Although dental insurance helps clients afford dentistry, they work hard for this benefit. Dental insurance wasn’t designed primarily to help our clients. It is a business relationship between a company and an insurance company. During a series of negotiation sessions, these points will be worked out between the insurance company and the employer:
1. How many dollars the company will pay?
2. How many dollars the employees will pay?
3. Will the employee portion be made available as either a reduced salary or a raise to cover the cost of the employee’s premium?
4. Given this amount of money, what the benefit will be?
5. The more premium dollars spent, the better the coverage.
UCR’s (Usual, Customary, Reasonable Fees)
The UCR is determined by the employer. The more money the employer has to spend on dental insurance, then generally, the higher UCR fees they select. Insurance companies write policies with differing UCR’s to fit the budgets of their customers, the employers. The Washington State Dental Assoc did a study several years ago, finding over 17 different UCR fees for the same procedure in the same zip code. So, there’s no such thing as one UCR for one procedure! An employer can also choose the percentile of UCR its allowable fee is based on. If they choose to base their payment of claims on the 70th percentile, their premiums will be lower than if they choose to base their payment of claims on the 90th percentile. This creates a wide variation in what EOBs refer to as “usual and customary.”
This concept of UCR is one of the most misunderstood in dental insurance. Patients often think that for their geographical region there is one usual & customary fee that is accepted by all the dentists in the area. So, if your fee is higher then the patient may think you’re more expensive than another dentist whose fee was at or less than the UCR for his or her employer.
PPO insurance (Preferred Provider Organization)
This type of dental insurance requires that for a dentist to receive benefits for their patients, the dentist must be a member of the insurance plan. To become a member, the dentist must accept a discounted rate for the patients on the insurance plan. This is generally at least a 20% discount. The reason the dentist signs up for this type of insurance is that they are hoping to generate more new patients because their name will be “on the list.”
Some PPO insurance plans will refuse to pay any benefits to dentists that are not members – for example, in Ohio, Superior Insurance is a PPO plan. If a patient goes to a dentist “off the list” then they will not receive any benefits through their insurance at all.
Other PPO insurance plans maintain a list of dentists that patients will receive a discount if they go to, but they also pay some benefits for ‘out-of-network’ dentists. One example of this is Delta Dental insurance, they have a list of dentists that patients are encouraged to use, but if a patient wants to see a dentist that is not on the list, they will receive out-of-network benefits. The difference between in-network and out-of-network benefits is that if the dentist is a member, then the insurance company will send the insurance check to the dentist. This is a benefit to the patient because they can pay their portion to the dentist and the insurance company will pay their portion to the dentist. If the dentist is not a member of the PPO, then the patient will have to pay the full treatment fee and the insurance plan will reimburse the patient. This can be tougher for the patient to manage cash flow while they wait to receive their insurance benefits.
HMO (Health Maintenance Organization) / Capitation
HMO’s are also known as Capitation plans. This type of dental insurance agreement with the dentist determines an annual dollar amount per patient signed up for this insurance and pays the dentist per patient. Since the dentist has been paid for the patients, the patients expect to come in for appointments any time. This can be a problem for the dentist when a patient wants to come in frequently, and actually incurs costs to the practice beyond what he has received in payment for them. It does not match up actual treatment costs with payment. So, an HMO member dentist will make more money if he has patients that he is receiving dental insurance payments for, but he is not providing any treatment or appointments.
Who wins and who loses in a PPO plan? Dentists who sign up with a PPO elect to take a 20-50% reduction in fees. To cover a drop of 20-50% in revenue contracted dentists need to provide in excess of 40% more dentistry with the same staffing, office , and time scheduling within the same patient pool. Some contractual dentists feel that with the additional pool of PPO patients even more dental services will be needed, far greater than the 40% needed to meet overhead demands. Implementation of time saving procedure and procedure selection such as delegation to subordinates, less time with patients, using cheaper dental laboratories, adjusting appointment times, and prioritizing more profitable procedures, and incentive to handle more complex/expensive cases ” in-house”…are some of the adjustments made. The question becomes can dentists do this and still maintain the necessary standard of care???. After the dusts settles: the insurance company has paid out less benefits in term of premium dollars, the employer has reduced costs while continuing to offer employees a dental benefit, and the patient receives care from offices that have contracted to receive larger volumes of patients for lower fees…who do you think loses?????
DR (Direct Reimbursement)
This is a concept that is NOT dental insurance. Dental insurance acts as a middleman between dentists and patients, often taking a 20-30% profit which drives up the costs for patients and dentists. Since most dental insurance plan maximums are $1000/person per year, this is not a large amount to “insure” and dental insurance profits reflect this. Have you ever noticed how grand a dental insurance building is? They seem to always be the ones that have enough money to put in a fountain!
Direct reimbursement removes the dental insurance middleman. Here is how a DR plan works:
1. Company offers a DR plan for employees to receive dental benefits
2. Employees sign up for the plan & are told up front how much money they will receive for their dental care – can be as much as $1000/year per person but perhaps just $250/year per person or 100% of the first $100 and then 50% of the next $500.
3. Employee (patient) goes to any dentist (there is no list) and has whatever treatment they want done.
4. Employee pays for their treatment and receives a receipt for payment.
5. Employee turns the receipt in to the DR administrator and receives reimbursement up to the amount according to the plan.
DR is a great thing for many reasons:
• Insurance plans have many restrictions – they will pay only 50% on major treatment, not pay anything on cosmetic procedures like whitening, not provide orthodontic coverage, etc. DR generally has no restrictions.
• Insurance plans are difficult to understand – most people have no idea what their dental insurance covers, what is in their insurance booklet, or even where their dental insurance card is! DR plans are easy to understand and people can budget around what they know they will receive from their plan.
• No lists – with DR the patients can go to any dentist they want because the dentist will be paid by the patient & the patient will be reimbursed.
Knowing this, please stress three things to our clients
1. Dental insurance isn’t designed to pay everything
2. Coverage is based on how much the employer was willing to pay into the fund.
3. Some insurance companies say “Fees are above average,” When they should say “our benefits are low”
As a receptionist, you have some extra responsibilities. These are:
1. Send out predeterminations (which is a request to an insurance company to let the patient and the dentist know in advance how much they would cover on a treatment plan) when expensive treatment is presented. Most insurance companies return these in 3 weeks or less and this helps your patient plan for the expense of dental care.
2. Become familiar with the plans that we often use. Learn what you can expect. It saves you lots of time.
3. Understand the contract language. Learn the key words and clauses that define the benefit the client can expect.
4. Learn how to handle secondary carriers.
Some patients think that since they have insurance, they won’t have to pay anything at all. This is not reality. There are deductibles and co-pays on most plans. Plus, for out-of-network plans, the patient is reponsible to pay the difference between the UCR and the dentist’s full fee. Your task now is to give your client a clear understanding of their coverage.
First, seat your client in a quiet place. Don’t try to explain insurance over the front desk with phones ringing, people talking, and the clients in the reception room eavesdropping. Second, don’t guess. Call up their plan on the computer. Make sure you know the procedure they want to check for coverage. Third, let your client know this is only an estimate. Fourth, do you have extra circumstances to deal with? Fifth, make a note on the treatment sheet that you had a conference with the client and your estimate of the insurance coverage.
1. Predetermination – Sending an estimate to the insurance company usually takes about 3 4 weeks. Many insurance companies request a predetermination on anything over $100 – $200. This wastes your time. If the treatment is straight forward for example a broken tooth, shows on the x ray why send a preauthorization for a crown? You know they’ll cover it. You know how much the plan will pay. Be efficient. Be in control. Reassure your client, make your financial arrangement, and schedule the appointment. However, if the fee is over $400 or involves esthetics, bridges, partial dentures, complete dentures or TMJ then send the estimate to be safe. This is for our benefit as well as the patient’s. If after the claim comes back from the insurance company, other treatment is provided, just add these services to a new claim and submit it.
Watch out for changes that could occur that would make the predetermined estimate invalid. These changes could include
1. The client or doctor change the treatment plan based on the estimate received.
a. Part of the treatment may not be covered
b. The insurance portion may be less than expected
2. Further treatment may be necessary.
3. Any changes in fees or coverage if treatment has been delayed more than 60 days.
4. The predetermination is more than one year old
5. We can find out some limited information for emergency clients, but predeterminations must be in writing
2. Coordination of benefits – When both a husband and wife both work and both have dental benefits, they sometimes have very little out of pocket expense. There are certain rules that must be followed.
a. It either spouse’s plan does not have a “coordination of benefits” clause, use this as the primary plan. This will increase coverage.
b. The spouse who is being treated is the “primary” coverage and must be submitted first.
c. We can’t send “pre determinations” to both companies at the same time. The second company wants to see what the first company will pay before they decide what their coverage will be. Be sure to include X-rays in both claims. Also send a copy of the explanation of benefits from the primary carrier to the secondary carrier.
d. The Birthday Rule – is to be followed when submitting claims for the children. The plan of the parent whose birthday falls earlier in the year is primary. (If the parents are divorced, this may not always be the case. The divorce decree may ovrerride the birthday rule, so be sure to ask.) Explain to your client that no matter how good the benefits of each policy, they won’t be able to collect more than 100% of the dental fee charged.
e. Non duplication of benefits clause: if the secondary insurance has this clause, they may not pay anything beyond what the primary insurance paid. For example: if the charge is $200, and the primary carrier pays 150, and the secondary carrier would have paid $120 had they been primary, they will not pay anything, since the primary paid more than the secondary would have. If however, the charge is $200, and the primary carrier pays 150, and the secondary carrier would have paid $160 had they been primary, they would then pay $10 on this claim.
3. “Alternate Benefits” – The client’s insurance company may decide to pay for the least expensive adequate treatment. This could mean a partial denture rather than a bridge.
4. Exclusions – Many policies will not cover 1) any TMJ treatment 2) treatment to improve esthetics (such as porcelain veneers). 3) crowns needed due to abrasion or attrition. Read the “fine print” closely. An insurance company can choose to exclude anything they want to. The client’s only recourse to gain coverage is to go to their company and complain.
5. Pre existing conditions – Some insurance company policies (Remember it’s not the insurance company that establishes the benefit package it’s the client’s company.) won’t pay for replacing any tooth that was missing before the policy took effect. In the trade this is called the “old hole” “new hole” policy. This also applies to congenitally missing teeth (those missing at birth).
6. Statute of limitations – insurance companies won’t pay to replace a crown, bridge, denture, etc. until a certain number of years has passed (usually 5). They won’t allow payment for a regular cleaning until 6 months has passed.
7. The benefit year all insurance coverages renew on an annual basis, but most are on a calendar year. If your client wants more treatment than can be accomplished in one year, it can be spread to the beginning of the second contract year.
8. Age limitation
a. Fluoride seldom after the age of 19
b. Sealants seldom after the age of 14 (also teeth must be caries free and filling free)
Be careful to submit x rays as needed. Make sure the x ray is current. If a missing tooth is to be replaced, partial dentures, or STM, you will need to submit a complete x ray series. If it is a single crown or root canal, an x ray of the tooth showing the need for treatment is enough. Place single x rays in a small envelope with stamp (our name, address, and date) and clients name on the outside. Make sure a panoramic or CMX is identified also.
Finally, don’t force your client to wait for the return of this predetermination before starting treatment. You can start with a cleaning and fillings or root canals. These procedures are always covered well and will absorb the waiting time.
9. When to submit for medical not dental coverage. Generally, medical insurance won’t help cover dental treatment, but occasionally, these treatments could be considered medical:
a. cysts, lesions, tumors
b. biopsies (not tooth related)
10. Emergency Treatment – If the patient had an accident, you could try to submit to the medical insurance plan. However, usually this will just apply to their deductible and the patient will be responsible for the fees. If their tooth caused them pain not due to an accident, use dental coverage.
11. TMD/TMJ – Jaw pain treatment – usually includes a splint
a. Even though TMJ maybe excluded, there will be some dental coverage for exam, x rays,
models, physiotherapy, muscle testing, etc.
b. Medical insurance usually doesn’t cover this treatment – but you can try to submit it based on the patient’s headaches or other physical,medical symptoms
12. Extraction of impacted teeth – insurance generally covers extractions at 50%
13. Missing tooth clause – Most dental plans do not consider root removal to be an actual extraction which causes problems when the patient’s plan has a missing tooth clause (which about 50% of all dental plans have). If less than 25% of the crown is visible on an x-ray, carriers may consider the procedure a root removal, instead of an extraction. They would then not approve a bridge to replace the tooth, since according to their guidelines the tooth was not “extracted” while the patient had coverage.
14. Implants – Dental insurance often pays for the surgical placement of the implant and for the abutment and crown.
15. Denial of claim – This seems like a bad thing, but in 2009 only 20% of denied claims were appealed – and 90% of those were paid on appeal.
1. My plan says exams and other procedures are 100% covered, but I still owe you.
“This means your insurance company will pay 100% of the amount they allow, not what our fees are.”
2. If my insurance won’t pay for this procedure maybe it’s not a good idea to do it “Every insurance
company has exclusions. That doesn’t mean the treatment is wrong or not important. It is a way to
reduce an insurance company’s expenses. You can go back to your company and complain. They
may be able to get this covered for you.”
3. “My plan says it pays 100% for a cleaning, but I still have to pay $10.” Your plan pays on a schedule
and our fee (and that of most practices in our area) is higher than the fee in your plan.
4. Their insurance company paid less than expected. “Our computer estimates what most plans pay. Unfortunately, your plan pays less. From now on, we’ll add your insurance company profile to our computer so it won’t happen again. In the meantime, we can submit a request to your insurance company to tell us in advance what they’ll pay for any new procedures. This will slow up treatment a couple weeks.
We are often asked by our patients, “Your fee for this is over what my insurance company calls ‘usual and customary’, does that mean you’re overcharging me?” That’s a good question, and one we’re happy to answer.
Insurance companies on an individual basis come up with “usual and customary” fees for all dental procedures for a certain geographical region. When our state dental association asks these companies for data to see how the numbers were arrived at and who, if any, dentists were surveyed, they are told categorically by every insurance company that this is confidential, internal information and they will not reveal it.
Our answer is, “If this survey was done fairly, and truly represents the fees in a given area, then why can’t we see how it was done?” The insurance industry seems to be incapable of understanding this type of logic. The fact is that different insurance companies have different reasonable and customary fees for the same area. If the calculations were done correctly and fairly, they should all have the same fees. They do not because the “calculations” were not done fairly and correctly. The insurance company’s only reason for establishing artificially low “reasonable and customary” fees is to cause animosity between the dentist and the patient. It is the insurance company’s hope that the dentist will then lower his/her fees so the company will have to pay our less money. Any time an insurance company says they’re on your side, grab your wallet to see if it’s still there.
A dental plan is nothing more than a contract between the employer and the insurance company to partly pay for certain services. There are deductibles, some services are paid on a percentage while others may not be covered at all. You employer buys a contract at a specified premium and includes as many or as few benefits as the employer is willing to pay for. It is a well known fact within the industry that a higher premium paid by the employer will get you, the patient, a higher “usual and customary” fee schedule.
Our fees are set by the actual costs of doing business in this particular office. Obviously, costs can vary from office to office depending on the quality of service, materials used, lab costs, and many other factors. We have never tried to be a dental office for everyone, and by the same token, we have never tried to be the cheapest office. Our fees reflect the quality of service and the care with which it was delivered. We also want our patients to know that our sterilization standards are second to none and are well above what is required by the profession.
If price is your only concern when choosing a dentist then our office may not be the right one for you.
Here are some dental insurance terms:
Administrative Agent -The third party to a dental prepayment contract that may collect premiums, assume financial risk, pay claims and/ or provide administrative services. Synonyms: Administrative Agent, Carrier, Insurer, Underwriter.
Allowance Table- A table of payments for covered services. The table may not be relative to the dentist’s charges for treatment. The patient pays the difference between the set fee (table of allowances) and the dentist’s charge.
Allowable Benefit- Any item of service or treatment covered (in whole or in part) under a program. By contract terms it is possible for a dental treatment at the provider’s office to not be included as an allowable benefit. For example, crowning pegged laterals, or making two or three fixed bridges in the same jaw. This is not to be explained as an attempt to disallow good quality dental care but in reality is an attempt to employ the virtue of cost containment to reduce expenditures and keep premium dollars at a minimum.
Alternate Benefit – Alternate Treatment- The contractual concept by which the insurance carrier can substitute an “equal but less expensive” treatment plan for the one submitted by the attending dentist. This clause is necessary to protect the carrier from the over-utilization and excessive costs. We remind you that these policies call for equal or professionally acceptable treatment. The attending dentist and the patient have the option of which procedure to use although payment for the procedure may be based on the “alternate treatment” principle. The alternate benefit must provide that the alternate treatment be professionally sound and acceptable. I remind all concerned that the only true mechanism for determining the appropriateness of treatment rests with Peer Review. If the attending Doctor-Provider feels a contest is in order between the carrier’s decision and his decision, it is the ultimate responsibility to have the final adjudication of what is appropriate treatment. Doctor-Provider and consumer patient must not be expected to roll over and to “play dead” because carrier language has allowed alternate benefit provision.
Assignment of Benefits- A procedure whereby a covered person authorizes the third party/ carrier to make payment directly to the dentist of any allowable benefits. The patient must always be held responsible for the full cost of any and all dental treatment regardless of what may be assumed as a dollar amount covered by the dental benefits contract. Please note that this signature (part of section #15) is revocable and can be stopped and cancelled without any caution. This signature is NOT IRREVOCABLE.
Alternate Dental Delivery System- Refers to approaches for delivering dental services other than the traditional fee-for-service, private practice mode of delivery.
Audit- The review of dental services rendered or proposed by a dentist which may take the form of a comparison of patient records and Claim Form information, a patient questionnaire, and examination of pre- or post-operative radio-graphs, or a pre- or post-treatment clinical examination of a patient, also may involve fee verification, as in the case of fee forgiveness.
Benefit- The amount payable by the third party/ carrier toward the cost of various covered dental services.
Benefit Booklet- A booklet for the employee which contains a “general” explanation of the benefits and related provisions. The dental office manager should request a copy from each “new” patient when he enters the practice.
Bill Payer-Direct reimbursement- A method of assistance in which beneficiaries are reimbursed by the employer or benefit administrator for any dental expenses, or a specified percentage thereof upon presentation of a paid receipt or other evidence that such expenses were incurred.
Capitation- A fixed monthly fee payment paid to the dentist in a closed panel. It is based on the number of patients assigned to him whether utilized or not. The dentist is obligated to render a set number of services, at no charge, and is provided a surcharge schedule for other services. The dentist assumes the financial risk of high utilization and demand for dental service plan members. See Pre-Paid Dental Plan.
Certificate Holder- Subscriber- Enrollee- The employee who represents the family unit covered by the pre-payment plan.
Claim Form- The form used to file for benefits. It is divided into three sections: A) the patient section, 1-15; B) the dentist section, 16-32; and C) the area noted by procedure codes describing the treatment rendered or to be rendered.
Closed Panel- A practice established if patients eligible for dental services in a public or private program can receive these services only at specified facilities by a limited number of dentists. If the services are provided in a group practice facility and are prepaid by some agency, the practice is more precisely termed “pre-paid group practice.” For example, a State Delta Plan is a dental service corporation legally constituted, not for profit, organization sponsored by a constituent dental society to negotiate and administer dental care.
Coinsurance – Co-payment- The provision of a program by which the insured shares in the cost of covered services on a percentage basis. A typical coinsurance arrangement is 80%-20%. This means the carrier will pay 80% of the benefit of the covered dental service and the patient will pay the difference of 20%. Percentages vary and may apply to both table of allowance programs as well as usual, customary and reasonable payment programs.
Coordination of Benefits- Plans which contain Coordination of Benefits provision can allow employees and their dependants to collect up to 100% of the allowable expenses. Since the definition of “plan” under the standard non-duplication (COB) provisions includes group dental plans as well as group medical plans, coordination can occur not only between a medical and a dental plan provided that each of the plans is a separate policy. This broadens the usual concept of COB in two distinct ways:
1. Coordination can occur between a medical and dental plan as long as the incurred expense is considered as a covered charge under at least one of the plans.
2. Coordination can occur between a medical plan and a dental plan even where both are insured through one policy holder and one employee, provided that the two plans are separate policies. This holds true whether both plans are insured through the same or different carriers. See additional Coordination of Benefits section in Chapter V.
Cosmetic Dentistry- Encompassing those services provided by dentists solely for the purpose of improving the appearance when form and function are satisfactory and no caries or pathological conditions exist.
Coverage- Covered Charges- Benefits available to a covered individual under a dental program. Charges for services rendered or supplies furnished by a dentist which would qualify as covered expenses and for which the program will pay in whole or in part, subject to any deductible, coinsurance or table of allowance, included in the program.
Deductible: Individual Deductible- The individual deductible is determined as follows:
1. For non-integrated plans, a cash deductible must be met by each insured person, each calendar or fiscal year.
2. For integrated plans, a single cash deductible is applied to both major medical, or health care and dental coverage charges.
Family Deductible- The family deductible provision applies when three or more persons, while insured under the plan as members of the same family, each met the individual deductible. Under this provision, usually no cash deductible will be applied to covered dental charges incurred by any additional family member if these charges are incurred on or after the date the third family member meets the deductible. When this provision applies, the standard policy wording will read: “Limit of $XYZ deductible per family calendar year.” The policy will advise the deductible amount and show the number of family members which have to satisfy the individual deductible amount.
Aggregate Family Deductible- A total family deductible may be satisfied by any or all members of the family, however, no one individual may contribute toward the family deductible more than the specified individual deductible. For example:
1. Standard policy wording for this provision will indicate total per family deductible of $XYZ per calendar year limited to $XY per individual.
2. If the family deductible is $150.00 and the individual deductible is $50.00 per individual.
Lifetime Deductible- The lifetime deductible provisions applies to the charges designated by the plan’s provisions and once satisfied will never have to be satisfied again, except in the situation where the person might be terminated and then later re-hired by the same company.
Three Month Carry-Over Provision- Some policies may include a three month carry-over period for expenses incurred during the last three months of a calendar year. Monies are applied toward the deductible for such calendar year and also are applied toward the deductible for the next year. It is not necessary that the deductible be completely satisfied during the previous year. In addition, these provisions apply to both the individual deductible and the family deductible.
Deductible Application- The deductible is applied to charges incurred in chronological order. It is particularly important that the chronological order be applied to covered expenses which are paid at different co-insurance factors. If charges reimbursable at varying percentages are incurred on the same day, the deductible is applied first to the charges reimbursable at the lowest co-insurance percentage.
Dependents- Generally the spouse and children of a covered individual as defined in a contract. Under some contracts parents or other members of the family may become dependents. Some contracts stipulate as to age and student status of children. (see Eligibility Date)
Direct Reimbursement- A method of financial assistance in which beneficiaries are reimbursed by the employer or benefits administrator for any dental expenses, or a specified percentage thereof, upon presentation of a PAID receipt or other evidence that such expenses were incurred. (See Bill Payee)
Eligibility Date- The date an individual and/ or his dependents become eligible for benefits under an existing contract. Spouse is determined by the state in which you reside. Unmarried children under age 19, other unmarried children and step-children under the age of 19 are also eligible if they are principally dependent upon insured for maintenance and support and, when not in attendance at school, are permanently residing in insured in what is generally considered a parent/ child relationship. Unmarried children who are at least 19 years of age but who have not reached age 23, if they are not employed full time and if they are principally dependent upon insured for maintenance and support.
Exceptions or Exclusions- Dental services not covered under a dental program. Contractual denial of benefits by administrative decision.
Expiration Date- The date the dental insurance contract expires. The date an individual or employee ceases to be eligible. (See Term of Benefits)
Family Deductible- A deductible which is satisfied by combining expenses of all covered family members. For example, a program with a $25.00 deductible may limit it’s application to a maximum of three deductibles of $75.00 for the family, regardless of the number of family members. (See Deductible)
Fee Schedule (Third Party)- Maximum dollar allowances for dental procedures which apply under a specific contract. ( See Table of Allowances)
Free Choice of Dentist- The provision of a dental program which permits the insured to choose any licensed dentist of his/her choice.
Health Maintenance Organization- An organized system of health care which accepts the responsibility for providing or otherwise ensuring the delivery of an agreed upon set of comprehensive health maintenance and treatment services for a voluntarily enrolled group of persons in a geographic area and is reimbursed through a pre-negotiated and fixed periodic payment made by or on behalf of each person or family member enrolled in the plan.
Incentive Program- A dental program which pays an increasing share of the treatment cost provided that the covered individual utilizes the benefits of the program during each incentive period and receives the treatment prescribed. For example, a 70%-30% co-payment program in the first year of coverage may become an 80%-20% program in the second year if the subscriber visits the dentist each year as stipulated in the contract. The following year, co-payment might reach 90% or 100% to allow the patient NO co-payment. Usually there is a corresponding percentage reduction in the co-payment level if the covered individual FAILS to visit the dentist in a given year.
Limitations- Restricting condition regarding payment, contained within a group dental contract such as age, materials used, period of eligibility and waiting periods, deductibles and exclusions.
Maximum Benefit- The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period based usually on a calendar or fiscal year.
Maximum Fixed Fee Schedule- A compensation arrangement in which a participating dentist agrees to accept a prescribed sum as his total fee for one or more covered services. The dentist agrees NOT to exceed the set amount.
Noncontributory Program- A method of payment for group coverage in which all of the cost of the plan is paid for by the policy holder.
Non-duplication of Benefits- When a patient is covered under more than one group of dental programs the carrier with the non-duplication provision will only pay as the primary payer and will not pay as a secondary carrier. (See section of Coordination of Benefits in Chapter V)
Participating Dentist- Any dentist with whom a service plan has a contractual agreement to render care to covered subscribers; a non-participating dentist who wishes to perform services is usually reimbursed at a reduced fee.
Peer Review or Professional Review- A professionally sponsored and operated system for the rendering of professional judgment on disagreements between dentist, patient and third-party carrier relating to dental fees, quality and/or appropriateness of care.
90th Percentile- A range of distribution of dental charges determined by a pre-payment third party of charges by dentists for a specific dental service. For example, if the third party uses a 90th percentile, maximum payment may be made for any charge at or below that level, that is 90% of all fee amounts charged to patients are paid in full. (see discussion in Chapter V)
Predetermination- An administrative procedure whereby a dentist submits his treatment plan to the carrier before treatment is initiated. The carrier then returns the treatment plan indicating the patient’s eligibility, covered service amounts payable, application of certain deductibles, co-payment factors, and maximums. Under some programs, predetermination by the carrier is required when coverage charges are expected to exceed a certain amount but in NO set of circumstances may a patient’s benefits be reduced or denied if this step in procedure is overlooked. Caution: The provider MUST be sure to have on hand all necessary information before proceeding with treatment to be able to satisfy further questions of incurred liability by the carrier at a later date. The patient, as well, must commit to be willing to pay for any and all dental treatment NOT payable by carrier contract. (See discussion in Chapter V)
Pre-filed Fees- The submission of a participating dentist’s usual fees to a dental service corporation or pre-payment plan for the purposes of establishing a customary range of fees for that geographic area, and the payment of participating dentists on a usual, customary, and reasonable basis.
Pre-paid Dental Program- A program that finances the cost of dental care in advance of receipt of service, which entitles covered individuals to specific dental services. It may be offered by a pre-payment organization (Blue Cross, Blue Shield), private insurance companies, or a dental service corporation (Delta Plans).
Self Insured Dental Trust- Funds set aside by an organization to meet it’s dental care expenses or it’s dental care claims and accumulation funds to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated may be administered by fee-for-service or capitation dental plans.
Termination Date of Benefits- Date after which no benefits are payable; mostly layoffs and strikes, are usually retirement, unless otherwise specified.
Usual, Customary and Reasonable- The usual, customary and reasonable plan is designed to pay a given percentage of the dentists charge as long as the fee meets the following criteria:
Usual- The fee must be the dentist’s usual fee. This is the fee ordinarily charged patients for a particular service. (The author reminds the dental profession of the California Attorney General’s 1981 Opinion that, at best, the term usual fee is “ambiguous”.
Customary- The fee charged must be within the range charged by most other dentists in the same geographical area.
Reasonable- Due consideration will be given to unusual circumstances that require more extensive or special treatment.
Some contracts allow for a reasonable fee for the difficult or superior service and purchasers would be well advised to check to make certain that the contract provides for such an allowance.
Utilization- The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a specified period of time. Usually expressed as a number of services used per year.
Waiting Period- The period of time between employment or enrollment in a dental program and the date when an insured person becomes eligible and may receive benefits for treatment.
If a client hands you an insurance card, first check to see if we already have this employer and dental insurance in Dentrix. If not, then you must gather information from the client or call the insurance company and scan the card into their account
Go online to the insurance company and print a copy of the patient’s benefits. You will use this information to set up their insurance information properly so your insurance estimates will be accurate.
Some of the key info you’re looking for on the benefits page:
Once you have the benefits page printed, now you can begin to set up the plan in the computer.
In order to set up the insurance for the patient – you first, have to set up the insurance for the subscriber. Even if the subscriber for the insurance is not a patient – you have to set him up first with all the insurance information. For example, if the father carries the dental insurance but he’s not going to come to the dentist – you need to set up the father in Dentrix. In the family file, set him to Non-patient – but set up his insurance first.
First, enter the Employer – Double click the box, then type the first letter of the employer, then the arrows to the right so you can select it from the list. NEVER TYPE THE FULL NAME OF AN EMPLOYER – THIS WILL CREATE DUPLICATES!! Click ok. Only enter the employer if the patient has insurance through that employer. If the employer is not on the list, go ahead and type the employer name into the pop up screen.
Enter the Primary Insurance – Click on the button next to carrier – this will bring up a screen where you can find the insurance plans that company offers.
1. Click Search by Employer and it should give you a list of the insurance plans attached to that company.
2. Select the one you want and click okay.
3. If the result of this search is NO match then click cancel to get back to the insurance information screen.
4. In the carrier box, type the first letter of the insurance company you want and click the double arrow button. This will bring up a list of all the employers that work with that insurance company. Look for the employer in the list. If you find it, highlight it and click okay.
5. If you do not find the employer listed for that insurance company you will need to add a new insurance plan for that employer. Start by clearing the carrier box and clicking on the double arrow button.
6. Then click New Insurance Plan – enter all information needed here. Line 1 is the insurance company name, line 2 is the employer name – you must type it exactly as it shows up in the Employer list so it will match, next fill in address and phone numbers.
7. Enter Group #
8. Change claim format to DX2012F (this format sends the full fee to the insurance company and enters the allowed amount into the ledger)
9. Note today’s date in the Update box.
10. Benefit Renewal box – if you find out that the benefits do NOT run from January to December (calendar year), you can change the start month here.
11. Fee schedule – If this plan is a PPO that your office is a member of, then select the fee schedule that matches the plan name. If this is an out of network plan, then we won’t have a fee schedule so just leave this blank.
12. You must choose a Payor ID. Look to see if the insurance company is listed, if not you must click on 06126 ALL OTHER PAYORS NOT LISTED. We send all insurance claims electronically, by clicking this code the claim will get sent. If this Payor ID is left blank the insurance claim will not be sent – this is a problem.
13. The system defaults to “commercial” for the type of insurance company
14. Click okay to return to the Dental Insurance window – and when the window pops up to ask if you want to “Change Plan for All” click ok.
15. Mark both assign benefits boxes on the Dental Insurance window and make sure the Member ID or Social Security number is showing on the white box just above
16. Click on the Coverage table button and enter the annual maximum and the deductible as well as each of the %’s.
17. Also click the Notes button (bottom left in Coverage table) & type your name & date entered (example: Kelly entered on 7/8/04). This is also where you can type any other information you received from the insurance company, like the age for sealants or any waiting periods, and the notes will also show in the insurance plan notes box for claims.
18. Click okay twice to go back to the family file screen
Ok – you’ve successfully set up the insurance for this person. But, if this person is not the patient (remember our example from earlier – this may be the father who carries the dental insurance, but he won’t come to the dentist?) then your next step is to go to the actual patient and attach this subcriber to the plan. To do this:
Patient Notes Box– You can put in a note for this client here but it will only appear for that selected family member and not for the entire family. A note for the entire family should be put in the G note from the Ledger screen.
Billing Type – Choose the billing type that matches this type of patient
Referred by /Referred to – This field is used to provide an analysis of your referrals from other professionals and/or sources such as Yellow Pages – a referral must be entered for each new person
If the child is the patient and both parents have dental insurance be sure to ask the parents’ date of birth and note this on the top of the treatment sheet where the insurance information is. Ohio follows the “Birthday Rule” which states that the primary plan (the plan whose benefits are paid first) must be the plan of the parent whose birthday falls earlier in the calendar year. The other parent’s plan will be considered the secondary plan and will pay after the primary plan has paid. If both parents’ birthdays all on the same date, the primary plan will be the plan which covered the parent longer. In the case of plans covering dependent children of divorced or separated parents, benefits will be paid from the plans in the following order:
1. The plan of the parent with custody of the child
2. The plan of the spouse of the parent with custody
3. The plan of the parent without custody of the child
However, if the terms of a court order identify the parent who is responsible for the child’s health care, that parent’s plan will be the primary plan.
How to Add a New Insurance Plan in EagleSoft:
Instructions for BCBS & Delta Patients
Blue Cross Blue Shield
Special BCBS Situation: Rate Schedule Plans
If you see listed in the BCBS benefits “Rate Schedule Plan” this means that this patient has a special BCBS plan.
We charge the BCBS fee schedule – but the patient also has another fee schedule called the Rate Schedule Plan – and they will pay the difference between this plan and the BCBS fees. The dentist must follow the BCBS fees as a PPO member, but the patient will have a balance between their rates and the BCBS fees also.
To handle this, we set the %’s as: 50% coverage for Diagnostic & Preventive only (just because it looks like the patient’s rates are about half the BCBS fee schedule) and then 0% for everything else.
Since we’re leaving all treatment at 0% coverage, we will send a pre-treatment estimate for any treatment the patient may need so we can find out exactly what they will pay and what the patient owes (and how much we have to write off).
If you’ve entered this information for an existing patient with new benefits and this patient has an existing treatment plan, you have to update with these new fees.
How to update the treatment plans to show the Delta and BCBS fees
Now, Delta doesn’t provide a fee schedule you can use to create the Delta PPO Fee schedule, so use your old EOBs to find the Maximum Allowed Fee on as many codes as you can find. As you continue to enter insurance payments, you will find additional codes that you can use to update the Delta PPO fees.
How to change the fees for Delta
Insurance Companies will usually require additional information for most major treatment, such as: crowns, bridges, partials, dentures and STM appointments. Since we send all claims electronically, the insurance companies can take up to 30 days to request this information. In an attempt to be pro-active, we send the information we know they are going to request before they even request it.
The information that insurance companies request is:
1. For crowns, bridges, partials and dentures – x-rays and narrative if initial or replacement. If replacement, date of original and reason why replaced (always worn out).
2. STM appointments – perio charting
Steps to submitting insurance claims with attachments:
1. Look at each providers schedule from the day before and find all those that had STM, crowns, bridges, partials and dentures
2. Look at the ledger for each of these patients
a. if no insurance – you’re done
b. if insurance – there are several steps:
(a) print the claim to paper
(b) print the digital x-ray from the Patient Gallery or the perio chart from the tooth chart
(c) staple the digital x-ray or the perio chart to the claim and indicate that it is attached in the comment section of the claim (section #61)
(d) for the claims with x-rays you will need to look at the x-ray and determine if initial or replacement. If initial, indicate this on the claim (section #55). If replacement, you will need to pull the chart and read the entries to determine date of the extraction and then indicate all this information on the claim (section #55).
(e) Before you mail the claim, go back to the patient ledger and note the same information that you’ve sent the insurance company – click on the claim:
1. Double click on the Claim Information section. At the bottom of that page (almost) there is a section called Prosthesis. Click on Initial or Replacement (if replacement then type in Worn Out for reason and prior/initial date). Click OK
2. Click on Insurance Claim Status box. Click on Tracer sent box. Click on Claim Status notes box and insert dateline and your notes about what you attached to this claim (x-rays or perio chart). Click OK
(f) Once in a while you will have a patient who does not have digital x-rays. For these patients, you will need to duplicate the required x-ray but all other steps remain the same.
Managing the Claim Attachment Submissions:
Since you indicated on the claim in the system all the same information you sent to the insurance company, we can utilize the same 30-60-90 day tracking system that we use for all other claims.
FAST LOOK ATTACHMENT SYSTEM
6-30-10 – WE DO NOT USE THIS SYSTEM, BUT SAVED FOR THE FUTURE
We have signed up for a new system available through the internet. This web page provides information on what additional information (x-rays, perio charting, etc) is required by which insurance companies for various procedures.
It is called Fast Look and can be accessed at www.nea-fast.com.
Click on the “Provider Login” link – located at very bottom of left hand side of page
Our NEA Facility Number is:
Our Provider Password is:
Note: both passwords are upper case and lower case sensitive
Once you have logged in at the site, you type the name of the insurance company in the Payor Name box provided.
From there, you can enter a specific ADA code or you can select a range of codes from the drop-down list.
The system will show you a page of codes with description of the treatment and if x-rays, perio charting and/or narrative are required by the insurance company.
We hope to be able to shorten the turn around time for some claims by providing the information to the insurance company before they ask for it.
ADDITIONAL INSURANCE INFORMATION:
1. SEALANTS – Not all insurance companies cover sealants. It is always a good idea for the parent/employee to contact their insurance company to verify if sealants are covered and what the age limit is (the usual is up to the age of 14). We have some sealant coverage information listed in the dental claim located on the ledger page but even that is subject to insurance company/employer policy changes.
2. TMJ EXAMS AND SPLINTS – Get copy of medical insurance card and place in chart. Give this chart to the insurance manager to file with medical insurance. Most medical insurance companies do not cover TMJ but even when they do cover it, they pay directly to the employee or it applies to their medical deductible.
QUESTIONS TO ASK WHEN INITIALLY CALLING AN INSURANCE COMPANY
Patient’s name _______________ Policy Holder’s name ______________ SS# ___________
Name of Insurance Company___________________________ Phone # ________________
Insurance Rep’s name _____________ Secretary’s name ____________ Date ____________
Effective date? ___________What is the per person yearly maximum? ________The individual yearly deductible? ________Benefit period? ______________ (calendar year or some other month?)Coverage percentages:
a. Preventative/diagnostic ______%
b. Restorative/crowns ________%
c. Endodontics __________%
d. Bridges/dentures ________%
e. Extractions __________% Wisdom teeth extractions ______%
Is there a wait period for major treatment? _______ How long ______________?Do you have a Missing Tooth Clause? __________ (which means, do you cover the replacement of a missing tooth if the tooth was extracted before the patient had insurance coverage with the company)Special treatment coverage :Sealants ______ age maximum? ________ percentage? __________TMJ splint _______Implants _______Fluoride _________ age maximum? _______Frequency for exams _________ (6 months or anytime in year?)Frequency for cleanings _________(6 months or anytime in year?)Frequency for bite-wing x-rays ________(6 months or anytime in year?)Frequency for Pano or CMX __________If secondary insurance, ask if they have a non-duplication clause __________If possible, have them fax you a copy of the benefits to scan in their account.Update the information in the Dentrix system Date entered _____________
BEFORE MAJOR TREATMENT IS STARTED THERE ARE SPECIFIC QUESTIONS TO ASK AN INSURANCE COMPANY
Patient’s name _________________ Policy Holder’s name ________________ SS# ___________
Name of Insurance Company__________________________ Phone # ________________
Insurance Rep’s name _____________ Secretary’s name ____________ Date ____________
Has the patient used any benefits this year? $ _______ used as of ________Any pending claims? $ _______ Can also find in their Dentrix account $ _______Crowns – replacement policy ________________ Wait period? _______________Bridges, partials, dentures – Missing tooth clause? _____________ and
Replacement policy? ______________
Implant coverage? _________Missing tooth clause? ____________Coverage on surgery? ___________ and coverage on crown? _____________TMJ splint (code D9940) coverage? _______________ Update the information in the Dentrix system. Date entered __________________
Met Life www.metdental.com
For people who have Met Life dental insurance: www.metdental.com. Enter the ID/Password for your dentist. At bottom of screen enter the person’s social security number and choose to either check their eligibility/plans or their claims/pretreatments status. Click submit. You can click on their name to see eligibility and group #, then click on Dr and this will take you to the plan maximum, etc screen. Then click on Benefit levels to get the percentages of coverage, frequency limits, etc.
Delta Dental www.toolkitsonline.com
For Delta Dental – there are several different Deltas – Michigan, Tennessee, Virginia, etc. – you can check most online: https://www.toolkitsonline.com Click on Dental Office Toolkit – top left orange box. Enter the ID/Password for your dentist. This will get you to the main screen – click on Patient Info/Enter claims link. Type in employee’s social security number in the Member ID box then click on the Get Member info box. From this screen you can get the group # and view benefits (click on “I” box for patient in question). This screen will also tell you if active coverage or not.
If you cannot find your patient online – then call that Delta and ask for the website they use for their state.
Type in employee’s social security number in the Member ID box then click on the Get Member info box then click on Get Family Claim History box. You only need to type in a start date (use the 1st of the month you’re checking) then click on Get Claim History box. This will bring up all claims/pretreatments they’ve received since the start date. Scroll down to the service date (treatment date) you are looking for and click on that claim number box to see the actual claim and scroll down to see how much Delta paid.
You can also see pretreatments on this screen (the service date will be blank).
Superior Dental and Dental Care Plus and Shenandoah Dental Insurance www.ANSLink.net
For people who have Superior Dental Insurance, Dental Care Plus (including Denta Select) Dental Insurance and Shenandoah Dental Insurance: www.ANSLink.net – enter your dentists User ID and password. You can only check eligibility for these insurance companies at this web-site. To check claim status, you will need to call them.
To check eligibility: click on ANS Link box then select Carrier from the drop down box. Since we can only check eligibility, you can select any provider from the drop down box. Then type in the last name, first name and date of birth for your patient in the appropriate boxes. (Julie from ANS strongly suggests that we do NOT use social security numbers). Click Submit. Patient information page will appear then click on the display button located next to the plan/schedule number and the breakdown of benefits will appear – yearly max, deductible, percentages for coverage, etc.
Aetna Dental insurance www.aetnadental.com
To check eligibility for AetnaDental Insurance: go to www.aetnadental.com – click on log in (in welcome box) and enter your dentists user name and password. Click continue, click check eligibility (right side of page), click continue, click on eligibility (under real-time on left side of page), select provider, select payer – use Aetna Dental Plansmust have W id number (or SS#)); patient relationship to employee; patient’s birthdate the screen for benefits will pop up and you can look for whatever info you need.
To check eligibility and benefits left for a specific patient, you don’t need to be under the specific doc but you do need to be under that specific patient – that’s why the relationship and birthdate are so important. If you just want to see what the family has then you can use the employee’s info.
Ideas for tracking PPO Plans in Dentrix:
ALL CAPS – This helps us to identify which patients are Managed Care patients since they are receiving a significant discount (at least 25%) on all their treatment. Our goal is to have less than 15% of our total active patients in managed care. This allows us to see in our computer schedule how many managed care patients we are seeing each day.
Chart label in ALL CAPS – Yet another way to identify these patients. This is important for doctors and clinical staff to be aware of additional financial restrictions for managed care patients.Fee schedules – We are now working with our regular fee schedule as well as the adjusted fee schedules from the Managed Care Insurance Companies. Adjustments for the managed care fee schedules are updated as we receive them.
Billing type – All managed care insurance plan patients are in certain billing types based on the Managed Care Insurance Company.
The fee schedules for each of the Managed Care Insurance Companies have been loaded into our computer system. The system will automatically use those fees so we do not have to adjust off any more dollars except for the risk pool for certain plans. If the correct fee schedule was not selected prior to treatment being submitted to the Managed Care Insurance Company, then we have to do the adjustments once the claim is paid.There are two types of adjustments. One is the adjustment for the fee schedule (which should not have to be done based on using the correct fee schedule) and one is the adjustment for the insurance withhold.
The withhold is an extra amount that the PPO Plan does not pay us – they keep this money until year end when they confirm the profit they want to earn that year and then they may return a portion of this extra withhold back to us in one check at year end. They call this their risk pool.
Waivers – Scan the copy of a signed waiver into Dentrix for all posterior composites & posterior PVCs. The patient must sign that they are aware they will be billed up to our full fee for these procedures – not just up to their PPO’s UCR fee.
We’ve added a section at the bottom of our new patient form to fill out if the client has a Managed Care Dental Insurance.
If PPO Plan we’ve joined: Name in ALL CAPS
Referral source noted
Change to new patient color & type NEW in the appointment note
Mailed NP packet / Emailed NP letter- Date__________
Contact previous dentist for records transfer______________
Once the patient comes in:
Update all patient info into family file – In appt book, click the appt once, then go to family file, File, New patient with Appt
Fee schedule selected
Billing type selected
Entered employer & insurance benefits into Dentrix
Confirmed benefits used (other offices) $_____________
Called insurance company & confirmed benefits
Patient aware of their portion due after insurance
First visit date changed
Managed Care Insurance Informed Consent for Alternative Benefit
Some insurance plans will downgrade their coverage for posterior composites (tooth-colored fillings on back teeth) – meaning that if the dentist places a posterior composite, the insurance company will pretend that you charged out a posterior amalgam (silver-colored filling on a back tooth – usually cheaper) and they will pay their % based on this lower UCR. So, to make sure we don’t have upset patients who look at their EOBs and say that we were supposed to adjust off the amount down to the amalgam fee, we have the patient sign a waiver.
This waiver to be signed in order to confirm fees for the following treatment:
Posterior composites (Tooth colored fillings on back teeth)
My dental practitioner has advised me and fully explained the dental treatment program considered a cost effective, professionally accepted course of treatment for my dental care. In addition, alternative benefits in the course of treatment have been explained. After review with my dentist, I agree to be billed directly for additional benefit alternatives by the dentist. I further agree to reimburse the dentist directly for these charges.
Patient Signature / Date
Dentist Signature/ Date
Could you use a joke right about now?
How many dentists does it take to change a light bulb?
We don’t know, we have to determine the procedure code and file a pre-authorization.
___________________________________ has demonstrated an understanding of the material in this section and can accomplish all these functions accurately.
Adds New Insurance Plans and Companies into Dentrix.
Ins Coordinator Signature Date