American Dental Association position on disparaging explanation of benefits statements

Have you experienced any denied claims with confusing explanation of benefits language? Have you seen plans use disparaging language on their EOBs to patients? Has this created turmoil in your doctor patient relationship regarding not only completed treatments but future treatment plans yet to be fulfilled?

The American Dental Association has created a position statement on the content of EOB statements and some sample letters to help you address this very issue with insurance carriers. Insurance EOB language should provide information that clearly delineates the benefit limitations of the plan and any balance due to the dentist by the patient without interfering with that relationship.

The ADA has provided principles for insurance plans to use when developing EOB statements that include:

1. Standards for dental benefit plans
2. Explanation of benefits statement and identification of claims reviewers (to dentist and beneficiary)
3. Dental procedure code changes
4. Identifying dental consultants
5. All EOBs should include information if plan is self-funded or fully insured
6. Limitations in benefits by plan
7. Statement on determining the usual, customary and reasonable fees
8. Carriers should be cautious on EOB statements mentioning savings by changing to in network dentists
9. EOBs should include ADA copyright notice for Codes on Dental Procedures and Nomenclature listed

The ADA Center for Professional Success has these samples for download:

• Model EOB statement
• Sample letter to insurance plan regarding EOB necessity language
• Sample letter to insurance plan regarding EOB UCR language
• Sample letter to employer regarding EOB UCR language