May 2021 Volume LVI Number 3


Coding Corner

November 2020 Volume LV Number 6

Self-funded Plans Versus Fully-insured Plans
Medical and dental plan claims are adjudicated according to provisions estab- lished in the plan document or insurance contract. For self-funded and federal plans, this document is referred to as the plan document and these plans follow Employee Retirement Income Security Act of 1974 (ERISA) laws. Fully-insured plans follow the insurance laws of the state in which the plan was purchased and fall under the jurisdiction of the state insurance commissioner. This document is referred to as an insurance contract for fully-insured plans. For the purpose of this article we will use the term plan document.
A common provision of the medical and dental plan document is known as the family-related exclusion. The family-related exclusion means that a doctor or other healthcare provider cannot treat her immediate family member as defined by the plan or file a claim requesting reimbursement for services rendered. This provision applies to both in- or out-of-network providers. The language defining immediate family members of this provision varies by plan and may be stated in a variety of ways.
Some examples of language defining immediate family members include but are not limited to the following:
  • "immediate family or immediate family of spouse"
  • "enrollee’s spouse, child, brother, sister, or parent"
  • "a person who lives in the covered person’s home or who is related to the covered person by blood or marriage"
Only the patient or plan subscriber (not the provider’s office) can obtain a copy of the plan document. This is not the plan summary given to the patient or subscrib- er at the time of enrollment. The plan document must be requested from the HR department if the plan is an employer sponsored plan or directly from the payer if the plan is an individual plan purchased directly from the payer.
Be aware of this provision and do not bill insurance for services rendered to im- mediate family members. Recoupment of monies paid by the plan can and often are made from providers who have received reimbursement for immediate family members.
Contract Analysis
Stop, read and consider Insurance Pro- vider Contracts before you sign! When you sign a contract, you make promises that will be legally binding on you. If you fail to do what you promise, the other party may be able to terminate the contract or may initiate legal action against you for breach of contract. It is, therefore, essential that you review any contract carefully before you sign it.
By signing the contract, what are you promising to do? Are you able and willing to do it? What promises are the other party making to you? What remedies will you have if something goes wrong?
The American Dental Association’s Legal team has created a useful guide for dental providers to follow prior to signing a contract. To view, visit Member%20Center/Members/DBIS_den- tal_provider_contract.pdf.
For more information or questions please contact AAPD Dental Benefits Director Mary Essling at (312) 337-2169 or messling@

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