1. Dental Administration 101
INSTRUCTOR
Robbie Heath |

2. What is Dental Insurance
Coverage for individuals that provides assistance with paying for the cost of dental treatment
Medical designed to cover costs associated with diagnosing and treating medical illness
Dental designed to provide coverage for preventative dental services-Patients assume larger portion

3. Dental benefits sponsored by an employer
Group Dental Plans
Dental benefits sponsored by an employer
Insured- Employer pays a portion of monthly premiums to an insurance company on behalf of the employee. Insurance company pays providers
Self-funded- Employer collects premiums and invests the funds. Dental claims are processed and paid by the employer to the provider

4. Preferred Provider Organization- PPO
Patients have a choice in choosing providers but benefit most by using an “in-network provider”
In Network
Insurance carriers and dental providers agree upon a contract that sets pre-negotiated contracted rates for reimbursement by providers. Rates are determined by the insurance carrier and are based on UCR (usual, customary, and reasonable fees)
Out of Network
Refers to a patient covered by a PPO plan who chooses to receive care from a dental provider that does not have an agreed upon contract with the insurance carrier

5. Managed Care Plans- DMHO, HMO
Insured patients must see participating assigned providers only
Less expensive to employers
If patients go outside of network they are financially responsible for all charges
Managed care plans do not pay non-participating providers
Providers may only refer to specialist also participating in the managed care program

6. Direct Reimbursement Plans
Self-funded plans
Reimbursement to the plan member by the employer/plan
Plan member pays total bill to the provider at the time of service
No insurance carrier involvement

7. Who is Involved?
Carrier- The insurance company (ex. Metlife, Cigna, Guradian)
Group- Employer or organization that provides the dental plan to the employee
Group number- Unique number assigned by an insurance carrier to identify the employer or group sponsoring the insurance coverage for an employee
Subscriber- The employee or member who holds the insurance plan
Dependent- Family member or spouse of a subscriber who is eligible for benefits sponsored by the subscriber
Provider- Dentist or dental office that provides dental treatment

8. Individual Plans Tax Funded Plans
Work as group plans except there is no employer.
Patient purchases and pays premium for their own insurance coverage
Copays and deductibles still apply
Tax Funded Plans
Medicare- Provides medical coverage as part of social security benefits; does not provide dental coverage
Medicaid- State and federal funded medical and dental insurance coverage. Fees are paid directly to the provider through state or federal funded plans
Pays approximately 50% of the bill to providers
Participating providers must write off the remainder bill for patients under the age of 18
Adult patients are only billed $3.00 per visit
Strict rules regarding allowable procedures

9. Discount Plans Uninsured Patients Not an insurance plan
Provided through insurance carriers
Participants pay a small yearly fee to be allowed to receive the discounted contracted fee from participating providers
No insurance claim to file
Participants directly pay discounted fees to provider at the time of service
Uninsured Patients
Subject to full price of dental procedures
Does not benefit from contracted rates
May need or benefit from payment plan
Care Credit vs In-house financing

10. This form covers certain needed information
Understanding Patient’s Benefits
Breakdown of Benefits refers to the outline and criteria of benefits a plan offers
Breakdown of Benefits form is specific to the needs of an office and is used to notate plan benefits
This form covers certain needed information
Subscriber Information
Patient Information
Insurance Company Information

11. What is an Effective date & Why is it Important?
Eligibility-Is the patient eligible for services on the date of service
Waiting periods-An amount of time a patient must wait before eligible for services
Preventative Services usually are not subject to a wait period
Basic restorative services are usually subject to a 6 month wait
Major services may include oral surgery, prosthodontics, periodontics, and endodontics and usually are subject to a one year wait

12. Prior placement or service dates
Replacement Period- The amount of specified time a patient must wait before the insurance will pay towards replacing certain procedures such as dentures, partials, bridges, and crowns. Usually 5-10 years
Missing Tooth Clause- Protects insurance carriers from tooth replacement costs for teeth missing prior to the plans effective date

13. Benefit time period Deductibles
Calendar year- January 1 to December 31
Benefit year- Start date of plan running for one year
Deductibles
A set dollar amount a patient will have to personally satisfy prior to the insurance carrier contributing to the dental bill
Usually $25.00, $50.00, or $100.00
Usually applies to services other than preventative and diagnostic

14. Yearly Maximum Coinsurance Usually 1,000, 12,00, or 1,500 per year
An annual dollar amount an insurance plan will pay toward the cost of dental care within a specific benefit period
Usually 1,000, 12,00, or 1,500 per year
All payments for any reason paid by insurance is subtracted from this amount
Coinsurance
A percentage or portion of the cost per procedure that is paid by the plan member
Outside of the deductible
Usually in a percentage amount

15. Three Levels of Coinsurance
Preventative & Diagnostic
Exams, Prophies, X-rays, Sealants, Flouride
Basic Restorative
Fillings
Perio, Endo, and Oral Surgery Vary by Plan
Major Services
Crowns, Dentures, Partials, Implants, Bridges

16. Services Particular to the Individual Provider or Group
Sealants & Flouride treatment coverage and age limitations
Debridements
Buildups
Implants
Nightguards
Nitrous Oxide (N2O)

17. Other Important Benefit Information
Frequency Limitations
Describes how often a particular service is covered by a dental insurance plan.
Exams
Prophy
FMX/Panorex
Bitewings
Perio Mainanence
Scaling and Root Planing
Fillings
6 months vs 2 per calendar year

18. History
Due to frequency limitations, providers must know the dates of most recent services
Date of last FMX/Pan
Date of last prophy
Date of last Exam
Date of last bitewings

19. Billing of Dental Crowns
Prep Date- insurance carrier requires that the crown be billed on the day that the tooth is prepped
Seat Date- insurance carrier requires that the crown be billed on the date the crown is permanently delivered. Date of prep and seat must be notated when billing
Common area for insurance fraud
When billed on seat date- core buildup is billed on prep date

20. How Are Insurance Carriers Billed
Dental providers communicate with insurance carriers through dental claim forms
ADA Dental Claim Form
Mail
Electronic
Insurance carriers have 30 calendar days to respond to dental claims
Non-compliant insurance carriers can be reported to the NC Insurance Commissioner

21. Assignment of benefits
Patient is assigning his or her insurance benefits to the dental office as payment of the treatment received
Payment goes directly to the provider
Assignment of benefits must be authorized on the dental claim form
Predeterminations
Itemized list of dental services that a patient requires, rather than has been completed, and is submitted by dental claim form
Not a request for authorization to begin treatment
A written document stating exact amount of reimbursement an insurance carrier will pay towards needed treatment
Not a requirement

22. Secondary Insurance
Patient is covered by his/her own sponsored employer insurance
Patient, in addition, is covered by spouses employer sponsored insurance plan as a dependent
Coordination of Benefits applies
Responsibility of dental office administrator
Patients employer sponsored insurance plan is always the primary
Birthday rule- applies to dependents of parents who both have employer sponsored insurance plans: the insurance plan of the parent whose birthday occurs first in a calendar year is the primary plan for all dependents