DA117 Practice Management

1. DA117Practice Management Dental Insurance

2. Terms to know • The Plan – A contract between the employer and the Insurance company • Provider – The healthcare facility where treatment is rendered – ie- hospital, dental office

3. Carrier – The insurance company • Subscriber – Insured individual – usually the employee • Dependent – Children of the subscriber – can be step-children. Only accepted up to a certain age depending on the insurance plan or state regulations

4. Spouse – Husband or wife of the insured • Primary Insurance – Insurance of the employed • Secondary Insurance – Insurance of the spouse

5. Dual Coverage – Person is covered by more than one plan – primary insurance and secondary insurance • Coordination of Benefits – Process of determining benefit payments when more that one insurance carrier may be responsible

6. Birthday Rule – A method for choosing whether the mother’s or father’s insurance will be primary insurance for the dependent • Based on whose birthday comes first in the year • Example – Mother born February 1960 • Father born December 1955 • Mother’s insurance is billed first

7. Exclusion – Service not covered by the insurance plan • Deductible – The amount the patient must pay before the insurance makes any payment. Usually a set yearly amount

8. EOB – Explanation of benefits – Statement from the insurance company that explains how a claim was paid -

9. CDT Codes • CDT – Common dental terminology • Billing codes for dental procedures – developed by the ADA for purpose of describing dental services in a universal language. • Represented by a series of numbers • Renewed every two years to incorporate new procedures

10. Breakdown of CDT codes • First number – Represents the form of healthcare 0 – Dental • Second number represents category of dental services 1 – preventative • The remaining numbers describe the service in more detail

11. Pre-treatment Estimate • A treatment plan submitted on an insurance form to insurance company for estimation of payment before dental services are completed.

12. Electronic claims • Due to the increase in practice management software, more offices are submitting claims electronically, through the insurance company website or a clearing house • A clearing house is a company that accepts claims. Checks for errors, and submits the claim to the insurance company for payment • The clearing house charges for this service, either by claim or a monthly fee.

13. Claims sent through a clearing house are sorted by carrier and submitted for processing. Any claims with missing information are sent back to the office for corrections.

14. Direct to carrier • The dental office can enter claim form information into an electronic claim form on the insurance company’s web site. This eliminates the sorting and data entry required with paper claims. Processing time is reduced to 2 to 4 days versus 30 days for paper claims.

15. Electronic funds transfer • Most carriers and deposit insurance claim payments directly into the office account. This, combined with electronic claims can receive payment in 24 – 48 hours.