First Payor Process for FEHB and Other Coordination of Benefits (COB)
If you have dental coverage through your FEHB plan, your FEHB plan will be the first payor of any benefit payments. This is called the First Payor process. The First Payor process and/or coordination of benefits for a Dental HMO will occur when you receive services from your assigned in-network provider or participating specialist. If you receive services from a general dentist to which you are not assigned, or visit an out-of-network specialist, there will be no benefit from the Dental HMO plan. This is only a summary; please see the plan brochure for more information.
I have FEHB coverage, as well as FEDVIP. Do I have to provide my FEHB ID card when I have a dental appointment?
Yes, when you receive dental services, you should present both your FEHB and your FEDVIP ID cards. The dentist’s office can then bill both plans and the plans will facilitate the first payor process. If your dentist will only bill one plan, make it the FEDVIP plan. Your FEDVIP plan will then contact your FEHB plan to facilitate the first payor process.
I signed up for FEDVIP to cover dental expenses. Why do I have to submit my dental claim to my FEHB plan?
The law which established FEDVIP states that if an individual has dental coverage under FEHB and also has FEDVIP coverage, the health benefits plan shall be the first payor of any benefit payments.
Dental HMO as Primary under COB with non-FEHB plans
When the FEDVIP Dental HMO plan is determined to be primary coverage, the maximum fee collected by the dentist will be the Dental HMO copayment. Secondary coverage will be applied to (deducted from) the subscriber’s Dental HMO copayment. If the secondary insurer’s payment is less than the Dental HMO copayment, the subscriber would then be responsible for paying the difference between the copayment and the reimbursed amount.
Example Dental HMO as primary:
|D2160||Amalgam – Three surface filling|
|Secondary Insurer (80% coverage)||- $60.80|
|Plus: Dominion Office Visit Copay||+ $10.00|
|Total Subscriber Owes:||$25.20|
Dominion Dental HMO as Secondary under the First Payor Process with FEHB Plans
When facilitating the first payor process with our FEDVIP Dental HMO and a member’s FEHB medical plan, with an embedded dental benefit, the FEHB plan is the designated first payor and will pay benefits first, however the FEDVIP plan allowance will be the prevailing charge. This is important for the HMO process due to the fact that the allowed amount for any service is the member’s copay, and for most preventive and diagnostic services, the copay is zero. Therefore, the allowed amount is also zero. In these situations there will be no primary payment due from the FEHB plan.
1. Simple Coordination: Primary payment and member copay
With a Dental HMO product, the member will never have a financial responsibility greater than the combined total of the $10 office visit charge and the agreed-upon copay(s) for performed procedure(s). In the case where there is a primary payment from a different plan, the primary amount paid will be applied to the Dominion member copayment, thus reducing the member’s responsibility.
|D2751||Crown - Porcelain fused to predominantly base metal||$555.00|
|Dentist’s Usual Charge submitted to primary insurer:||$850.00|
|Less: Primary Insurer paid (50% coverage):||- $425.00|
|Total Subscriber Owes:||$140.00|
2. No copay coordination: primary payment and zero-dollar copay
In the case where a Dental HMO member has services performed in which there is no copayment owed to the provider, there will also be no primary payment for those services, as the FEDVIP’s allowance is the prevailing charge (the member copay). There will be no additional responsibility from either the primary payor or the member.
|D0120||Periodic Oral Evaluation||$0.00|
|No primary payment due.|
|Total Subscriber Owes:||$10.00|
|D0120||Periodic Oral Evaluation||$0.00|
|D1110||Prophylaxis (cleaning) – adult||$0.00|
|D2330||Resin Based Composite Filling – one surface||$55.00|
|Dentist Usual Charge Submitted to Primary Insurer:||$162.00|
|Less: Primary Insurer (Primary benefit does not offer Filling coverage||- $0.00|
Dominion Office Visit copayment