Health Insurance Marketplace

Why Should I choose an HDS Participating Dentist?
 

Save Money
 

HDS participating dentists have agreed to accept a discounted rate (eligible fee) as payment in full for services to our members unlike a non-participating dentist who can charge you any amount. See example below.
 

Participating dentists agree to processing policies and are prohibited from billing and collecting fees in excess of the agreed upon schedule even in the event you exceed your annual plan maximum. Non-participating dentists will continue to charge the full retail rate as they have not contracted with your HDS plan.  A non-participating dentist can set a higher cost for a service than a participating dentist. Depending on the dentist, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover and/or the extra amount charged by the non-participating dentist.

Pay Copayment Only
 

Because HDS pays the participating dentist directly, the dentist will only bill you for the difference between the eligible fee and the amount HDS is expected to pay. A non-participating dentist may require that you pay the retail amount of all services in advance.

How do I submit a dental claim to HDS?
 

• The non-participating dentist will render services and may submit a completed claims form to HDS on your behalf or provide you with a completed claims form to submit to HDS. If the non-participating dentist provides you with a completed claims form, mail the completed claim form to:
  
  HDS – Dental Claims
  900 Fort Street Mall, Suite 1900
  Honolulu, HI 96813-3705
   
• HDS payment will be based on the HDS non-participating dentist fee schedule and a reimbursement check will be sent to you along with your Remittance Advice.
• A blank claim form can be found at https://www.hawaiidentalservice.com/members/forms under General section.
• HDS participating dentists will submit claims for services rendered on your behalf.
   

Whether you visit a participating or non-participating dentist, please be sure to discuss your financial obligations with your dentist before you receive treatment. All dental claims must be filed within 12 months of the date of service for HDS claims payment.
 

What are retroactive denials?
 

A retroactive denial is the reversal of a claim we have already paid. If your claim was retroactively denied, you would become responsible for payment to your dentist. You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit in your plan.
 

How do I terminate my dental plan and obtain any applicable refunds from HDS?
 

All requests for termination must be made through HealthCare.gov. Any overpayment resulting from an approved termination request will be refunded. Any re-enrollment will be considered a new enrollment; therefore, any waiting periods and deductibles will apply as new.

If you believe you have paid too much for your premiums and should receive a refund, please contact the Individual Dental Plan Division at (808) 529-9313, toll-free 1-800-232-2533, extension 313, or email [email protected].
 

Does HDS require prior authorization for any covered dental services?
 

HDS does not require prior authorization for any covered dental services. If you are concerned about coverage or the cost of a service, you may submit a request for a preauthorization to obtain coverage information and an estimated benefit amount. A decision for urgent/emergency cases will typically be made within 72 hours of HDS receiving the request.
 

What is an Explanation of Benefits (EOB) statement?
 

HDS provides its members with Explanation of Benefits (EOB) statements which summarize the services you received from your dentist and lists payment information, which includes the date you received the service, the amount billed, the amount covered, the amount HDS paid, and any balance you’re responsible for paying the dentist.

An EOB will be provided if a service is not covered (in whole or in part). You will not receive an EOB for services with no patient share or when only tax is due.

It is important to note that the EOB statement is not a bill. Depending on your dentist’s practice, your dentist may bill you directly or collect any portion not covered by your plan at the time of service. Each time you receive an EOB, review it closely and compare it to the receipt or statement from your dentist.

 

Calculating Your Benefit Payments
 

Determining the amount you should pay your HDS participating dentist is based on a simple formula (see example below). HDS will pay the “% plan covers” amount.
 

You are responsible for the balance owed to your dentist which includes the Approved Amount (the maximum amount that the member is responsible for), any applicable deductible amounts, and taxes, less the HDS payment. Participating dentists are paid based upon their Allowed Amount (the amount to which the benefit percentage is applied to calculate the HDS payment).

It is important to note that when determining payment, HDS may consider your prior dental work performed under another plan and your current plan’s limitations.
 

What is Dual Coverage/Coordination of Benefits?
 

• Please be sure to let your dentist know if you are covered by any other dental benefits plan(s).
• When you are covered by more than one dental benefits plan, the amount paid will be coordinated with the insurance carrier(s) in accordance with guidelines and rules of the National Association of Insurance Commissioners. Total payments or reimbursements will not exceed the dentist’s Allowed Amount when HDS serves as the second plan.
• There is a limit on the number of times certain covered procedures will be paid and payment will not be made beyond these plan limits.
• Coverage of identical procedures will not be combined in cases where there are multiple plans. For example, if you have two plans and each includes two cleanings during each calendar year, your benefits will cover two cleanings (not four) in each calendar year.
   

Grace Periods and Pending of Claims
 

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. If you do not pay your premium on time, you will receive a 30-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the dentist until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly.

If you receive an advance premium tax credit, you will get a three-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will not be paid, subject to the following: If you pay your full outstanding premium before the end of the three-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any claims submitted for you during the second and third months of the grace period. Your dentist may bill you for these services up to their full retail rate.