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For Dentists

Horizon BCBSNJ Manual for Participating Dental Professionals

Horizon Dental Choice (HDC)/TotalCare Networks

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Verification of Patient Eligibility

Each month, you will receive a Patient Roster that identifies all patients who have chosen you as their Primary Care Dentist (PCD). In addition to listing all eligible members for the current month, the roster provides you with the Benefit Plan Code to determine appropriate copayment. If you have more than one office location participating in the HDC Plan, separate rosters will be produced. Each location is assigned an office code and receives a separate list of patients assigned to that local office. HDC patients are instructed to identify themselves as participants in the HDC plan when they call your office for an appointment. In addition, each member is provided with a member ID card. We recommend that your office confirm patient eligibility when the member calls to schedule an appointment to avoid possible misunderstandings on the day of his or her appointment. You may verify eligibility by:

  • Patient Roster. You may check your current HDC Patient Roster to determine if a member is covered.
  • Customer Service.If a member’s name does not appear on your current patient roster you may call Customer Service at 1-800-4DENTAL (433-6825) to confirm the member coverage or termination date. If a patient is found to be ineligible for HDC benefits, you may seek payment from the patient. Members requiring assistance may call Customer Service at the above number.

PDC Revenue Sources

Capitation/Distribution Amount

Under the HDC plan, the PCD receives revenue from several sources. The sources of revenue are:

  • Capitation
  • Patient copayments
  • Horizon BCBSNJ reimbursement for specific services

The primary source of revenue for the PCD under the HDC plan is a monthly payment, commonly called “capitation”. Capitation is paid for each HDC member and may vary by employer group. It is determined by Horizon BCBSNJ, and is based on the group’s chosen plan design. The basic capitation will be different for the employee, spouse and other dependents.

Patient Copayments

HDC patients are responsible for copayments and/or coinsurance for certain services, which vary by plan. The copayments and related services are determined by the group’s chosen plan design.

Other Sources of Revenue

In addition to the income sources described above, HDC Primary Care Dentists may collect their usual fees for noncovered services. The PCD is required to provide the HDC patient with a formal treatment plan as well as any optional treatment plans. Ineligible services are determined by each plan design. If the service is not listed as covered, the service is not covered.

Optional Treatment Plans

Due to the development of new dental materials and equipment/technology, there are often many ways to treat dental conditions. Some of these involve the multitude of new restorative materials and prosthetic procedures being introduced to the marketplace, many of which are purely cosmetic in nature. Additionally, there are now alternative and enhanced techniques to render certain services with new technology, although the underlying procedures remain unchanged. This section provides guidance for determining benefits in situations where the PCD and the patient are considering optional treatment plans.

Whenever cosmetic procedures or enhanced technology are used, the patient must be fully advised as to those procedures that are covered by the plan and those that are optional, so that an informed choice can be made. As with other noncovered services, if the patient elects to receive the services, then the patient is responsible for the additional cost of the enhanced procedures or materials. The total amount due from the patient is determined by establishing the copayment, if any, for the underlying covered service plus the incremental charge for the cosmetic/enhanced procedures/materials or enhanced technology. This incremental charge is based on your usual fee for the procedure in question.

An Informed Consent Form, or an equivalent, must be completed and signed by the patient and the dentist prior to beginning treatment for optional treatment plans involving cosmetic services, enhanced technology/materials or other ineligible services. The PCD is required to document the patient’s informed consent that cosmetic/enhanced procedures/materials or enhanced technology services have been chosen in lieu of an otherwise covered service before proceeding with treatment.

Encounters

Complete and accurate reporting of all services rendered to HDC patients is required on a monthly basis. Fully capturing this encounter data is crucial to the validation of the oral health of your patients, and can ultimately affect premiums paid, the resulting capitation rates you receive and our ability to fully report the dental care provided to HDC patients. Failure on the part of dentists to report all services rendered can falsely indicate low utilization.

Encounter forms may be submitted through EDI submission or through the mail. You may use a Horizon BCBSNJ Encounter form or a generic ADA claim form. If you use a generic ADA form, it must be stamped with an “encounter” stamp.

As per your Agreement, you are required to submit an encounter for services performed on all HDC/TotalCare patients monthly.

Emergency Dental Treatment/Coverage

Patient access to emergency dental treatment must be available on a 24/7 basis. As required by state dental practical law, you must designate another dentist to treat emergencies that may arise when you are not available. Usually, this is best accomplished by designating another mutually agreeable participating dentist. Your Professional Relations Representative can help you in locating nearby participating offices. The PDC may be financially responsible for services delivered to his/her plan patients when he or she is not personally available to deliver treatment or has not made arrangements for emergency care.

Specialty Referrals

The PDC shall be required to perform all routine dentistry. If a PCD refers a procedure to a specialist and the procedure is deemed appropriate for a general dentist, the cost of the treatment may be deducted from the PDC’s monthly capitation payments.

Specialty Network

HDC uses the Horizon Dental Preferred Provider Organization (PPO) specialty network for referrals. Please use our Online Doctor and Hospital Finder to find a specialist. You may also call 1-800-4DENTAL (433-6825) or contact your Professional Relations Representative.

Specialty Referral Forms

Forms are to be completed by the PCD when a service is referred to a Horizon Dental PPO specialist.

There are two types of specialty referrals:

  • Direct Referral:When a service is listed as a direct referral service on the HDC plan summaries, the PCD may directly refer this member to a participating PPO specialist. A completed referral form listing the referring specialist is required and should be given directly to the patient. The patient will contact the specialist to schedule an appointment and provide the referral form at the appointment. Coverage for treatment by a pediatric dentist is considered a direct referral for children under the age of six (ends on child’s sixth birthday).
  • Indirect Referral:An approval by Horizon BCBSNJ is required prior to referral for any capitated service. If the PCD warrants a need for an over-age child referral to a pediatric dentist, he or she may request an approval from Horizon BCBSNJ. If an emergency/extraordinary authorization is needed, the PCD will contact Customer Service requesting an authorization for a referral. 

Specialty Treatment Reimbursements

Upon completion of services, the specialty dentist submits a claim form to Horizon BCBSNJ along with a copy of the previously approved Specialty Service Referral Authorization Form Horizon BCBSNJ reimburses the specialty dentist at scheduled fees (minus any copayments) for covered services rendered. The specialty dentist collects any applicable copayment from the member.

HDC/TotalCare/Plan J Benefit Plan Descriptions