Understanding Your Affordable Care Act Coverage
As part of the Affordable Care Act (ACA), Renaissance Dental has outlined the following transparency in coverage information for members enrolled in a dental plan through Healthcare.gov.
What is balance billing?
Balance billing occurs when an out-of-network provider bills an enrollee for charges - other than copayments, coinsurance, or any amounts that may remain on a deductible.
What is my liability for out-of-network services?
If the submitted amount for an out-of-network dentist is more than the allowed amount, the enrollee is not only responsible for paying the dentist that percentage listed in the policy, but is also responsible for paying the dentist the difference between the submitted amount and the allowed amount.
If an enrollee requires emergency treatment and receives covered services from an out-of-network dentist, covered services for the emergency care rendered during the course of the emergency will be treated as if they had been provided by an in-network dentist. If an in-network dentist is not readily available within a reasonable period of time or driving distance, it may be possible for an enrollee to receive covered services from an out-of-network dentist and be reimbursed at the same benefit level as if the covered services were provided by an in-network dentist. If an enrollee feels this may be the case, he or she may call our group customer service department at (888) 358-9484 or individual customer service department at 888-791-5995 (TTY users call 711).
How do I submit a claim?
Your dental office will submit claims on your behalf when you utilize an in-network dentist. However, if you utilize an out-of-network dentist, you will need to submit a claim and do so within 12 months of the date of service to:
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department
You can also call our group customer service department at 888-358-9484 or our individual customer service department at 888-791-5995 (TTY users call 711). You can also download a claim form
What is the grace period and claims pending?
A claim is pending when it has been submitted to Renaissance and is still being processed by the Renaissance claims department.
If an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month's premium during the benefit year, information regarding a 90 day grace period will be provided. A grace period is the time period during which the policy may remain in force even though a premium installment has not been paid on or before its due date.
During the grace period, Renaissance will pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.
What is a retroactive denial and how can I avoid them?
A retroactive denial is the reversal of a previously paid claim, as a result of which the enrollee then becomes responsible for payment.
A claim can be denied retroactively, for example, if Renaissance pays a claim during the grace period and it is discovered that the enrollee has terminated the policy prior to covered services being rendered.
The best ways to prevent retroactive denials are: pay your premium online or over the phone on time, ensure you have provided us with the correct information and ensure you are covered when services are performed. To update your individual account information, you can visit the Individual Account Manager
What happens if I overpay the amount of my premium?
If an overpayment occurs, it will automatically be given as a credit toward the next month’s premium unless the member contacts customer service to request a refund. A refund will be issued in the way the premium was paid, or a refund by check can be requested.
What is a prior authorization and do I need one for services?
Prior authorization is the process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.
Renaissance does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a Pre-Treatment Estimate.
What care is considered a medical necessity and is it covered?
The Essential Health Benefits requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary, i.e. only orthodontia treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered to be an essential health benefit. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.
What is an Explanation of Benefits (EOB)?
An Explanation of Benefits (EOB) is a document that Renaissance may send to you after you receive dental treatment. This document will explain what procedures were covered under your benefit plan, as well as any procedures that might not have been covered and why they were not covered.
EOBs are issued after the claim has been processed. When you receive dental services and do not owe any balance, you will not automatically receive an EOB. You can access a copy online using Individual Account Manager
, calling our group customer service at 888-358-9484, or calling our individual customer service at 888-791-5995 (TTY users call 711).
How do I read an EOB statement?
We send the EOB directly to you, and it will provide you with the information you need, including: dental services performed (procedure description), dentist fees, Renaissance's payment, your required payment, coordination of benefits information (if applicable), and annual maximums used during the current benefit year.
What is coordination of benefits (COB) and does Renaissance participate?
Coordination of Benefits (COB) is a procedure for paying health care expenses when people are covered by more than one plan. The goal of COB is to make sure the combined payments of the plans do not exceed the amount of your actual bills. If you are covered by two or more dental plans - usually because both you and your spouse receive coverage through work - your coverage will be coordinated.