Page 4 - GDP - Provider Reimbursement Guide 2022

Golden Dental Plans Reimbursement and Billing Guidelines
Revenue Streams:
• Monthly Capitation Payments
• Member Co-Pays
• Supplemental Reimbursement Payments • Office Visit Fees
• General Performing Specialty (Optional)
Monthly Capitation Payments
GDP compensates our network providers by means of a monthly capitation payment which is based on the number of subscribers assigned to the facility. In most cases each subscriber falls into one of three CAP rate tiers, Single (1), Family of Two (F2) and Family of Three to Five (F3-5), the CAP rate increases based on the size of the family.
All monthly CAP checks are accompanied by a CAP summary report which details the members assigned to your facility. Please see page 16 of this document for a copy of the CAP payment schedule and the monthly CAP payment fees and benefit levels by group.
Member Co-Payments
All co-payments are calculated by using the providers fee schedule as the basis for the approved amount. If there is a co-pay due by the member the provider calculates the co-pay due by subtracting the covered percentage from the UCR, the balance remaining is the member co-pay. Provider must check available annual maximum via GDP’s provider web portal or by calling GDP prior to treatment.
Co-Pay Calculation Example:
ADA Code 2150 - Two surface filling covered at 75%
Provider UCR @ $200.00 x 75% coverage = $150.00, Member Co-Pay is $50.00
Supplemental Reimbursement Payments
GDP has developed a unique hybrid provider reimbursement system which corrects the deficiencies associated with strait cap plans. This solution incorporates a supplemental or additional fee for the most frequently utilized procedures. For example, in the illustration above the provider would receive an added $13.00 supplemental payment for the two-surface filling in addition to the $50.00 co-pay plus monthly CAP payments. Please see Supplemental Payment Schedule located on pages 11 – 15 of this document.
Office Visit Fees
Some of GDP dental plans include an office visit fee which ranges from $5.00 to $10.00 dollars per visit. Please see pages 5 – 9 for office visit fee details included on CAP payment schedule. GDP does not prohibit providers from charging PPE fee or Sterilization fee.
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