DLA 1216

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Dental Insurance
Chapter 14
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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
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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
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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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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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Parties Involved
 Patient
 Dentist
 Dental Benefits Carrier
 Group or Program Sponsor
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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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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
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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)
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Alternative Benefit Plans
 Group discounts
 Discount card
 Health flexible spending arrangement
 Health savings account
 Direct reimbursement
 Voluntary plans
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Preparing Dental Claim Forms
 Two ways to submit insurance forms:
 Paper
 Electronic
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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
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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
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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
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Electronic Claim Form: Code on
Dental Procedures and Nomenclature
15
Courtesy Patterson Dental, St. Paul, Minnesota.
Courtesy American Dental Association, Chicago, Illinois.

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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
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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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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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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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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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Reviewing Completed Forms
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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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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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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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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
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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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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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Dental Insurance Terminology
 Allowed amount
 Approved amount
 Benefits administrator
 Benefit plan summary
 Benefit year
 Cafeteria plan
 Claim audit
 Claimant
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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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Dental Insurance Terminology (Cont.)
 Open enrollment
 Overcoding
 Participating dentist
 Peer review
 Preexisting condition
 Schedule of benefits
 Waiting period
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Questions?
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