METHODOLOGY FOR ESTABLISHMENT OF THE DENTAL FEE SCHEDULE. Dental offices across the state charge varying prices for the dental services provided. As such, Blue Cross and Blue Shield of Louisiana has developed a dental schedule that attempts to compensate Providers for costs associated with operating a dental practice and to provide coverage for procedures that are necessary to maintain the Plan Participant’s overall Dental Care and Treatment. Dental fee allowances are calculated based on a combination of the following: charging patterns of dental Providers complexity of the service or procedure as determined by national dental consultants industry information The dental fee schedule is determined using the following steps:
1. Blue Cross reviews its Claims data for dental services (CDT codes) to analyze the average charges of Providers of dental services. The distribution of these charges are studied to gain an understanding of the charge patterns of Providers and how those charges compare to existing Blue Cross fee schedules and industry information.
2. In order to develop the actual fee schedule, each procedure code is assigned a factor to establish a relative value to each other, which takes into consideration such things as overhead costs to perform services, time involved in performing services, professional expertise required, labor costs, etc. These values define the complexity of these dental procedures as they compare or “relate” to each other. National dental consultants determine these relative value factors.
3. The fee schedule is then developed by multiplying these relative value factors by a number whose product results in the fee We will allow for the procedure. This number is selected as one that will produce a fee schedule that fairly compensates Providers and provides for a competitive product for our Plan Participants. These fee allowances are our “Allowable Charge” represents the maximum amount We will pay for a Covered Service. The Plan Participant is not responsible for charges in excess of this fee when using a Participating Dentist, but is responsible for the balance of the charges in excess of these fees when using a Non-Participating Dentist. All fees are reviewed and updated periodically using the criteria outlined above.
