Assignment of Benefits for Dental Insurance

WEST VIRGINIA INSURANCE BULLETIN No. 23-04 Insurance Bulletins are issued when the Commissioner renders formal opinions, guidance or expectations on matters or issues, explains how new statutes or rules will be implemented or applied, or advises of interpretation or application of existing statutes or rules. ► Assignment of Benefits for Dental Insurance ◄ This Insurance Bulletin is intended to set forth guidance and educate consumers regarding assignment of benefits in dental care coverage. West Virginia law requires that all insurers providing dental care coverage honor a written assignment of benefits by an insured person to a dentist for covered services under the insurance policy. 1 If a covered individual assigns his or her benefits under the dental insurance policy to a dentist, the dental insurer shall make payments directly to the dentist upon notice of the assignment. A dentist with a valid assignment of benefits may bill the dental insurer directly and notify the dental insurer of the assignment of benefits. A dental insurer may request a copy of the assignment of benefits prior to making payment. However, if the conditions for an appropriate assignment of benefits are met (i.e., the assignment was made in writing and notice of the assignment was provided to the dental insurer), then the dental insurer must honor the assignment and is further mandated to make payments directly to the dentist. A covered person may revoke an assignment of benefits to a dentist at any time with or without the consent or permission of the dentist. The revocation must also be made in writing and must be provided to the dental insurer. The dental insurer shall send a copy of the revocation to the dentist and the revocation is effective when both the dental insurer and the dentist have received a copy of the revocation of the assignment. The revocation is effective only for charges incurred after both the dentist and the dental insurer have received copies of the revocation. Importantly, a covered individual receiving care from an out-of-network dentist may be balance billed by the out-of-network dentist for amounts charged by the dentist that are more than the covered benefit allowance paid by a dental insurer through the assignment of benefits. Any dentist or dental office providing dental care shall provide conspicuous notice to the covered person that an assignment of benefits is optional and that additional payments may be required from the covered individual if the assigned benefits paid from the dental insurer to the dentist are not sufficient to pay for the services received. If, under an assignment of benefits, a dentist collects payment from a covered individual and subsequently receives duplicate payment from a dental insurer, the dentist shall reimburse the covered individual, less any applicable copayments, deductibles, or coinsurance amounts, within 45 days. 1 West Virginia’s assignment of benefits law is generally found at W.Va. Code §§ 33-15-22, 33-16-18, 33- 24-45, 33-25-22, and 33-25A-36. 2 Nothing in West Virginia’s assignment of benefits law limits a dental insurer’s ability to determine the scope of benefits or services or its ability to negotiate any contract with a dentist or health care provider regarding reimbursement rates. An assignment of benefits is a valuable tool that consumers may utilize in seeking care from a dental provider of their choice because it allows consumers to have benefit payments sent directly to their provider regardless of whether that provider is in-network or out-of-network with their dental insurer. However, it is important to understand that out-of-pocket costs to consumers may vary depending on the policy terms, the type of care received, and the place the care is received. Consumers should always review their dental insurance benefits to determine what coverage is available under their dental insurance policy and whether their chosen provider is in-network or out-of-network with their dental insurer. If you need assistance in reviewing your dental insurance benefits or want to file a complaint regarding assignment of benefits, you may contact the Insurance Commissioner’s Life & Health Consumer Division at 1-888-TRY-WVIC or contact the OIC’s Health Policy Division at OICHealthPolicy@wv.gov. Please e-mail any questions concerning this Insurance Bulletin to OICBulletins@wv.gov. Issued: April 19, 2023 ______________________________ Allan L. McVey CPCU, ARM, AAI, AAM, AIS Insurance Commissioner