2-125: New Database - FAIR Health - for OON Dental Claims

Apr 13, 2011

Anthem will no longer use Ingenix® PHCS and MDR® databases for out-of-network dental claims after March 31, 2011

For dental services received after March 31, 2011, Anthem will stop using the Ingenix^® Prevailing Healthcare Charges System (PHCS) and the Ingenix MDR^® Payment System ("Ingenix databases") for guidance when reimbursing out-of-network dental claims. This will affect some of Anthem's Dental Blue^® PPO plans and some Prudent Buyer dental plans.

A little background: What is Ingenix?
Ingenix (a subsidiary of UnitedHealth Group, Inc.) is a company that gathers information about dental and health claims across the country. It then creates databases that show how much providers charge for all different kinds of services. Health and dental plans can use those databases for help when deciding on their own reimbursements for out-of-network claims.

Why will Anthem stop using Ingenix?
In 2008, New York Attorney General Andrew Cuomo began looking into whether there was a conflict of interest in how health care plans used the Ingenix databases. In 2009, UnitedHealth Group and the New York Attorney General agreed that Ingenix would stop offering the use of its PHCS and MDR databases. Instead, an independent, not-for-profit service would replace the Ingenix databases.

In a separate agreement with the New York Attorney General, Anthem agreed to stop using the Ingenix databases after the new database became available. You may be interested to know that Anthem is just one of many health care plans that will stop using the Ingenix databases. Others include United HealthCare^®, Aetna^®, Guardian, GHI, HealthNet^®, HIP^®, CIGNA^®, EmblemHealth^®, MVP^SM and Capital District Physicians Health Plans^®.

Beginning April 1, 2011, Anthem will be using a new database called FAIR Health
The new FAIR Health database for dental claims became available in early February 2011. Health plans that used Ingenix for dental claims have 60 days to begin using FAIR Health. Anthem will begin using it on April 1, 2011 for dental plans that reimburse out-of-network claims based on percentile methodologies. The FAIR Health database for health claims will be available at a later date.

NOTE: This change does not apply to every plan. For example, this change does not apply to any dental plans that use a fixed fee schedule for out-of-network reimbursement.

For more information about this change, you can get in touch with your b&p Group Sales Representative.