Open Dental Forum

Need your help when Cigna is the secondary coverage.

Our patient needed a crown. Our fee is $1800, Delta (in network) is primary, and Cigna (out of network) is secondary.
Delta pays at 50% of the Delta Fees of $1135, Delta pays $567.5, and adjust $482.50.

Now here is the problem. Cigna accepted UCR fees for a crown is $1500, and the crown covered at 50%.
Cigna says that both insurance portions should be $750, and now Cigna is paying only $182.50 because the primary paid already $567.50...
AND NOW ACCORDING TO CIGNA PLAN, the patient portion is $750.

The calculation made in OD for dual coverage shows that the patient portion is ZERO, because OD estimate that the secondary is going to pay $750.
This only happens mainly with CIGNA, because Cigna process dual coverage differently than other insurance companies.
Is anyone experiencing this when you are in network with primary, and out of network with Cigna as secondary.

Could that be fixed in OD, to show the right estimated patient portion?

*Dons Insurance Nerd Cap*
**I am probably the only person in the world who loves Coordination of Benefits**

First Question- What are the Coordination of Benefits settings in the seconday plan? They should always be set to Standard or Carve Out (Waaaay less likely to be carve out). The default setting was updated to Standard a few years ago, however, early adopters of Open Dental will likely still have Basic COB rules as default. There is a tool to change that in the program, though.

This Cigna plan is Carving Out. Simply stated, they are reducing their obligation by the amount already paid by the primary plan. The one pitfall at play is that Open Dental didn't (remember I've been out of the game for about a year) coordinate in and out of network benefits (PPO Percentage and Standard Plan Types). I'd love for someone still at OD to chime in here and tell me this has been corrected. Go ahead and change the COB Rule on your Cigna Plans to Carve Out, treatment plan this case again and see if that gives you the numbers you are expecting.

And please let me know how it goes.

IT WORKED !!!! . THANK YOU
Did not know that it was an option in OD. Like usual, just one check and everything works in OD.
Carve Out = non duplication benefit
Insurance calls it a "non duplication clause."
Arna, you are the best!!!
I changed the coordination of benefits in plan benefits. It sounds like a non duplication clause in CIGNA contract.