1. Chapter 14 Dental Insurance Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

2. Dental Insurance: Four Parties 1.The patient 2.The group or program sponsor, such as an employer, union, or business 3.The dental benefit carrier 4.The dentist

3. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Dental Benefits Programs  Reimbursement depends on the dental plan design.  Two basic models of benefit programs  Indemnity  Capitation  Many variations of each model exist.

4. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Indemnity Programs  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.

5. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Types of Fee-for-Service Programs  Usual, customary, and reasonable (UCR)  Payment for covered benefits is based on a combination of usual, customary, and reasonable fee criteria.  Reasonable and customary (R & C)  Payment for covered benefits is based on reasonable and customary fee criteria.

6. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Types of Fee-for-Service Programs  Preferred provider organization (PPO)  Participating dentists agree to accept discounted fees for covered services rendered to plan enrollees.  Exclusive provider organization (EPO)  This plan provides benefits only if care is rendered by institutional and professional providers.

7. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Types of Fee-for-Service Programs  Point of service  Reimbursement levels are determined by the participation status of the dentist rendering treatment.  Table of allowance  Covered services have an assigned dollar amount that represents the total dollar amount payable for each service.

8. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Types of Fee-for-Service Programs  Open panel  Any licensed dentist may participate.  Enrollees may receive dental treatment from any licensed dentist.  Benefits may be payable to either the enrollee or the dentist.  The dentist may accept or refuse any enrollee.

9. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Types of Fee-for-Service Programs  Closed panel  Enrollees can only receive benefits when services are provided by dentists who have signed an agreement with the benefit plan to provide treatment to eligible patients.

10. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. 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)

11. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Capitation  Enrollees select a primary care dental office from a list of participating providers and must go to that office for all of their dental care unless the primary care dentist provides a written referral to a specialist.  Enrollees usually have no out-of-pocket expense for routine services, although they may have a copay for extensive, expensive services such as fixed bridge work.

12. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Alternative Benefit Plans  Group discounts  Employers contract with dentists to deliver services to their enrollees at a discounted rate.  Enrollee pays an annual or monthly fee and pays the dentist directly for services rendered.  Dentist does not file claims.  Plan has no exclusions, limitations, or maximums.

13. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Alternative Benefit Plans  Discount card  Annual fee  Purchasers have access to a network of participating dentists who have agreed to charge reduced fees to cardholders.  Cardholder pays the dentist directly.  Dentist does not file any claims.

14. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Alternative Benefit Plans  Health savings account  Employer offers the employee a pretax salary savings account for payment assistance with health care-related expenses.  Contributions to the account are made by payroll deduction.  Employee pays the dentist, submits a receipt to their employer, and receives reimbursement up to the limit they have selected for the plan.

15. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Alternative Benefit Plans  Direct reimbursement  Employer or organization sets up a self-funded program for reimbursing covered individuals based on a percentage of the amount spent for dental care.

16. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Alternative Benefit Plans  Voluntary plans  Many of the same advantages of employer- sponsored plans, including lower rates and comprehensive benefit designs  Eligible persons pay the full premium.  No cost to the employer or organization  Program administration can be assigned or shared between the employer, an insurance broker, and the benefit carrier.

17. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Preparing Dental Claim Forms  Two ways to submit insurance forms  Paper  Electronic

18. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Paper Claim Form  Use an ADA standardized form.  May purchase forms from the ADA or a local dental supply company or download from a carrier’s web site.  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.

19. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Electronic Claim Form  Electronic files may be done in two ways:  Through a clearinghouse  Batch files are sent to a clearinghouse that 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.

20. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Electronic Filing  Filing 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) mandates all healthcare providers, health plans, and healthcare clearinghouses that transmit PHI electronically must use a universal language, a standard format, and a government-assigned, unique identification number.

21. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Code on Dental Procedures and Nomenclature  The administrative assistant must become familiar with the ADA codes for reporting dental services and procedures for dental benefit plans.  Refer to the ADA manual Current Dental Terminology (CDT) for codes.  CDT manuals are updated regularly.

22. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. 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.

23. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Coordination of Benefits  Coordination of Benefits (COB) is the process of paying health care 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, etc.) must pay.  This system ensures that the patient received maximum payable benefits without exceeding the actual fee charged.

24. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. 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 if the patient is the subscriber or a dependent and any special COB rules for either plan.

25. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Identifying the Primary Plan  The primary carrier must meet at least one of the following criteria:  The plan has a no-COB clause.  The patient is the employee (subscriber).  The patient is a dependent child.  The patient is a dependent child of divorced or legally separated parents.

26. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Submitting Claim to Secondary Carrier  The claim for the primary carrier is always filed first.  If reimbursement from the primary carrier leaves an unpaid balance, then a claim listing the same services and the amount paid by the primary carrier can be submitted to the next liable, or secondary, carrier.

27. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Reviewing Completed Forms  The administrative assistant will find it necessary to review insurance claim forms to become familiar with the content of each form.  Take time to practice form completion.

28. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Payment Voucher and Check  A voucher explaining the claim payment is called an explanation of benefits (EOB).  Voucher may have a detachable check or the check and voucher may be separate items.  Patient also receives an EOB to advise them that the claim is paid and indicate the amount they are responsible for paying the dentist.

29. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Medicaid Claim Forms  Each state administers its own Medicaid program.  Rules and regulations governing covered dental services vary.

30. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Medicaid Claim Forms  Most programs have the following general conditions:  Reimbursements are made only to dentists participating in the Medicaid program.  Dentist agrees to accept amount paid by the state.  Any other third-party payer is primary.  Reimbursement to the state is required if the patient or dentist receives payment from another third-party source.

31. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Medicaid Claim Forms  General conditions  Records must be retained for a specified length of time.  May be reviewed by an authorized state or federal official  Dentist may not discriminate against a Medicaid patient for reasons of race, gender, color, creed, or financial status.  All claims must be submitted within 12 months of the date of treatment.

32. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Medicaid Claim Forms  General conditions  Prior authorization is required for certain treatments as outlined by the state.  All patient records remain confidential.  Handwritten forms are not accepted; forms must be typewritten, computer generated, or submitted electronically.

33. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Veterans Administration Claim Form  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, and the form includes all information necessary to assess benefits.  Prior approval of treatment usually is required.

34. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Guidelines for Preparing Claim Forms  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.

35. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Guidelines for Preparing Claim Forms  Ask the patient if there are any changes in coverage at each appointment.  Inform each patient about his or her benefits and copayment amounts.  Establish a routine for preparing claim forms.  Keep a current file or computer record of outstanding claims and review it frequently.

36. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Guidelines for Preparing Claim Forms  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 using paper claims, maintain an adequate supply of forms.

37. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Guidelines for Preparing Claim Forms  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 benefits carriers to stay current on billing practices and learn new techniques.

38. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Insurance Fraud  Misrepresenting treatment or inaccurately reporting fees and dates of service to benefits carriers is illegal.  Administrative assistants who participate in any way with actions that defraud benefits carriers may be liable to legal prosecution.

39. Copyright © 2011, 2006 Mosby, Inc., an affiliate of Elsevier. All rights reserved. Insurance Fraud  Fraud includes  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