If you have other dental insurance in addition to
the TDP, United Concordia will coordinate benefits
between the two dental plans.
Which Plan Pays First?
If a member receives services that are covered under
both TDP and another dental plan, coverage and
benefits are governed by coordination of benefits
rules. These rules determine which plan
pays benefits first and which plan pays second. Depending
on the situation, the TDP may be the primary or
secondary dental plan.
The primary plan pays benefits without regard to
the secondary plan.
When TDP is the secondary plan, it pays for covered
services that have not been paid by the primary
plan. TDP will coordinate with the primary insurance
carrier and pay for TDP-covered services according
to TDP provisions and limitations. When acting as a
secondary carrier, the TDP payment will not exceed the
provider charge or the amount that would have been
paid as the primary carrier.
Follow these guidelines to determine if the TDP may
be the primary or secondary dental plan:
When a spouse's or child's
other plan is primarily a medical insurance plan, but includes
a dental benefit, the plan is considered secondary. The
TDP is considered primary and claims should be submitted to
United Concordia.
When a spouse has his or her own dental
plan, the spouse's dental plan is considered primary
and the TDP is secondary.
In the case of a child who is covered
under two dental plans, the primary plan is typically
determined by the "birthday rule,"
established by the National Association of Insurance
Commissioners. The birthday rule determines the first
plan to pay benefits based on which parent's birthday
falls earlier in a calendar year. For example: If the
mother's birthday is January 2 and the father's
birthday is January 12, the mother's dental plan is
considered primary and would therefore pay benefits first.
The year of the parent's birth is not relevant in
determining which coverage is primary.
An exception
to the birthday rule occurs if the other dental plan uses
the "gender rule." The gender rule
specifies that the male parent's dental plan is
considered the primary plan. If the other dental coverage
uses the gender rule in determining coordination of benefits,
United Concordia will defer to the gender rule and will consider
the male parent's dental plan as the primary plan.
In situations where the natural parents
are not married and there are two dental plans, United
Concordia considers the insurance plan of the parent
with custody the primary plan. If the parent
with custody has remarried, the stepparent's plan
will pay before the plan of the parent without custody.
An exception to this rule occurs when there is a court decree
specifying which parent is responsible for insurance coverage.
Processes for Filing Claims
If it's determined that the TDP is the primary dental plan,
you should submit your dental claims to United Concordia first.
If your other plan is the primary dental plan, you'll follow
that plan's claims processing rules first and then
submit the remaining liability to United Concordia. When
submitting a claim to United Concordia when TDP is the
secondary plan, include a copy of the primary carrier's
DEOB. Payment may be denied if the primary carrier's
payment information is handwritten or typed on the claim
form and a physical DEOB is not provided.
Participating Dentists
Participating Dentists accept United Concordia's allowance for
covered services as payment in full, charging the enrollee only
the applicable cost-share percentage. Balance billing by
participating dentists is prohibited. Enrollees do not have
to pay any part of the dentist's charge that exceeds United
Concordia's allowance, except when alternate/optional services
are provided. In addition, when TDP is the secondary carrier
and the annual or orthodontic maximum has been exceeded, the
participating dentist is permitted to balance bill.
