Dental Questionnaire

  1. How long has your organization been providing dental insurance nationally?
  1. Provide references for your three (3) largestmulti-state dental clients, by enrollment using the following format:

Employer Name / Total Number of Employees / Number of Employees Enrolled in the plan(s) / Date Services Commenced / Contact Person / Address / Phone Number
  1. Provide information for your three (3) largest multi-state dental clients by enrollment that has terminated your plan(s) during the past 24 months using the following format:

Employer Name / Total Number of Employees / Date Services Terminated / Reason for Termination / Contact Person / Address / Phone Number
  1. Provide the location of the office that will manage the City’s account and provide the names of the individuals who will be responsible for all aspects of City account service.
  1. Provide an electronic copy in a usable Excel format(NOT PDF) of your most up-to-date provider directory including TIN numbers, Name, Address, City, and Zip Code for the network that you are proposing for the PPO product.
  1. Complete the following exhibit for your proposed networks.

Total Number of Dentists / Total Number of Specialists / Percentage of Dentists accepting new patients / Percentage of Specialty Dentists accepting new patients
Number of General Dentists / Number of
Endodontists / Number of
Periodontists / Number of
Orthodontists / Number of
Pedodontists
  1. Have you changed the size or structure of your network during the past twelve months?

Yes No. If yes, describe such changes.

  1. Detail any mergers/acquisitions involving your organization which have occurred in the last 12-month period, and any which are planned for the next 12 to 24 months.
  1. Are members required to select a dentist when in the PPO Plan? Yes No.
  1. How frequently may members be permitted to change their dental selection?
  1. Describe, in detail, your out-of-area coverage for traveling members, residing outside established service areas and emergency care after normal working hours both within and outside the U.S. Describe your capabilities for negotiating fees with out-of-area providers.
  1. What is your average wait time to speak with a live customer service representative? Use chart below:

2015 / 2016 / 2017 (YTD)
Average Time to Answer
Call Abandonment Rate
  1. Indicate how you track verbal and written complaints received by your organization. Are you able to report the number and types of complaints (both written and telephonic) received in a calendar year for all plan members (total population) and City members specifically?

Yes No.

  1. Report the schedule/time frame for ID card distribution. Include an explanation of how providers are instructed to handle members who have not yet been issued member ID cards.
  1. Will you mail to each member a copy of the benefit plan description detailing the terms and conditions of receiving benefits and documentation of the complaint and appeals process? Yes No.
  1. What information is available via voice response unit (IVR)?
  1. Can your plan track and report member enrollment information? Yes No. Can your plan track and report on customer service activity? Yes No.
  1. Are claims forms ever required of patients? Yes No. If yes, in what instances?
  1. Describe the specific measures used by your organization to monitor provider access. Provide the most recent corresponding statistics available. (Examples: provider to member ratios, average waitstime required for an appointment, etc.).
  1. Provide a complete list of any time frame, limitations, and/or exclusion that are applicable to each procedure for the plan you are proposing. The list must include, but is not limited to:

PPO

Procedures / Time Frame
Cleaning and Scaling (Prophylaxis)
Fluoride Treatments
Space Maintainers
Routine Examinations
Full Mouth X-Rays
Bitewing X-Rays
Replacement of Existing Appliances
Repair of Existing Dentures
Relining or Rebasing of Existing Dentures
Replacement of Crowns and Gold Fillings
Replacement of Missing and Un-replaced Teeth
Orthodontics
Other(s)
  1. Describe your reimbursement / payment methods for the following types of services:

PPO

Service / Capitation / Discounted Charges / Full Charges / Other
Restorative
Endodontics
Preventive
Periodontics
Prosthodontics – Removable
Prosthodontics – Fixed
Extractions
Oral Surgery
General Services (office visits after scheduled hours, drug injection, emergency and routine prescriptions, TMJ appliance)
  1. Can you accept electronic enrollments? Yes No. Paper enrollments? Yes No.
  1. What standard reports are available?
  1. Are there additional costs associated with any of these reports? Yes No. If yes, what is the cost?
  1. How frequently are these reports available? ___ Monthly, ___ Quarterly,

___Semi-Annually, ___ Annually. Provide a sample of these reports.