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Chapter 14- Dental Insurance
- 1. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance
Chapter 14
1
- 2. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance
1. Define the key terms for this chapter.
2. Discuss the evolution of dental insurance and the four
parties affected by dental benefit plans.
3. Differentiate among the different dental benefit
programs.
4. Discuss the preparation of dental claim forms including
the use of the current American Dental Association
(ADA) Code on Dental Procedures and Nomenclature
and the Code of Dental Terminology (CDT) manual.
Lesson 14.1
2
- 3. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance (Cont.)
5. Understand the rules for coordination of benefits.
6. Discuss reviewing the completed claim form, dental
claim payments and special programs associated with
dental insurance.
7. Understand the guidelines for successful claims
administration and identify actions that constitute
dental benefits fraud.
8. Explain common dental benefit and claims
terminology.
Lesson 14.1
3
- 4. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Benefits Programs
Reimbursement depends on the dental plan
design
Two basic models of benefit programs:
Indemnity
Capitation
There are many variations of each model
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- 5. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance Evolution
The emergence of dental insurance in the
middle of the twentieth century was a major
factor in the expansion of general awareness
of the importance of oral health
As more companies and organizations added
dental benefits to their group health
coverage, the percentage of people seeking
regular preventive services and restorative
treatment increased
Nearly 60% of insured people go to the
dentist
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- 6. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Parties Involved
Patient
Dentist
Dental Benefits Carrier
Group or Program Sponsor
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- 7. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Indemnity
Frequently referred to as fee-for-service
Provides payment on a service-by-service
basis
Payment may be made to the enrollee or, by
assignment, to the dentist
Several types of indemnity, or fee-for-service
programs, exist
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- 8. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Indemnity: Types of
Fee-for-Service Programs
Usual, customary, and reasonable (UCR)
Reasonable and customary (R&C)
Preferred provider organization (PPO)
Exclusive provider organization (EPO)
Point of service
Table of allowance
Open panel
Closed panel
8
- 9. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Capitation
A benefit system in which a dentist or dentists
contract with the program’s sponsor or
administrator to provide all or most of the
dental services covered under the program in
return for a fixed monthly payment per
covered person (per capita)
May also be called a dental health
maintenance organization (DHMO)
9
- 10. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Alternative Benefit Plans
Group discounts
Discount card
Health flexible spending arrangement
Health savings account
Direct reimbursement
Voluntary plans
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- 11. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Preparing Dental Claim Forms
Two ways to submit insurance forms:
Paper
Electronic
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- 12. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Paper Claim Form
Use an American Dental Association (ADA)
standardized form
May purchase forms from the ADA or a local
dental supply company or download from a
carrier’s website
Be certain to print or type information neatly
and accurately
In a computerized office, forms can be
generated and printed using the practice
management software
12
- 13. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Electronic Claim Form
Claims may be filed electronically in two
ways:
Through a clearinghouse
• Batch files are sent to a clearinghouse, which scans the
claims for errors and missing information and transmits
the approved claims to the appropriate carrier
Directly to the carrier
• The administrative assistant sorts the claims according to
the carrier and makes separate transmissions to each
13
- 14. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Electronic Claim Form
E-claims must comply with federal laws
governing electronic transactions that include
personal health information (PHI)
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) requires
all healthcare providers, health plans, and
healthcare clearinghouses that transmit PHI
electronically to use a universal language, a
standard format, and a government-assigned,
unique identification number
14
- 15. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Electronic Claim Form: Code on
Dental Procedures and Nomenclature
15
Courtesy Patterson Dental, St. Paul, Minnesota.
Courtesy American Dental Association, Chicago, Illinois.
- 16. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Electronic Claim Form:
Electronic Data Formats
HIPAA requires the use of standardized
formats for electronic transactions of health
information
Standard forms are used for:
Claims
Remittance advice (explanation of benefits)
Eligibility inquiry and response
Prior authorization and referral
Claims status inquiry and response
16
- 17. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Electronic Claim Form:
Unique Identifiers
Dental offices that submit insurance claims
electronically or use the Internet to look up
eligibility, benefits, or claims status are
required to have and use a National Provider
Identifier (NPI)
The NPI is a permanent, 10-digit number that
replaces any other identifiers used in
electronic transactions
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- 18. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Coordination of Benefits
Coordination of benefits (COB) is the process
of paying healthcare expenses when a
person is covered by more than one plan
Dental benefit carriers follow rules
established by state law to decide which plan
pays first (primary carrier) and how much the
other plan (secondary carrier) or plans
(tertiary carrier, and so on) must pay
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- 19. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Determining the Order of Liability
The administrative assistant must be familiar
with the rules for determining which plan is
primary when determining the COB for a
patient
To identify the primary plan, the
administrative assistant needs to know
whether the patient is the subscriber or a
dependent and any special COB rules for
either plan
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- 20. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Coordination of Benefits Limitations
Some programs, such as group contracts,
limit the scope of benefits coordination with a
nonduplication of benefits clause, or carve-
out
Some plans do not allow coordination of
benefits for spouses who are both employees
(subscribers) in the same group, although
dual coverage may be allowed for their
dependents
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- 21. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Reviewing Completed Forms
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- 22. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Claim Payments
A voucher explaining the claim payment is
called an explanation of benefits (EOB)
Vouchers may have a detachable check, or
the check and voucher may be separate
items
Patients also receive an EOB to advise them
that the claim is paid and to indicate the
amount they are responsible for paying the
dentist
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- 23. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Special Programs:
Medicaid
Each state administers its own Medicaid
program
Rules and regulations governing covered
dental services vary
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Special Programs:
Veterans Administration
Veterans of the U.S. armed forces may be
eligible for limited dental benefits
Patients with this coverage receive a claim
form from the Veterans Administration to give
to the attending dentist
The form includes all information necessary to
assess benefits
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- 25. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Guidelines for Successful
Claims Administration
Document each subscriber’s scope of coverage
Note any special information or procedures the
carrier requires
Require new patients and patients of record who
have a change in coverage to provide their benefit
carrier’s complete mailing address and the
telephone number for claims and inquiries
At each appointment, ask the patient whether any
changes in coverage have been made
Inform each patient of his or her benefits and
copayment amounts
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- 26. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Guidelines for Successful
Claims Administration
Establish a routine for preparing claim forms
Keep a current file or computer record of outstanding
claims and review it frequently
Submit preauthorization for treatment when required
by the subscriber’s plan or benefit carrier and when
requested by the dentist or patient
Regularly verify and update patients’ general
information
If paper claims are used, maintain an adequate
supply of forms
26
- 27. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Guidelines for Successful
Claims Administration
Focus on accuracy, and complete all required
fields on the claim form
Add comments only for codes that require
documentation, such as miscellaneous codes
(D2999, D6199)
Use the current CDT codes
Attend seminars presented by benefit carriers to
stay current on billing practices and learn new
techniques
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- 28. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Insurance Fraud
The following actions, whether deliberate or
unintentional, constitute fraud:
Billing the carrier for higher fees than the patient is
charged
Billing before completion of service
Predating or postdating services on claim forms
Improperly reporting treatment
Billing for services not rendered
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- 29. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance Terminology
Allowed amount
Approved amount
Benefits administrator
Benefit plan summary
Benefit year
Cafeteria plan
Claim audit
Claimant
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- 30. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance Terminology (Cont.)
Covered charges
Covered services
Deductible
Direct billing
Extension of benefits
Individual practice association (IPA)
Maximum allowable amount
Nonparticipating dentist
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- 31. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Dental Insurance Terminology (Cont.)
Open enrollment
Overcoding
Participating dentist
Peer review
Preexisting condition
Schedule of benefits
Waiting period
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- 32. Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Questions?
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