Aetna recently resolved a system configuration error that caused some out-of-network Medicare Advantage dental claims to be adjudicated under Medicare medical rules rather than dental benefit rules, the American Dental Association reported Sept. 3.
The issue came to the ADA’s attention after dentists reported receiving explanations of benefits that appeared to restrict balance billing for out-of-network Medicare Advantage dental services. The ADA raised concerns with Aetna and requested a comprehensive review, pushing back against the payer’s initial characterization of the problem as isolated errors. Aetna determined that approximately 55,000 claims may have been affected — roughly 8% of the out-of-network claims reviewed during the insurer’s investigation.
Aetna said it is implementing system changes to process affected claims correctly and will review previously impacted claims to determine whether reprocessing and correction are needed. The ADA encouraged dentists who believe they were affected to contact Aetna about reprocessing.
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