Understanding Your Affordable Care Act Coverage

As part of the Affordable Care Act (ACA), Renaissance Dental has outlined the following transparency in coverage information for members enrolled in a dental plan through Healthcare.gov. Please note that ACA dental plans are not available from Renaissance in certain states, including, but not limited to Idaho.

What is balance billing?

Balance billing occurs when an out-of-network provider bills an enrollee for charges – other than copayments, coinsurance, or any amounts that may remain on a deductible.

What is my liability for out-of-network services?

If the submitted amount for an out-of-network dentist is more than the allowed amount, the enrollee is not only responsible for paying the dentist that percentage listed in the policy, but is also responsible for paying the dentist the difference between the submitted amount and the allowed amount.
If an enrollee requires emergency treatment and receives covered services from an out-of-network dentist, covered services for the emergency care rendered during the course of the emergency will be treated as if they had been provided by an in-network dentist. If an in-network dentist is not readily available within a reasonable period of time or driving distance, it may be possible for an enrollee to receive covered services from an out-of-network dentist and be reimbursed at the same benefit level as if the covered services were provided by an in-network dentist. If an enrollee feels this may be the case, he or she may call our group customer service department at 888-358-9484 or individual customer service department at 888-791-5995 (TTY users call 711).

How do I submit a claim?

Your dental office will submit claims on your behalf when you utilize an in-network dentist. However, if you utilize an out-of-network dentist, you will need to submit a claim and do so within 12 months of the date of service to:

Renaissance
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department

You can also call our group customer service department at 888-358-9484 or our individual customer service department at 888-791-5995 (TTY users call 711). You can

also download a claim form.

What is the grace period and claims pending?

If you fail to pay the full amount of the premium by the date it is due, a grace period will apply. The grace period allows you additional time to pay the premium without losing coverage. The grace period refers to either a 3-month grace period for members receiving advance payments of premium tax credit, or a general grace period for members not receiving advance payments of premium tax credit.

• The general grace period is a 31-day grace period. This means that if a premium, other than the initial premium, is not paid by the date it is due, it may be paid during the following 31 days. Your policy will remain in force during this grace period. The grace period will not apply if, at least 30 days before the due date, Renaissance has delivered or mailed to your last known address a written notice of our intent not to renew your policy
• The 3-month grace period applies to members receiving advance payments of the premium tax credit who have previously paid at least one full month’s premium during the benefit year. Your policy will remain in force during this grace period. If premium payment is not received within the 3-month grace period, your coverage will terminate on the last day of the first month of the grace period.

During the 3-month grace period, Renaissance will pay all appropriate claims for services rendered to you during the first month of the grace period and may pend claims for services rendered to you in the second and third months of the grace period. A claim is pending when it has been submitted to Renaissance and is still being processed by the Renaissance claims department.

What is a retroactive denial and how can I avoid them?

A retroactive denial is the reversal of a previously paid claim, as a result of which the enrollee then becomes responsible for payment.
A claim can be denied retroactively, for example, if Renaissance pays a claim during the grace period and it is discovered that the enrollee has terminated the policy prior to covered services being rendered.

The best ways to prevent retroactive denials are:

• Pay your premium online or over the phone on time.
• Ensure you have provided us with the correct information and ensure you are covered when services are performed.

To update your individual account information, you can visit the Renaissance Member Portal.

What happens if I overpay the amount of my premium?

If an overpayment occurs, it will automatically be given as a credit toward the next month’s premium unless the member contacts customer service to request a refund. A refund will be issued in the way the premium was paid, or a refund by check can be requested.

What is a prior authorization and do I need one for services?

Prior authorization is the process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.

Renaissance does not require prior authorization for any covered services. If you are concerned about your coverage or the cost of a covered service, you can request a Pre-Treatment Estimate.

What care is considered a medical necessity and is it covered?

The Essential Health Benefits requirement for pediatric oral care services (for children up to age 19) may limit certain covered services, including orthodontia, to those that are medically necessary, i.e. only orthodontia treatment that is assessed as being reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care may be considered to be an essential health benefit. Medically necessary orthodontia was not specifically defined by federal law or regulation and may vary by state.

What is an Explanation of Benefits (EOB)?

An Explanation of Benefits (EOB) is a document that Renaissance may send to you after you receive dental treatment. This document will explain what procedures were covered under your benefit plan, as well as any procedures that might not have been covered and why they were not covered.

EOBs are issued after the claim has been processed. When you receive dental services and do not owe any balance, you will not automatically receive an EOB. You can access a copy online using the Renaissance Member Portal, calling our group customer service at 888-358-9484, or calling our individual customer service at 888-791-5995 (TTY users call 711).

How do I read an EOB statement?

We send the EOB directly to you, and it will provide you with the information you need, including: dental services performed (procedure description), dentist fees, Renaissance’s payment, your required payment, coordination of benefits information (if applicable), and annual maximums used during the current benefit year.

What is coordination of benefits (COB) and does Renaissance participate?

Coordination of Benefits (COB) is a procedure for paying health care expenses when people are covered by more than one plan. The goal of COB is to make sure the combined payments of the plans do not exceed the amount of your actual bills. If you are covered by two or more dental plans – usually because both you and your spouse receive coverage through work – your coverage may be coordinated.