Acknowledgement of Financial Responsibility - Dental

In some instances, payment may not be made for services defined as benefits if those services are determined not to be clinically necessary or appropriate, or do not meet HMSA guidelines for coverage.

Specifically, eligible charge limits will not be applied when payments have not been made to a participating dentist due to the following reasons:

• The entire charge was applied to the patient's annual deductible.
• The patient already has exceeded the annual dollar limit of the plan.
• The service exceeds the service maximum for the year (e.g., two cleanings).
• The patient has a waiting period to meet before the services are a covered benefit.
• The service is not a benefit of the patient's plan (e.g., vital bleaching).

In addition, when the patient chooses a more expensive treatment option (e.g., resin instead of amalgam on posterior teeth), the patient is responsible for the difference between the eligible charge for the amalgam filling and the dentist's charge.

In all such cases, participating dentists may collect payment from the patient only if the patient has been fully informed and has signed an Acknowledgement of Financial Responsibility [PDF] before services are rendered.

The patient should sign and date the document once it has been determined that he or she will either pay for the entire amount of a noncovered service, or for the difference between HMSA's payment to the dentist and HMSA's eligible charge for the more expensive service.

Please keep in mind that if a partial payment has been made because of a deductible or dollar limit having been applied, the eligible charge will be applied, and the participating dentist may not bill the member in excess of the eligible charge.

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