Insurance Legislation
Special Notice to CHIP Providers
The Pennsylvania Department of Human Services (DHS) is implementing the Affordable Care Act (ACA) Provider Screening and Enrollment provisions which require all providers who render services to CHIP patients to enroll with DHS. Federal regulations require states to screen CHIP providers the same as it does Medical Assistance (MA) providers. Dentists must enroll immediately!
Act 6 (Automobile Insurance)
Act 6 limits the amount of payment that may be received by a health care provider in treating an injured automobile insurance policyholder. The health care provider must accept payment from the insurance company as payment in full. The provider may not balance bill the patient for the remaining balance.
The fee schedule that is used to determine the reimbursement level is that of the Medicare Fee Schedule. If the charges that occur cannot be calculated under Medicare, payment is not to exceed 80 percent of the provider's usual and customary charges. Charges for services must be billed directly to the insurer and not the insured.
The provisions of Act 6 are applicable in all cases where services are rendered by a provider licensed by the Commonwealth of Pennsylvania.
Act 68 (Prompt Payment)
Pennsylvania's Quality Health Care Accountability and Protection Act (Act 68) took effect on January 1, 1999. Act 68 requires that Pennsylvania's managed care plans, HMOs, point of service plans and gatekeeper PPOs pay "clean" provider claims within 45 days of receipt or be subject to a 10 percent interest penalty.
Clean claims as defined in Act 68 are claims for payment for a health care service that have no defect or impropriety. A defect or impropriety includes lack of required sustaining documentation or a particular circumstance requiring special treatment that prevents timely payment from being made on the claim. Full text of Act 68
Title 23 (Child Custody)
Title 23 under the Pennsylvania Domestic Relations Code helps custodial parents and health care providers receive payment from insurers in instances where payment is not forthcoming from non-custodial parents.
Under Title 23, in cases where courts issue child support orders custodial parents have the ability to submit claims for payment or to authorize payment to the health care provider from the non-custodial parents' insurance. The insurance company is required to reimburse custodial parents or providers directly, even if the dentist is a non-participating provider.
This law prevents non-custodial parents from pocketing money that does not belong to them.
Act 186 (Non-Covered Services)
Act 186 allows dental provider the ability to charge their full and customary fee for services that are not covered under the terms of a patient’s contract, regardless of whether or not the provider has signed an agreement with the insurance carrier.
However, if a dentist signed an agreement with an insurance carrier, the dentist is obligated to accept the insurance carrier’s allowance – even if the insurance carrier does not make payment – if the reason for nonpayment is based on one of the following scenarios:
- Deductible has not been satisfied
- Co-insurance is applicable
- Patient reached a lifetime or annual maximum
- Service is limited by frequency
- Payment was made for an alternate form of treatment
Further, the Act stipulates that insurance companies may not require a participating dentist to limit their charge to patients for non-covered services. Rather, the dentists are to be given the option to do so.