Stay Competitive in Your State and Offer the Best Oral Care for Members

Greater operational efficiency is a critical element to staying relevant in today’s ever more competitive industry.

Graphic: Maintain and grow market share

Gaining perspective based on real data is a great way to begin uncovering inefficiencies that can lead to less than optimal oral healthcare outcomes and/or undermine the value of the dental benefit for your members. A deep data analysis is the breath of fresh air you need to answer the big questions:

  • Is your utilization management as effective as it could be?
  • Is your benefit plan aligned to provide the best care to members? (exclusions, limitations, and frequency limits, etc. where applicable)
  • What codes should you include or not in utilization review?
  • Are there opportunities for right-sizing the benefits paid?
  • And more…

Getting a perspective based on real data is a great way to uncover inefficiencies. We make the daunting task of improving operations like your utilization management and claim review procedures simple with our suite of data-driven solutions.


The Utilization Management Optimization Report — Benchmark Your UM Practices

Improve your organization’s understanding of its utilization management practices with this comprehensive, turnkey report that features actionable insights to move your organization in the right direction. Key benefits include:

  • Enables evaluation of strategic policy to adjust processes and optimize benefits adjudication.
  • How do you stack up? Review current practices of benefits, utilization management and claims administration.
  • Best practices considerations are highlighted to optimize processes and meet business objectives.
  • Identify cumulative incremental savings opportunities when implementing all of the identified best practices.
  • Receive recommendations based on:
    • Reducing/mitigating impact of outlier behavior
    • Edit processor effectiveness across all procedure categories

1. Assess clinical criteria and guidelines

2. Evaluate edit/processor effectiveness

3. Reduce/mitigate the impact of outlier behavior

Evaluate Every Facet of Your Utilization Management

The Utilization Management Optimization Report is an extensive look at your organization’s operations that ensures no part of your utilization management processes is left unexamined. We break it down to the individual CDT Code and evaluate your:

  • Clinical criteria and current guidelines
  • Contract limitation, exclusions and frequency limits
  • Percentage of clinical recommendations for approval and/or alternate benefit coding
  • Edit/processor effectiveness
  • Standard documentation requirements for clinical review (where applicable) and comparison of clinical review guidelines

Once you have a greater understanding of your utilization management operations, the next step is often to examine your position in the marketplace.

The Market Landscape Analysis Report — How Do You Stack Up?

Take a deep dive into how your products stack up against the competition with this “diagnostic exam.” You’ll see how you’re performing relative to a de-identified group of other payers from a cost and utilization standpoint. All information is drawn from DentaBase®, the most extensive dental database in the U.S., so you can be sure that you’re always compared against the most accurate and complete data.

  • See de-identified real examples of competitive offerings in your state.
  • Gain insight on differences in claims costs for in-network services vs. a de-identified group of competitors, organized by specific procedure code.

Why is my cost per Patient so high? Is my Price per Treatment typical?

Answers to questions like these are simple to answer using real-world data and the guidance found in the Market Landscape Analysis Report. The Market Landscape Analysis Report provides:

  • Both in-network and out-of-network performance metrics
  • State level analysis of Price per Treatment (Price), Treatments per Patient (Utilization) & Cost per Patient (Cost)
  • Geographic implications (e.g., statewide, regional, etc.)
  • Adult claim costs compared to Children claims costs
  • And more…

You Know You Need to Optimize. What Are the Next Steps?

Put newly discovered utilization management and market landscape insights into action. Our suite of data-driven solutions can help you take the next steps to inform strategy and contain costs.

Streamline and Lighten Your Administrative Load: Professional Claim Review (PCR)

Professional Claim ReviewLet the recognized national market leader in dental claim review take care of your claim review process, freeing up your budget and workforce to focus on other priorities. Providing coverage across all 50 states, our team of highly skilled dentists expertly analyze claims to lighten a payer’s administrative load and ensure you’re not reimbursing for dental services that are not medically necessary or improperly documented.

  • 100% Federal and state Utilization Review compliance
  • Consultants in all states that require Home State Licensure
  • URAC Accredited
  • Comprehensive reporting capability
  • Rigorous quality assurance program for hiring, training and monitoring of consultants

Smart Dental Claim Selection for Incremental Savings: Pronto®

Smart Claim Selection with ProntoPronto® evaluates all of a payer’s daily claims volume in near real-time to predict which claims have the highest probability of generating savings and should be sent for utilization review. The insight Pronto® provides creates additional capacity to review those claims that generate further savings.

  • Predict which claims have the highest probability of savings and should be sent for utilization review.
  • Reduce clutter in your system by eliminating consultant review of claims that are ultimately approved.
  • Improve provider relations by eliminating the “hassle factor” and targeting only those dentists that exhibit outlier behavior.
  • Scale and create additional capacity to review other types of claims and gain incremental savings.

Utilization Management the Way You Want It: The Utilization Management Module (UMM)

Utilization Management Module (UMM)Profile dental providers, identify and prioritize outlier behavior, manage corrective actions and create actionable reports, all from a web application powered by DentaBase®, our multi-payer database.

  • Gain greater insight into dentist practices
  • Prioritize and address over-utilization by identifying and segmenting behaviors
  • Target providers in need of corrective education or action
  • Access a provider report card showing a dentist’s behavior by procedure code and with risk assessment insights

Comprehensive Network Management: The Network Development Module (NDM)

Network Development Module (NDM)The Network Development Module (NDM) is a self-service, web-based tool that empowers payers to identify the best dentists to include in their network. With deep insights based on our extensive, multi-payer database, DentaBase®, payers can use the NDM to:

  • Increase the range of potential recruits and network prospects.
  • Help manage a network with preferred capabilities and discounts.
  • Segment a dentist population by financial risk.
  • Gain insights on individual dentist fees to build a network that meets your needs.
  • Find and understand linkages between group practices and DSOs with affiliated practice search.

Or, if you’re looking for a turnkey, subscription-based network accuracy solution, try our Network Directory Accuracy Service.

See how you can leverage Big Data and smart analytics to deliver greater efficiency and value to your members — and care for their overall health more effectively. Contact us below to take the next step or email us at

Fill out my online form.