Claims, Coordination of Benefits, and Payments

• What are the different method options for submitting claims?
• Do you accept electronic attachments?
• How long will it take to process submitted dental claims?
• How do you coordinate benefits with insurance companies?
• What procedures require supporting documentation for claim submission and what is needed?
• How do I resubmit a claim or correct a claim submission?
• Can I appeal a denied claim for reconsideration?
• What steps do I take to submit an appeal?
• How is payment received for processed claims?
• What is an overpayment and how do you recapture funds that were overpaid?

SureCircle Provider Account Information

• What are the advantages of using the SureCircle web-based portal?
• Do I need to purchase any software to use your system?
• Do I need to pay any fees to use your system?

Eligibility Verification

• Do you issue ID cards for subscribers and dependents enrolled in the plan?
• How do I verify eligibility and obtain an overview of the dental benefit coverage for the subscriber and dependents?

Coverage, Restrictions, and Fraud

• How do I know what procedures are covered for my patient?
• Are there any waiting periods, alternate benefit or missing tooth clauses or frequency limitations?
• What are your guidelines regarding full-time students?
• What is dental insurance fraud?
• What are some examples of dental insurance fraud?

Claims, Coordination of Benefits, and Payments

What are the different method options for submitting claims?
The best way to submit claims is on the web through SureCircle.com. Log-in to your provider account, choose the Claim tab and then click on the "Create New Claim" tab.

You can also submit claims through your office management EDI system or by mail to the following address:

SureCircle
777 Mariner's Island Blvd, Suite 750
San Mateo, CA 94404
866-598-7579 Fax

Do you accept electronic attachments?
Yes, you can submit electronic attachments through SureCircle's secure online system.

How long will it take to process submitted dental claims?
Claims submitted on the web through SureCircle.com will be processed within a day or two. Claims submitted using other methods can generally be handled within 10 business days. However, the actual time it takes to process any claim depends on its complexity or need for additional documentation.

How do you coordinate benefits with insurance companies?
Standard coordination of benefit rules do not apply since the SureCircle plan is an employer self-funded plan. It is not an insurance plan and should always be considered secondary to any insurance plan. If any member, whether a subscriber or dependent, of the SureCircle plan has any insurance coverage, whether as a subscriber or a dependent, claims would be submitted to the insurance plan first and then to SureCircle as a secondary coverage. Please include a copy of the Explanation of Benefits from the insurance company when submitting the claim to SureCircle to expedite payment processing.

What procedures require supporting documentation for claim submission and what is needed?
Refer to the following chart for the guidelines on when x-rays or other information is needed for dental claim review. The submitted x-rays should be of diagnostic quality, the most recent available to you and should be labeled with the date taken, patient's name, and your practice contact information.

How do I resubmit a claim or correct a claim submission?
You can resubmit a claim on the web through the portal by entering a new claim. When preparing the claim for submission, please enter the original claim number in the remarks box #35, so we can match up the resubmission with the original processing of the claim. This is to prevent receiving a duplicate denial on the resubmitted claim.

Can I appeal a denied claim for reconsideration?
You can request a review of the claim on behalf of your patient within 180 days of the claim decision.

What steps do I take to submit an appeal?
The appeal request should be written and include a copy of the Explanation of Benefits (EOB) Statement form for the claim. Send to:

SureCircle
777 Mariner's Island Blvd, Suite 750
San Mateo, CA 94404
Fax: 866-598-7579

You should include any new supporting documentation with the request, including any comments, questions, documents or information you consider appropriate. Your reconsideration request must be submitted within 180 days after you receive notice of any denial. Please state the reason you believe the claim was improperly denied, and whether this is a first or second review request. The claim will receive a full and fair review involving someone other than the one who initially made the adverse decision. If there are medical considerations involved in the claim, we will consult appropriately trained and qualified professionals to make those decisions. We will review your claim within 30 days of receipt and provide you and your patient with an easily understandable written or electronic version of our decision. At this time, a claim cannot be reconsidered with information provided online or over the telephone.

How is payment received for processed claims?
Payment will be received by check or via direct deposit (if signed up). You can sign up for direct deposit payment once logged into your SureCircle provider account.

What is an overpayment and how do you recapture funds that were overpaid?
There may be an instance a claim was paid incorrectly. An example would be if we processed and paid for a claim and then received information from the employer that the member or dependent was not effective on the date of service. If we find that an overpayment has occurred, a request for refund will be sent to you in writing.

SureCircle Provider Account Information

What are the advantages of using the SureCircle web-based portal?
There are many advantages for using the SureCircle web based portal.

• Save time by verifying eligibility and benefit information right from your computer.
• Save money by submitting claims directly through the web for free.
• View the status of all your submitted claims.
• Find out if more documentation is needed instantly when you submit a claim.
• Receive your payments in a matter of days, not weeks with our direct deposit option.

Do I need to purchase any software to use your system?
No, the SureCircle system is web-based. You just need an internet connection.

Do I need to pay any fees to use your system?
We do not charge any fees for using our system.

Eligibility Verification

Do you issue ID cards for subscribers and dependents enrolled in the plan?
Yes, and ID card is issued for each eligible subscriber and dependent.

How do I verify eligibility and obtain an overview of the dental benefit coverage for the subscriber and dependents?
You can verify eligibility by logging on to your existing SureCircle account, click the Patients tab, click on the Verify Eligibility tab and enter the patients member ID# listed on their ID card or enter their social security number and click verify.

If you do not have a SureCircle provider account, you can sign up for a free account online.

You can also request fax back eligibility verification and benefit information by calling (877)388-1200

Coverage, Restrictions, and Fraud

How do I know what procedures are covered for my patient?
Under this plan, all dental procedures are considered for payment based on the plan adopted by the employer except cosmetic procedures, implants and treatments for TMJ.

Are there any waiting periods, alternate benefit or missing tooth clauses or frequency limitations?
No, these types of clauses or limitations typically do not apply to SureCircle plans; however it is advisable that you check eligibility and covered benefits.

What are your guidelines regarding full-time students?
Once a child turns age 19, they are no longer eligible for coverage unless they are a full-time student or they are enrolled in COBRA coverage. You can verify eligibility online by logging into your SureCircle account.

What is dental insurance fraud?
Dental insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in dental benefits being paid to an individual or group. Dental insurance fraud is a crime that costs honest consumers and businesses money. Fraud occurs when an individual, by means of deception, receives insurance payments after filing a false claim, inflating costs of services performed on claims, or billing for services not actually delivered. Insurance fraud is a criminal activity that the industry is committed to pursuing and prosecuting.

What are some examples of dental insurance fraud?
Some examples of fraud are:

• Billing for services not provided
• Up coding procedures-submitting a higher level of service than what was actually performed.
• Submitting unbundled codes when a valid ADA code is available that includes all services.
• Submitting a dental claim under one patients name when services were actually provided to another person
• Changing the dates of services on a claim form so it falls within a patients benefit period
• Submitting supporting documentation that is from another patient's record or creating false documentation