DA 2 Dental Insurance

Question 1

What is dental insurance?

Answer 1

plan that assists the patient financially with the cost of dental care

Question 2

How do you get dental insurance?

Answer 2

through an employer

individual basis (These have not been successful)

Question 3

What is the purpose of dental insurance?

Answer 3

dental care more accessible by reducing the cost

Question 4

dental care more accessible by reducing the cost ___ and ____

Answer 4

subscriber and insurance

Question 5

Benefits

Answer 5

Benefits

Question 6

Predetermination of benefits

Answer 6

Preauth
planned treatment submitted to ins

carrier responds with eligibility

Question 7

Approval/Authorization

Answer 7

authorization for the procedures on
predetermination of benefits from the carrier outlining
coverage details

Question 8

Claim

Answer 8

• A report of dental services to a patient’s dental plan

Question 9

Claim Form

Answer 9

from provide treatment provided and fees charged

Question 10

Explanation of benefits EOB

Answer 10

insurance response to claim

Question 11

Procedure Code

Answer 11

5 digit code used to determine fee

Question 12

Maximum benefit

Answer 12

Max. $ amt. a plan will pay

Question 13

Lifetime Maximum:

Answer 13

• Carrier may also establish a lifetime max for
certain procedures (eg. Lifetime max of $2000 for
ortho services

Question 14

Deductible:

Answer 14

amount insured must pay toward the cost of

dental treatment BEFORE benefits of the plan go into effect

Question 15

time Limits

Answer 15

Period of time claim filed

following completion of treatment is completed

Question 16

Clause

Answer 16

Provision of an ins. contract

Question 17

Alternate benefits clause

Answer 17

When ins. Agrees to pay the equivalent of another

procedure towards a proposed tx (e.g. Am instead of TC)

Question 18

DRC must ensure ______ because ins policies vary

Answer 18

ensure pt. is not scheduled prior to eligibility date

UNLESS pt. is aware they will need to pay the fee

Question 19

two ways of managing dental insurance:

Answer 19

Assignment or Non-Assignment

Question 20

Assignment

Answer 20

pt authorization

office send to insurance

pt pays co payment

claim form is sent

Question 21

Non-Assignment

Answer 21

Pt. pays full fees to dental office

Pt. receives calim to send to ins

ins sends reimbursement cheque to pt.

Question 22

Patient • Responsibility

Answer 22

Pay all amounts not covered by ins.

Provide current dental ins. Info

Question 23

Dental office Responsibility

Answer 23

Provide dental care

Assist pt. in securing benefits

Question 24

Dual Insurance

Answer 24

coverage by more than one insurance

Question 25

Divorced or Separated Parents sequence

Answer 25

1. parent with custody
2. spouse with custody
3. spouse without custody

Question 26

COORDINATION OF BENEFITS

Answer 26

process of submitting claim to primary and secondary insurance

Question 27

EDI acronym for

Answer 27

Electronic Data Interchange

Question 28

Claim Acknowledgement

Answer 28

ins received claim

will be review and process

Question 29

Definition of Fraud

Answer 29

deception or misrepresentation to secure unlawful gain

Question 30

Billing unrendered

Answer 30

charging for procedures that didnt take place

1 surface filling charged as a 3 surface filling

billing for covered service but performing cosmetics

Question 31

Upcoding

Answer 31

Billing for more expensive services

Billing for full mouth x-rays when only a single periapical

Question 32

Inflation

Answer 32

• Falsifying a patient’s diagnosis to justify tests that aren’t medically necessary.

Question 33

Un-bundling

Answer 33

billing each step of a procedure as if it were a separate
procedure

e.g MODB as MO, DB

Question 34

The administrator of all federal account is

Answer 34

Medavie Blue Cross