As a DENCAP Member, your best resource for information about your coverage is your plan’s Schedule of Benefits and Fixed Co-Payments and the Certificate of Coverage. If you have any questions about your coverage, please contact DENCAP directly.
Out-of-network Liability and Balance Billing
Your Certificate of Coverage and Plan Schedule of Benefits and Fixed Co-Payments outlines out-of-network coverage available for you and covered dependents. When seeing an in-network dentist, fees for non-covered services are the responsibility of the patient, and the provider may bill the patient directly for them. The nature of DENCAP’s coverage does not extend to providers that are not part of the DENCAP Network. When seeing an out-of-network provider, all fees, even those for covered services, are the responsibility of the patient (balance billing). DENCAP does not offer out-of-network coverage, except in the case of an emergency. When you or your covered dependent is 50 miles or more away from your selected in-network dentist, DENCAP will reimburse you 50% up to $100 for services that alleviate pain. Should you need to utilize this benefit, the member is responsible to submit a claim to DENCAP in a timely manner.
Enrollee Claim Submission
The DENCAP DHMO model does not receive primary care (general dentistry) claims at all. The provider is reimbursed monthly by capitation payments sent from DENCAP, and then at the time of service by patient co-payments. There is no need for a member to submit a claim to DENCAP, except in the case of emergency treatment as described in the Certificate of Coverage or Schedule of Benefits and Fixed Co-Payments.
Grace Periods and Claims Pending
DENCAP offers enrollees receiving Advance Payment of Premium Tax Credits (APTC) a three-month grace period upon the event that a premium in whole or part is unpaid by the enrollee. A grace period is a special circumstance that allows enrollees to pay premiums after they are due without penalty. Only enrollees receiving APTC qualify for a grace period. During this grace period DENCAP will continue to collect APTC on behalf of the enrollee to apply to member premium, or if the grace period is exhausted return APTC payments to the Department of the Treasury. DENCAP will pay claims on behalf of the member for the first month of the grace period, and pend claims for the second and third month of the grace period. Pended claims are held to allow the enrollee to catch up on their missed premium payments. If the premium remains unpaid, the pended claims will be denied.
DENCAP from time to time will review claims after they have been evaluated. Internal reviews ensure that DENCAP is diligent in paying claims appropriately. Reviews happen both randomly and circumstantially. Results of these reviews sometimes uncover that previously paid claims were not correctly evaluated and should have been denied. In the event of a retroactive denial, DENCAP will receive reimbursement from the provider for the claim that was paid, and the patient will be responsible to pay the provider for services rendered. The best way for a member to avoid a retroactive denial is to pay premiums in a timely manner and communicate eligibility and billing changes to DENCAP as soon as possible so that DENCAP records are always up to date.
Recoupment of Overpayments
As a DENCAP subscriber, you have the right to review your billing statements and history at any time. If you find that you have been overbilled by DENCAP, please let us know as soon as possible. We are happy to do an investigation. We may require documentation from you that we do not have access to (i.e. bank statement, credit card statement), and with your cooperation will determine if you have been overbilled. In the event overbilling has occurred, DENCAP will credit your account or refund you, as you prefer. Contact DENCAP at (313) 972-1400 or firstname.lastname@example.org to begin a detailed review of your account.
Medical Necessity and Prior Authorization and Enrollee Responsibilities
For some procedures at the Specialist, DENCAP requires prior authorization. Prior Authorization is a process through which DENCAP reviews a request from a provider for a member to access a covered benefit before the benefit is delivered to the member. The provider is responsible to initiate the process with DENCAP. DENCAP responds to providers within 14 days of receipt of the prior authorization information. In the event that a member receives care that requires prior authorization which was not initiated by the provider, the member is responsible only for the portion of the fee they would have been if the prior authorization had been approved and member benefits are available. The provider is responsible for DENCAP’s portion. It is the responsibility of the provider to communicate with DENCAP about DENCAP patients and to make sure that procedures are approved and benefits are available before beginning treatment. Details about procedures that require prior authorization can be found in the Certificate of Coverage.
Explanation of Benefits (EOB)
Because DENCAP does not receive (or pay) claims from general dentists, DENCAP does not generate an Explanation of Benefits (EOB) to send to DENCAP Members. An (EOB) is a statement sent to a patient by an insurance company to explain what procedures and/or services the insurance company paid for on an enrollee’s behalf, outlining the insurance payment and the amount the patient is responsible to pay as defined by the member’s policy. DENCAP pays participating providers a monthly fee called capitation to cover the costs of services that members may receive. DENCAP will never send a member an EOB for services received at the general dentist. Questions about claims and claim statements can be directed to the DENCAP Claims Department at (313) 972-1400.
Coordination of Benefits (COB)
Your DENCAP DHMO Plan may coordinate with other dental insurance or coverage that you may have. To learn more, review the Certificate of Coverage or ask your provider about their billing practices utilizing both of your plans.