DA 2 Dental Insurance Flashcards
What is dental insurance?
plan that assists the patient financially with the cost of dental care
How do you get dental insurance?
through an employer
individual basis (These have not been successful)
What is the purpose of dental insurance?
dental care more accessible by reducing the cost
dental care more accessible by reducing the cost ___ and ____
subscriber and insurance
Benefits
Benefits
Predetermination of benefits
Preauth
planned treatment submitted to ins
carrier responds with eligibility
Approval/Authorization
authorization for the procedures on
predetermination of benefits from the carrier outlining
coverage details
Claim
• A report of dental services to a patient’s dental plan
Claim Form
from provide treatment provided and fees charged
Explanation of benefits EOB
insurance response to claim
Procedure Code
5 digit code used to determine fee
Maximum benefit
Max. $ amt. a plan will pay
Lifetime Maximum:
• Carrier may also establish a lifetime max for
certain procedures (eg. Lifetime max of $2000 for
ortho services
Deductible:
amount insured must pay toward the cost of
dental treatment BEFORE benefits of the plan go into effect
time Limits
Period of time claim filed
following completion of treatment is completed
Clause
Provision of an ins. contract
Alternate benefits clause
When ins. Agrees to pay the equivalent of another
procedure towards a proposed tx (e.g. Am instead of TC)
DRC must ensure ______ because ins policies vary
ensure pt. is not scheduled prior to eligibility date
UNLESS pt. is aware they will need to pay the fee
two ways of managing dental insurance:
Assignment or Non-Assignment
Assignment
pt authorization
office send to insurance
pt pays co payment
claim form is sent
Non-Assignment
Pt. pays full fees to dental office
Pt. receives calim to send to ins
ins sends reimbursement cheque to pt.
Patient • Responsibility
Pay all amounts not covered by ins.
Provide current dental ins. Info
Dental office Responsibility
Provide dental care
Assist pt. in securing benefits
Dual Insurance
coverage by more than one insurance
Divorced or Separated Parents sequence
- parent with custody
- spouse with custody
- spouse without custody
COORDINATION OF BENEFITS
process of submitting claim to primary and secondary insurance
EDI acronym for
Electronic Data Interchange
Claim Acknowledgement
ins received claim
will be review and process
Definition of Fraud
deception or misrepresentation to secure unlawful gain
Billing unrendered
charging for procedures that didnt take place
1 surface filling charged as a 3 surface filling
billing for covered service but performing cosmetics
Upcoding
Billing for more expensive services
Billing for full mouth x-rays when only a single periapical
Inflation
• Falsifying a patient’s diagnosis to justify tests that aren’t medically necessary.
Un-bundling
billing each step of a procedure as if it were a separate
procedure
e.g MODB as MO, DB
The administrator of all federal account is
Medavie Blue Cross
