How can we obtain an alternate benefit for a patient?

Answer

Sometimes a procedure is denied due to a missing tooth or a non-covered procedure clause and an alternate benefit may be available. Most often, an alternate benefit is available with the patient’s benefit plan but may not be automatically applied. When this is the case, appeal the denied claim and ask for an alternate benefit of a similar procedure. Some examples would be:

• Fixed partial denture (bridge) is denied due to a missing tooth clause. Ask for an alternate benefit of a single crown for each of the retainer crown(s), if these retainers are in need of a crown on their own merit. Send a brief narrative stating why a retainer tooth needs a crown.
• Many plans will deny coverage for a fixed partial denture (bridge) or an implant when teeth are missing on each side of the arch. The patient may receive an alternate benefit of a removable partial denture. Patients are often surprised to learn their plan has this type of alternate benefit restriction. This is why the payer will ask for a full mouth series or panoramic radiographic image if reimbursement for a fixed partial denture (bridge) is sought.
• When a plan does not have an implant rider, the patient may receive an alternate benefit for either a single crown for the abutment or implant supported crown, or a complete denture benefit in the case of an abutment or implant supported overdenture. 
• When posterior composites are denied, ask for the alternate benefit of an amalgam restoration.
• If periodontal maintenance is denied due to a frequency limitation, ask for the alternate benefit of a prophylaxis if the plan also has a benefit for a prophylaxis. Be sure to include a brief narrative stating “… If a benefit for periodontal maintenance is not available, please consider the alternate benefit of a prophylaxis, as a prophylaxis was performed as part of the periodontal maintenance procedure.” While D4910 is reported, the hygienist should state in the clinical notes that a prophylaxis (D1110) was performed along with periodontal maintenance (D4910). 

The key is to always ask if there is an alternate benefit available. The plan document may also outline the alternate benefit provisions of the plan. The plan document may only be obtained by the patient, not by the provider. The patient may request the plan document from the Human Resources department at her place of employment, or from the insurance company if it is an individual plan purchased by the subscriber.