UPMC Dental Advantage is dedicated to improving the oral health of our members. We understand the importance of providing access to useful information about your coverage so that you are able to make informed decisions. This information is an overview of our claims payment and other relevant policies associated with our Small Business Health Options Program (SHOP) stand-alone dental plans. After reviewing this information, if you have questions or need assistance, please contact Member Services at 1-877-648-9640.
Out-of-Network Liability and Balance Billing
"Balance Billing" occurs when a non-participating (out-of-network) dentist bills a member for the difference between what your insurance policy reimburses for dental services and what the dentist charges UPMC Dental Advantage. “Balance billing” does not include cost-sharing charges like copayments, coinsurance, or deductible balances. Not all plan types provide coverage for non-participating providers. Even if your plan includes benefits for services received from a non-participating provider, you may still be balance billed by non-participating providers.
As a preferred provider organization (PPO) dental plan member, you have two levels of benefits. If you use participating dentists, you will receive the highest level of benefit coverage. If you obtain services from a non-participating dentist, you will receive a lower level of benefit coverage and may be billed for the difference between the dentist’s charges and the amount that UPMC Dental Advantage pays the dentist for his/her services. This means that the non-participating dentist may bill you for any amount over and above what UPMC Dental Advantage covers.
Enrollee Claims Submission
If you receive care from a participating dentist, you will not have to submit a claim to UPMC Dental Advantage. The participating dentist will submit the claim to UPMC Dental Advantage and UPMC Dental Advantage will pay the dentist directly. However, if you obtain dental services from a non-participating dentist and that dentist does not submit the claim directly to UPMC Dental Advantage, you may have to file a claim yourself. To submit a claim, please review your Certificate of Insurance for instructions on how to complete the claim form.
An out-of-network claims form is available here: www.upmchealthplan.com/pdf/dental-oon-claim-form.pdf
Mail completed claim forms to:
UPMC Dental Advantage
PO Box 1600
Pittsburgh, PA 15230-1600
All claims must be filed within one year of the date of service. UPMC Dental Advantage will not be responsible for payment of claims for covered services that are submitted more than one year from the date of service.
Claims for Orthodontic Treatment
For medically necessary orthodontic treatment, prior approval is required and must be submitted to UPMC Dental Advantage before services are performed. Upon review of the information, we will notify you and your dentist of the approval status, reimbursement schedule, frequency of payment over the course of treatment, and your share of the cost.
Grace Periods and Claims Pending Policies During the Grace Period
Not applicable to SHOP stand-alone dental plans.
A retroactive denial is the reversal of a claim that was previously paid. UPMC Dental Advantage makes all claims payment determinations based on the information available at the time the claim is processed. If UPMC Dental Advantage determines that a claim was paid in error (e.g., due to changes in member eligibility status, dentist participation, or coordination of benefits with other coverage), the claim may be retroactively denied.
Tips to Help Avoid Retroactive Denials:
- Make premium payments on time to avoid a possible retroactive denial due to member ineligibility.
- Before visiting a new provider for the first time or going back to a familiar provider after your plan has changed, confirm that they are a participating provider in the UPMC Dental Advantage network.
- Tell UPMC Dental Advantage about other dental coverage that you may have. This can include coverage from a spouse’s employer-based plan or coverage through a government program like Pennsylvania Medical Assistance.
Enrollee Recoupment of Overpayments
UPMC Dental Advantage has established a process to help members obtain reimbursements for premium overpayments in a timely manner. Members who have had their insurance policy canceled or terminated and who have made payments for a coverage period beyond their cancellation or termination date will be refunded after the next premium billing cycle. Requests from members for recoupment of other types of overpayments, such as making a duplicate monthly premium payment, will also be processed in a timely manner. Members may make a request for a recoupment of overpayment by calling Member Services at 1-877-648-9640.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Prior authorization is required only for medically necessary orthodontic treatment for members under the age of 19. Providers must receive prior authorization before beginning treatment by completing and submitting a Salzmann Index Evaluation. Patients must meet a score of 25 or greater to be considered eligible for orthodontic treatment. Scores of less than 25 are generally considered ineligible for treatment. Providers may submit prior authorization requests by visiting www.upmchealthplan.com/dental. Prior authorization decisions should be received within 30 days. If prior authorization is not received, your orthodontic treatment may not be covered by the plan.
UPMC Dental Advantage encourages, but does not require, members to seek predetermination for major services such as crowns and bridges. A predetermination gives you and your dentist an advance estimate of your benefit and how much of the cost may be your responsibility. Providers may submit predeterminations electronically, so the response may take only a few business days. Predeterminations are not a guarantee of payment. Payment is based on eligibility at the time of claims submission.
It is your responsibility to confirm that prior authorization for orthodontic treatment has been granted before you have any associated procedures, tests, or services. The fact that your provider has prescribed, recommended, or referred you for orthodontic treatment does not mean that the service is medically necessary or covered under the terms of your benefit plan. If you fail to obtain prior authorization for orthodontic treatment, you may not be eligible for reimbursement under your plan.
If you have questions about whether a service requires prior authorization, please contact Member Services at 1-877-648-9640.
Drug Exceptions Timeframes and Enrollee Responsibilities
Not applicable to SHOP stand-alone dental plans.
Information on Explanations of Benefits (EOBs)
An Explanation of Benefits (EOB) is a statement that explains how UPMC Dental Advantage has processed and either paid or denied a claim for dental services under your plan. An EOB provides important information about your benefits, including the status of claims and confirmation of costs you are responsible for, such as copayments, deductibles, and coinsurance.
UPMC Dental Advantage will send you an EOB shortly after a claim has been processed for dental services that you received. UPMC Dental Advantage will also send you an EOB if we deny a claim. If you receive a service that is paid by UPMC Dental Advantage at 100% and you are not responsible for any cost-sharing, we will not mail you an EOB.
For further questions on an EOB, you may call Member Services at 1-877-648-9640.
Coordination of Benefits (COBs)
In addition to your UPMC Dental Advantage insurance, you may have additional dental insurance coverage through your spouse, another employer, or a government-sponsored program such as Medicare or Medical Assistance. If you have dental coverage from more than one source, your insurance carriers must coordinate the benefits from these different sources and determine which insurance company is your primary carrier. We do this to help ensure that your benefits are paid appropriately and to avoid duplicate payments for the same dental services. We follow standard health insurance industry guidelines to determine which of your insurance carriers is responsible for your primary coverage.
If you have questions regarding the terms and conditions of your coverage, please review your UPMC Dental Advantage Certificate of Insurance. Please note that if you enroll in any product offered by UPMC Health Plan Inc. or its affiliates, you will receive policy documents outlining the terms of coverage specific to the product in which you enroll.
The information on this page is specific to Small Business Health Options Program insurance products offered by UPMC Dental Advantage. If you have any additional questions, please contact Member Services 1-877-648-9640.