the dentist unless he has requested otherwise. Only about 5% of the actual charges Aetna processes for profes sional services exceed its calculation o f the up per limit of the range o f prevailing fee for the procedure performed. The Aetna does not encourage or aid its in sureds to initiate legal action against dentists. If a dentist brings legal action against a claim ant, Aetna may be required by its group policy holder to assist the insured patient provided the patient and dentist have not reached prior agree ment on the payment of fees for services ren dered, and provided all other means available to the Aetna, including referral to peer review, have failed. Aetna favors the establishment by the den tal profession o f effective peer review mecha nisms to consider matters relating to the quality and appropriateness of treatment, volume and type o f services provided, and fees. When, through contact directly with the attending den tist, the Aetna is unable to resolve questions re lating to the quality or appropriateness of ser vices, type and volume of services, or fees, it will ordinarily seek the advice of the peer re view mechanism o f the appropriate dental soci ety. The Aetna will consider the findings o f ef fective peer review, together with other rele vant factors, when determining its contractual obligation to pay benefits.
672 ■ REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 87, September 1973
A e t n a L ife & C a s u a lt y s t a t e m e n t o f c la im p r a c tic e s a n d p r o c e d u r e s w ith r e s p e c t to d e n ta l e x p e n s e b e n e fits
The intent of Aetna Life & Casualty is to deter mine for each claim the proper liability o f the dental benefit plan under which the claimant is covered in order to assure full and equitable payment to all claimants, and its claim prac tices and procedures are designed to achieve that intent. Each claim is reviewed and evaluated in terms o f the coverage provided by the plan. Informa tion pertaining to the claimant, and the nature and cost of treatment and services is obtained from the claimant, the attending dentist, and the policyholder. The claim information is screened by claim processors and additional information is obtained, or clarified as necessary. Where there are questions concerning the professional aspects o f the treatment or services, the claim is referred to experienced consulting dentists for review and evaluation. The calculation of
the benefit payment is described to the claim ant, and for those claims where pretreatment review (predetermination) takes place, explana tion of the benefits payable is usually provided to the claimant and his attending dentist. Sub mission for pretreatment review is encouraged. The information required for each claim must be sufficient to determine the disease or injury present, the nature and extent o f treatment and services, and the charges for each service. Pre treatment X-rays are required in connection with certain services for review with other avail able information by the consulting dentist. For some claims, in-mouth examinations are con ducted by an examining dentist on a pretreat ment or posttreatment basis. Aetna is fully in accord with the “ Guidelines on U se of Radiographs in Dental Care Pro grams” of the American Dental Association,
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 87, September 1973 ■ 671
and our practices and procedures are designed to be consistent with them. When, in the process of reviewing a claim, questions as to fact or interpretation arise con cerning the professional aspects o f treatment services, the attending dentist is contacted di rectly by the consulting dentist. A lso, the bene fit provisions may require discussion of treat ment or services alternatives with the attending dentist in order to determine the benefits pay able. In those few instances where this contact does not lead to sufficient clarification to allow Aetna to determine the benefits of the plan, the claim is considered for referral to a review com mittee. The professional aspects o f treatment services are not discussed with the claimant by Aetna; however, the claimant is advised of the services or charges which are not covered by the benefit provisions o f the plan. For dental plans where the benefits are based upon the “ usual and customary” charge, rath er than being determined in accordance with a schedule o f specific dollar allowances, Aetna compares the actual charge with data it has col lected on charges made by other dentists in the area for the same procedure. Under these plans, A etna’s liability is limited to the prevailing fee for the procedure performed, and this is de scribed in employee plan descriptions as well as in communicating our benefit determination to the claimant. H owever, in the event a charge exceeds in a significant amount Aetna’s cal culation of the prevailing fee for the procedure performed, Aetna will contact the dentist prior to communicating its benefit determination to the claimant; however, contact will not neces sarily be made when an individual dentist’s usu
al charge has been documented through past experience as routinely above the prevailing range as calculated by Aetna. A copy o f any correspondence advising a claimant of A etna’s fee calculation which is less than the dentist’s actual charge will be sent to the dentist unless he has requested otherwise. Only about 5% of the actual charges Aetna processes for profes sional services exceed its calculation o f the up per limit of the range o f prevailing fee for the procedure performed. The Aetna does not encourage or aid its in sureds to initiate legal action against dentists. If a dentist brings legal action against a claim ant, Aetna may be required by its group policy holder to assist the insured patient provided the patient and dentist have not reached prior agree ment on the payment of fees for services ren dered, and provided all other means available to the Aetna, including referral to peer review, have failed. Aetna favors the establishment by the den tal profession o f effective peer review mecha nisms to consider matters relating to the quality and appropriateness of treatment, volume and type o f services provided, and fees. When, through contact directly with the attending den tist, the Aetna is unable to resolve questions re lating to the quality or appropriateness of ser vices, type and volume of services, or fees, it will ordinarily seek the advice of the peer re view mechanism o f the appropriate dental soci ety. The Aetna will consider the findings o f ef fective peer review, together with other rele vant factors, when determining its contractual obligation to pay benefits.
672 ■ REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 87, September 1973