Week 4 PP

Question 1

Different forms of Dental Insurance Plans

Answer 1

-Traditional dental insurane plan (employer plan)
-Managed care dental insurance plan (individual plan)
-Government programs

Question 2

Traditional Insurance Plan / Idemnity Plan

Answer 2

A plan that helps with the cost of dental care.
Considered “fee for service” and come with limitations and co-payment options.

The patient has an annual limit on coverage for dental spending and specific coverage limits that may apply to specific procedures.

Question 3

Managed Care Dental Plan

Answer 3

-Method of providing low to medium coverage to everyone
-The type, level and frequency of treatment can be limited
-Disease prevention is encouraged
-Plan could also control the level of reimbursement for services

Question 4

Preferred Provider Oganizations (Dental PPOs)

Answer 4

Tehcnically a closed panel type of plan

• Closed network plan where individuals must visit a preselected or assigned network dentist to receive benefits
• A dentist may join a PPO in hopes of attracting new patients
  -Patients are charged the dentist’s usual fees
  -SAIT’s student dental plan is like this. Students can see a preferred provider or a dentist of their choice

Dental Benefits Maximum = $750 per her 80 % basic coverage

Question 5

Exclusive Provider Organizations (EPOs)

Answer 5

• Form of closed panel dental insurance
• Patient’s are offered NO option other than receiving their treatment from a dentist who is a member of the plan’s network of providers
• University of Calgary student insurance
• Maximum of $750 per year
• Note that these benefits can only be used at Dental Choice clinics in Alberta (6 offices in
  Calgary). Services performed at other dental centers will not be eligible for reimbursement.

Question 6

Direct Reimbusement Plan

Answer 6

• Self-funded program
• Individual is reimbursed by their employer based on a % of dollars spent for the dental care provided.
• Can seek treatment from the dentist of their choice.
• No insurance company involved.
• Employee pays the dentist and the employer reimburses the employee a portion of the
  expense.
• Amount reimbursed is decided by the benefit design established by the employer.

Question 7

Basic Procedure Coverage

Answer 7

Benefits covered to maintain and preserve the oral structure. Procedures covered may vary, but commonly include..
✓ Prophylaxis
✓ Scaling
✓ Fluoride (usually has age restriction)
✓ Restorations
✓ Extractions
✓ Root Canals
✓ Radiographs
✓ Study Models
✓ Biopsies
This is usually the area with the higher percentage of coverage. Most common is 80% or 100% coverage of the dental insurance company’s fee guide.

Question 8

What is Major Coverage?

Answer 8

These are benefits for more extensive treatment. Procedures covered may vary, but commonly include:
✓ Crown
✓ Bridge
✓ Dentures
✓ Complex Oral Surgery
✓ Periodontal treatment (surgeries)
These procedures are usually covered at a lower percentage of coverage. Most common is 50% coverage of the insurance company’s fee guide.

Question 9

What is the subscriber?

Answer 9

The person who carries the insurance and also the person receiving the treatment

Question 10

What is a Dependent?

Answer 10

child or spouse of the subcriber

Question 11

Who is the Carrier?

Answer 11

The insurace company who pays the claims and collects premiums

Question 12

Who is the Group?

Answer 12

The employer that purchased or arranged insurance as a benefit

Question 13

Who is the Provider?

Answer 13

The dentist or hygienist who performs the service

Question 14

3 Most Common Methods of Calculating Fee-For-Service Benefits

Answer 14

1. Usual, Customary & Reasonable (UCR Fees)
2. Schedule of Benefits
3. Fixed Fee Schedule

Question 15

UCR Fees

Answer 15

Usual: Refers to the fee that the dentist charges private patients for a given service. Fees are determined by the dentist and are the fees routinely charged by the practice. A dentist will confidentially file their fees with dental insurance companies. This information (prefiled fees) is sued by the insurance company to establish the customary fees for the area.

Customary: fee that is within the usual range of fees charged for the same service by similary trained dentists in the same geographical area. Established by comparing pre-filed fees of dentists in the area.

Reasonable: fee that is considered justified by special circumstances necessitating complex treatment (where dentist charges more than the usual fee wheven to a private patient). An example would be a complicated extraction. Dentist would need to submit written documentation explaining why the unusual fee is required.

Question 16

In an UCR system the patient is responsible for…

Answer 16

the difference between the insurance payment and the dentist’s fees

• limitations of the policy will influence the amount the dentist receives from the carrier and the amount the patient must pay

Question 17

Limitations and exlusions

Answer 17

Dental plans do not usually cover all procedures

Each plan contains a list of conditions or circumstances that limit (number of procedures permitted udring a time period; 1 cleaning per 6 months) or exludes services from coverage (no orthodontic treatment)

Question 18

Table of Allowance/ Schedule of Allowances:

Answer 18

-List of fixed amounts that the carrier will pay towards the cost of covered services
-Is not related to the dentist’s actual fee schedule
-Created by the insurance company (Eg. blue cross has its own fee guide)

Patient is responsible for the difference between what hte Carrier will pay and what the dentist charges

Question 19

What is a Fixed Fee Schedule?

Answer 19

An established fee for any treatment received by the patient.
- Often lower than average fees
This is used for Government Plans - (Alberta Child Health Benefit, AISH, Non-Insured Health Benefit - includes all registered First Nations & Inuit persons)

Dentist must accept this fee and cannot bill the patient the difference

*Some programs eligibility can change month to month so verification of coverage must be done frequently

Question 20

Determining Eligibility

Answer 20

When an employee starts a new job there is typically a waiting period before benefits become effective (employee pays into the benefits for a specified period of time)

If an employee retires, quits, or is laid off the insurance coverage will typically terminate within 30 days of the change

Question 21

Determining Benefits

Answer 21

The employer purchases benefits for their employees and negotiates the limitations and benefits of the plan

The insurance company is only responsible for covering the level of treatment outlined in the employer’s plan
This information can be found in the benefits booklet

If possible, the patient should bring their booklet to their first appointment or review it online prior to dental treatment

Question 22

Dental Insurance Limitations

Answer 22

-There are several factors that influence the level of benefits that the beneficiary is eligible for and the amounts they must pay as a share of these costs

Question 23

Least Expensive Alternative Treatment - LEAT

Answer 23

This is a limitation in a dental plan that allows for benefits only for the least expensive treatment.

For Ex: a patient needs to replace a missing tooth
Treatment options: Fixed bridge for $4000 or partial denture for $2500

Under LEAT the carrier will pay the benefits for a partial denture only. If the patient decides on the fixed bridge, the patient MUST pay the difference in cost

Question 24

Dual Coverage

Answer 24

-Patient has dental insurance coverage under more than one plan
-Steps to make sure the benefits are paid

Question 25

Determining Primary & Secondary Carriers

Answer 25

Which insurance company pays first and which one pays second
When the patient is the insured - their insurance company is the primary carrier.
Their spouses insurance would be their secondary carrier
When spousal coverage is in place for patient’s with insurance of their own, their insurance must be filed first

Question 26

Dual Coverage Birthday Rule

Answer 26

Explains which insurance company is the primary carrier when both parents have dental insurance
The rule stipualtes that when a child is covered under both parent’s plans the plan of the parent who’s birthday (month and day) falls earlier in the calendar year is billed first.

Other factors are involved when parents are divorced or separated or when step parents are involved. Offices need to work with the parents to define the billing in these situations. (do not worry about this for exams)

Question 27

Coordinations of Benefits

Answer 27

The patient or dental office will receive payment from both insurance carriers but the total received can not exceed 100% of the actual dental expense

The fee is $200
Primary carrier will pay $105
The secondary carrier will pay no more than $95
no matter what benefits the secondary carrier will
pay for the service.
The patient or office will not be reimbursed for
more than 100% of the cost.

Question 28

Nonduplication of Benefits (Benefits less Benefits)

Answer 28

a provision that releives a carrier from responsibility for paying for services covered under another program. Reibursement is limited to the higher level allowed by the 2 plans rather than to a total of 100%

Ex) A fee of $250 is charged.
The primary carrier will allow $175 for this service.
The secondary carrier allows for $190 for this service. In this situation the primary carrier pays $175 and the secondary carrier will only pay $15 to equal the $190 that they are willing to pay for that service.
* Many patients are unaware of this clause and may need to have it explained to them.

Question 29

What are Dental Procedure Codes?

Answer 29

• Is a system of categorizing dental services
  -Each dental service has a unique 5 digit number
  -Each province can have slightly different codes; however they are similiar enough for Canadian Dentists and insurance companies to use consistently
• Allows Canadian dentists to standardize their work and also allows governing bodies to regulate how dentistry is performed and the amount the dentist can charge for the service

Question 30

10 Basic Categories for Dental Procedure Codes:

Answer 30

• Diagnostic services
• Preventative services
• Restorative Services
• Endodontic Services
• Periodontal Services
• Removable Prosthetics
• Fixed Prosthodontic Services
• Oral and Maxillofacial Services
• Orthodontic Services
• Adjunctive General Services

Question 31

Dental Procedure Codes & Units of Time

Answer 31

The last number can refer to the number of units of that service you received

Ex) 11111 - 1 unit (15 min) of scaling
11112 - 2 units (30 mins) of scaling

The code can also indicate the type of filling
material being used, tooth being worked on and
the surfaces involved.

Question 32

Provincial Fee Guides

Answer 32

Every Province/Territory has its own Dental Association and each association issues a fee guide for the dentists who work within that province or territory

Sets the norm for the prices that all provincial dentists use. This fee guide is a suggestion of how much each dentist should charge for those procedures. Final amount is determined by the dentist (can charge as much or little as they want). The patient is responsible for any fees that their insurance company doesn’t pay

Question 33

Claim Forms can be filed in 2 ways..

Answer 33

1. Paper submission (mailed to insurance company)
2. Electronic submission

Question 34

All Claims require the following information:

Answer 34

1. Patient & Subscriber indentification
2. Dentist identifaction
3. Treatment details

All parts must be completed accurately before
submitting to the insurance company
If submitted incorrectly the insurance company will
not process the claim.

Question 35

Dental Claim Guidelines

Answer 35

-Transimt claims on a daily basis
-Must keeep a record of each claim that was submitted
-Transmission problems an occur so claims may need to be submitted again
-Report is generated weekly or monthly to ensure all payments have been received from the insurance company

Question 36

What is a Signature on file?

Answer 36

Signature authorization form or a blank
insurance form can be signed by the patient and when the claim form is completed “Signature on File” can be used in place of the policy holder signature.

Question 37

***Assignment of Benefits means…

Answer 37

When a dentist submits the claim form to the insurance co. the payment is to be made to the dentist

• When cheque or EFT is received by DDS, balance not covered by insurance is then billed to the patient

Question 38

**Non-assignment of Benefits

Answer 38

-The patient pays the dentist the full amount charged
-The dentist will submit an insurance claim with payment to go directly to the patient

Question 39

Estimates

Answer 39

-Provided to the patient with information regarding treatment
-A copy is given to the patient and a second copy is kept in the patient’s chart
- Can compare 2 treatment options
-The estimate helps the patient make an informed fincancial decision with their dental treatment
- An Estimate is NOT sent to the insurance company

Question 40

Pre-Treatment Estimate

Answer 40

Sending a pre-authorization (an estimate from the insurance company) is the only
way to be sure that the treatment recommended is covered.
The insurance company will process the preauthorization in conjunction with dental consultants to approve coverage.
The information is processed based on the current coverage balances. This information is typically sent to the patient. Authorization is only good for a certain period of time.

Question 41

What are Pre-Authorizations?

Answer 41

Some insurance co. require you to send a pre-auth for major or basic treatment over $300

This is a benefit to both the dental office and the patient. Once the pre-auth comes back to the patient and the office will know the exact amount that will be covered and what the patient is responsible for, up to the yearly maximum.

Insurance company will cover expenses up to a certain time period and as long as benefits are still available. (Ex. Pre-auth is good for 4 months)