Dentists

Frequently Asked Questions

How to Join Our Network Changes to Your Practice
Web Registration Claim Review
Direct Deposit Coordination of Benefits
Appeal Process Overpayments and Refunds
Complaints Process Affordable Care Act
Orthodontic Payment Schedule


How to Join Our Network

Who is eligible to join?
Any fully licensed dentist practicing in Massachusetts, Rhode Island and New Hampshire is eligible to join our network. Altus Dental does not credential dentists with a limited or faculty license. Dentists practicing outside of Massachusetts, Rhode Island and New Hampshire should contact Connection Dental at 1-800-505-8880. Altus Dental partners with Connection Dental to provide national network coverage.


How do I Join?
Complete our credentialing application packet, which includes the following documents and forms:

  • Dentist Application
  • Participating Dentist Agreement
  • IRS W-9
  • Participating Dentist Checklist

Click here to download the required application packet. E-mail, fax or mail your completed application packet to:

    FAX: 401-457-7272

    EMAIL: dentist@altusdental.com

    MAIL TO:  Altus Dental Insurance Co., Inc.
    ATTN: Network Development
    10 Charles Street
    Providence, RI 02904


How long will it take for my application to be approved?
Our Credentialing Committee meets every other week to review applications. Only completed applications are reviewed. Please include a work history for the past five years, along with a W-9 form that includes practice information (not the dentist’s personal data).

 

How often do you re-credential?
We re-credential network dentists every three years. You’ll receive a Dentist Profile with the information we have on file for you. You’ll need to verify, update, sign and return it to us by e-mail, fax or mail. If re-credentialing requests are not returned within 60 days, claims will be disallowed until we receive the required information.

 

Changes to Your Practice

How do I add a new dentist to my practice?
You should notify us as soon as a new dentist joins your practice so that we can accurately process your claims as quickly as possible. Use the Add Location form to make an addition. If a dentist leaves your practice, complete and send the Remove Location form. You can find both forms on our Forms and Resources page.


How do I change my business name, address or Tax Identification Number (TIN)?
Up-to-date information about your practice allows us to process your claims accurately and quickly. You should complete a Change/Add Location form and W-9 form whenever you need to change the following information:

  • Business Name or Payment Address
  • Tax Identification Number (TIN)

If you are retiring or selling your practice, complete the Remove Dentist Location Form or the Sale of Dentist Practice Form. You can find all of these forms on our Forms and Resources page.

 

Web Registration

How do I register to use your online services?
Registering for our online services is easy. Have your tax identification number (TIN), license number and business address nearby when you’re ready to create your online account.

You can register as an individual dentist, a location or an office administrator. See our Dentist Online User Guide to learn more about the registration type that’s right for you. Click here to get started.

What type of browser do I need to view my account?
Our online services are compatible with multiple browser platforms, including Safari, Chrome, Firefox, Edge, and Internet Explorer Version 11. We recommend using the latest version of your browser to get the most from our website features.


Can I check a patient’s benefits and eligibility online?
Yes. Once you’ve created your online account, log in to:

  • Verify benefits and eligibility (current and previous), as well as termination dates
  • Confirm deductibles and maximums usage
  • View time and frequency usage by benefit, including when a patient is next eligible to receive a service
  • Review tooth history for up to 84 months (Altus Dental plans do not include a missing tooth clause)
  • View benefits at the procedure code level, including percentage of coverage, applicable deductibles and waiting periods


Can I check the status of a submitted claim?
Yes. You can review paid claims, as well as claims in process. You can also:

  • Access and print patient-specific Explanations of Benefits (EOBs)
  • View pre-treatment estimates for the last three months
  • Print a summary of paid or in-process claims for the last six months


How do I find out if a specific CDT code is covered under a patient’s plan?

You can search at the procedure code level to determine if a patient is covered for that specific procedure. By entering a valid CDT procedure code, you can see a patient’s co-insurance percentage, deductible and waiting periods, if applicable. You should also review the patient’s benefit summary carefully for additional criteria associated with any procedure code.


What is Altus Dental Insurance Company’s payer ID number?

The payer ID number for Altus Dental Insurance Company is 50503.

 

Claim Review

What procedures require professional review?
Altus Dental’s Utilization Review (UR) Guidelines explain the criteria used to determine whether a procedure qualifies for coverage. The UR Guidelines are organized by dental procedure code and include any documentation needed to file a claim for a particular service (for example, x-rays, periodontal charting, etc.). Note that while you may recommend a service, it may not meet the “dentally necessary” criteria specified in our UR Guidelines and we may not cover the service. Also, a service may not be covered by your patient’s specific dental plan.

These guidelines are subject to change as new procedure codes are introduced, when existing codes are revised or when materials, techniques and insurance industry practices are updated.


Do any procedures require pre-authorization?

For any treatment that is expected to cost $300 or more, we recommend – but do not require – a “pre-treatment estimate” (Medically necessary orthodontic treatment must be authorized in advance or no payment will be made). The pre-treatment estimate lets dentists and patients know about coverage levels, as well as whether the service meets our Utilization Review Guidelines and co-pay amounts before the service is performed.


What type of supporting documentation may be required as part of the review process?
X-rays don’t always show the entire condition of a tooth or site, so any relevant supporting documentation may help a claim to be processed on first submission. We encourage dental offices to provide additional information, such as the patient’s clinical treatment notes and photographs, along with an x-ray, when submitting pre-treatment estimates or claims for procedures that typically undergo utilization review, such as crowns, bridges, post and core, etc. Log in to your online account to read our Utilization Review Guidelines for a complete list of required documentation.


Who makes the clinical decisions in the review process?
Clinical review of claims is done by our Dental Case Management staff, which includes licensed, clinically trained hygienists and dental assistants who are supervised by our Dental Director and a team of general and specialty dental consultants. On-site, clinically trained hygienists and dental assistants conduct the first level of clinical review. These professionals approve claims that meet our treatment guidelines, while referring questionable claims to an in-house dental consultant. Our dental consultants are all licensed dentists with at least 10 years of clinical practice and most of our consultants have more than 20 years of experience. In addition, specialty dental consultants (in the areas of oral surgery, periodontics, endodontics and orthodontics) are available on an as-needed basis to review the second level of appeals in cases specific to their area of specialization.

 

Direct Deposit

How do I register for direct deposit?
To register for direct deposit, you’ll first need to register to use our online services, including electronic funds transfer. Once you register, select the “Direct Deposit” link and complete the online form. You’ll need to provide the name of the bank where you would like funds deposited, the bank account and routing numbers, and your Tax Identification Number (TIN).

If you’ve already registered to use our web services, log in, click the “Direct Deposit” link and complete the online form, providing the required information.

Once you’ve completed the Direct Deposit application form, you’ll receive a confirmation screen that requests your e-mail address and electronic signature to complete the process. When you’ve provided your electronic signature, you’ll receive an e-mail notification stating that your Direct Deposit request was successfully processed. The e-mail will also let you know when to expect your first payment. Note: Typically, your electronic fund transfer will be deposited to your bank account the day before you would normally receive a paper check by mail. Review our Check Run Schedule here.


Can I also receive electronic settlement statements?
Yes. As part of our Direct Deposit program, you can also receive your Consolidated Explanation of Benefits (CEOB) electronically. Dentists will automatically receive electronic statements once they enroll in our Direct Deposit program.

Once funds are deposited to the approved bank account, your office will receive an e-mail letting you know that your electronic CEOB is available for review. Log in to your online account with your user name and password. Then, click ‘Direct Deposit/Paperless CEOBs’ in the menu at left.


How do I change or update my bank account information?

To edit banking information, select the Direct Deposit/Paperless CEOBs tab and click on Manage My EFT. You can edit your bank name, bank account number and bank account routing number.

 

Coordination of Benefits

Do you coordinate benefits?
Yes, we coordinate benefits when a member is covered by more than one employer-sponsored dental insurance plan. We typically use standard insurance industry guidelines to decide the order in which plans will make benefit payments. Coordinating benefits helps patients meet their out-of-pocket costs, such as co-insurance and deductibles. Generally, if the patient’s primary plan has paid for a dental service and there are no out-of-pocket costs remaining for the patient, the patient’s secondary carrier will not make a benefit payment.


Do you coordinate benefits for pre-treatment estimates?
We don’t coordinate benefits for pre-treatment estimates because these estimates are subject to change. Coordination of benefits happens after the dental service is performed, based on any payment made by the patient’s primary plan.


What is a “non-duplication of benefits” clause?
Some employer group contracts include a “non-duplication of benefits” clause that specifies the integration of benefits, rather than coordination of benefits. With a non-duplication of benefits clause, total payments from both plans won’t ever be more than the amount the dental plan would pay if it was the patient’s only coverage — patient benefits are never duplicated.

As an example, if a patient’s and/or patient’s spouse's dental policy covers two dental exams, the patient can’t get two exams from the primary plan and two from the secondary plan. The patient may get a total of two exams.

Another example of non-duplication of benefits is if the patient’s primary dental plan covers crowns at 50% and the patient’s secondary plan also covers crowns at 50%. In this situation, no additional payment would be made by the secondary plan and total coverage would be at 50%. But if the patient’s primary dental plan covers crowns at 50% and his or her secondary dental plan covers crowns at 80%, benefits would be coordinated to pay the additional 30%.

 

Appeals Process

What is your appeals process?
There are two types of appeals – Administrative Appeals and Utilization Review Appeals.

An Administrative Appeal asks us to reconsider a claim that we denied based on the provisions of a patient’s group contract. Typically, members file these types of appeals. For example, a subscriber appeals the denial of a sealant (CDT code 1351) rendered on tooth number 13. The patient's contract specifically excludes coverage for sealants done on bicuspid teeth.

A Utilization Review Appeal asks us to reconsider a claim that was denied or disallowed because of a decision about the dental necessity of the procedure, in accordance with Altus Dental's Utilization Review Guidelines. For example, a dentist appeals a dental consultant's denial of a crown on tooth number 15 because the tooth lacks the required breakdown to qualify for a crown.

 

How do I appeal an adverse determination based on your Utilization Review Guidelines?

Click here for a complete description of the Altus Dental Consumer Rights and Appeals process.


Complaints Process

A complaint is made when a member, authorized representative or provider is dissatisfied with any part of our practices or the quality of care received. A complaint differs from an appeal, which is a request to review a decision not to authorize a service (known as an "adverse benefit determination," which can include denials, reductions, terminations or decisions not to provide or make a payment for a benefit).

A complaint may be filed in three different ways:

  • By email at customerservice@altusdental.com
  • By telephone at (401) 457-7200 or (877) 223-0588
  • By U.S. mail at Altus Dental Insurance Company, Attn: Complaints, P.O. Box 1557, Providence, RI 02901-1557

We typically settle most complaints on first contact. Sometimes, we need to do more research, especially if a complaint is about the quality of dental care or if it might involve fraud or abuse. We will respond to complaints within 30 calendar days unless an extension is granted. If you are not satisfied with the result of a complaint to us, you may contact the Office of the Health Insurance Commissioner.

Those who need assistance with a complaint may contact the Rhode Island Resource, Education and Assistance Consumer Helpline (RIREACH) at 1-855-747-3224 or at 300 Jefferson Blvd, Suite 300, Warwick, RI 02888. Visit the RIREACH website at www.rireach.org for more information.


Overpayments and Refunds

A claim was submitted to Altus Dental in error. What should I do?
If your office submitted a claim in error – and a payment was made – you have two options for correcting the financial mistake:

  • We can retract the dollars paid from a future settlement check
  • You can send a check back to Altus Dental with a copy of your Consolidated Explanations of Benefits (CEOB)

If you ask us to retract the money from a future check, it will be reflected in a future settlement with the following processing policy:
PP 506: This amount reflects an overpayment for a previously paid claim. The dollar amount of this claim has been deducted from your check total.

If we receive a check from your office, it will be reflected in your next settlement check with the following processing policy:

PP 505: This amount confirms receipt of a check you sent to us. It has no effect on your payment total.

 

Orthodontic Payment Schedule

How do you reimburse for orthodontic services?
For a complete overview of our Orthodontic Payment Schedule, log in to your online account to read the Orthodontics section of our Utilization Review Guidelines. We recommend a pre-treatment estimate for all orthodontic treatment plans (Medically necessary orthodontic treatment must be authorized in advance or no payment will be made). The fee for orthodontic treatment includes all diagnostic procedures (exams, photographs, etc.), appliances, post-treatment stabilization, etc.

Orthodontic benefits are available only for members under age 19, unless the employer group has purchased coverage for adult orthodontics. Orthodontic coverage ends on the day before the member’s 19th birthday. Benefits are not payable for orthodontic services received prior to the effective date and/or after the termination date.

 

Affordable Care Act

What is the Pediatric Dental Essential Health Benefit?
The Affordable Care Act (ACA) requires that health insurance plans cover 10 essential health benefits for individuals and small groups (employers with 50 or fewer full-time equivalent employees). Pediatric dental benefits are one of these 10 essential health benefits.

To learn more about the Pediatric Dental Essential Health Benefit, click here.


Who is eligible for Medically Necessary Orthodontia under the ACA?
The Pediatric Dental Essential Health Benefit includes coverage for orthodontic services that are considered medically necessary for children under age 19 with serious orthodontic impairment that results from congenital abnormalities that affect their daily ability to function (for example, eating and speaking). Under the ACA, there are no lifetime or annual maximum limitations for medically necessary orthodontia, which is covered at 50%. Click here for more details.