dental insurance downgrade

Sourced answer

A dental downgrade is the payment of a lower allowance than the service performed, under a plan's alternate benefit provision: where more than one professionally acceptable treatment exists for a condition, the plan pays for the less costly one and the patient may owe the difference. Payers write it under different names — Aetna's Alternate Treatment Rule, Cigna's Alternate Benefit Provision, MetLife's Alternate Benefits, Delta Dental Insurance Company's Optional Services — and Aetna, Cigna, and Guardian all state that the provision varies by employer or plan. Named substitutions read for this page include posterior composite paid at the amalgam benefit (one Guardian Utah plan and one DentaQuest Ohio policy), inlays paid as an alternative benefit of amalgam, a crown paid at a four-surface filling allowance (United Concordia's FEDVIP brief), a fixed bridge paid at the removable partial denture rate (Aetna's published example), and a prefabricated restoration benefited under the composite code where it fails the crown guidelines (Delta Dental Insurance Company's clinical criteria). Two conditions decide most disputes and are missing from most summaries: the downgrade is rebuttable when evidence submitted with the claim explains why the less expensive treatment could not be done, and a participating dentist may bill the patient the difference only after documented advance notice of liability. Downcoding is a different act from a plan-driven alternate benefit — Aetna says so itself — and Medicaid programs generally deny rather than downgrade: Colorado's dental manual has no alternate benefit provision at all.