How To Show A Fee Discount On Claims
Fee discounts should be reflected in the total fee that is entered on the claim.
Example: If your fee for a service is $100 and you wish to give the patient a 20% discount, then $80 becomes the fee that is actually charged and $80 should be entered on the claim as the total fee.
Always notify Delta Dental of the actual fee charged. This helps ensure that you dont contribute to higher costs that can potentially jeopardize patients dental benefits plans.
Many Dental Insurance Companies Create A Paperwork Barrier To Processing Your Claim
Supposedly lost coverage requests and Insurance claim denials are a standard operating procedure with most dental insurance companies. It is called stall as long as you can. There are only two things that can happen with that game. The dentist gives up on collecting the money he earned and cuts his losses. Or the insurance company gets to keep his earned money a little longer to invest it somewhere else. When a claim is denied or ignored, it is not uncommon for a dental employee to be left on-hold for over 30 minutes. If a dental office has 16 unpaid claims you can see the dentist will have to hire someone full time to do nothing but listen to elevator music while trying to recover the money the office has already worked for. Some dental offices have a policy that if they dont get paid by the insurance company within 60 days you will pay and join them in the fight to get your insurance benefit back. How well do you like elevator music?
How To Read A Dental Predetermination
After the predetermination is processed by the insurance company, both the patient and the provider will receive a copy. From experience, the patient will often receive the predetermination a few days before the providers office. All dental insurance companies format their predeterminations a bit different. Some will clearly state that it is an estimate, while others will look very similar to an EOB that is received after a claim has been processed. In any case, there will always be at least 6 columns.
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What Do I Do If The Insurance Company Delays My Claim
If your insurance company is taking forever to process a claim, reach out to the adjuster to get an update and ask how you can expedite the process. If your state specifies a time limit in which insurers must resolve claims, make a note of the deadline and if the date passes, notify your insurance company right away.
Q: I Want To Take Charge Of My Health What Questions Should I Ask My Insurance Company/plan Administrator
A: Your insurance company can provide you with a breakdown of your dental benefits, but there are six key things to ask about:
Plan Year: Does your insurance follow a normal calendar year? If not, what month and day does your plan year start and end?
Deductibles/Yearly Maximum: What is your annual deductible? What is your family annual deductible? Does this apply to all family members or a limited number? What is your annual maximum benefit dollar amount?
Waiting Periods/Age Limitations: Are there any waiting periods for benefits to begin or age limitations?
Frequencies: How often does your plan cover cleanings, exams, x-rays, fluoride, and sealants?
Composite Restorations: Does your plan reduce coverage to the rate of old-fashioned amalgam restoration material or does it cover up-to-date composite fillings? Are there any other codes which are generally downgraded on your plan?
Percent Coverage: What percent does your insurance cover for:
Major Restorative Treatment and Prosthodontics?
Missing Tooth Clause: Does your plan cover replacement of teeth extracted prior to being on the plan?
Secondary Insurance: If applicable, does your secondary insurance policy have a non-duplication clause for dual coverage? If so, your second insurance may not help you unless you need a lot of dental treatment.
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Q22 What Dental Coverage Is Available After I Release
If you are receiving a Canadian Forces Superannuation Act pension, you may choose to have dental coverage for yourself and/or your eligible dependants under a separate premium-based plan. This plan is called the Pensioners Dental Services Plan and it is administered by the Sun Life Assurance Company. The necessary application forms are provided by your Release Office. Coverage under the PDSP is not automatic. You should be aware that the costs and coverage under the PDSP are not necessarily the same as under the CF Dental Care Plans.
Note: To ensure a smooth transition into the new plan and to avoid any delay in coverage, you have to complete and submit the correct forms within 60 days of the date you become entitled to your pension.
Timeframe For Claim Determination
If we receive all the information we need to process your claim, well send you an EOB within 20 days and 40 days of receiving your claim. However, if we need more information or are unable to make a decision due to circumstances beyond our control, well extend our response time for 15 days. Well let you know within 30 days why were extending our response time and when you can expect our decision. If we need more information, youll have at least 45 days to provide it to us.
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Q: Will You Change The Date Or Put A Different Date On My Procedure So My Insurance Company Will Cover It
A: No. This is insurance fraud. We are contracted with insurance companies to provide 100% honest information, otherwise our PPO relationship would be cancelled and our dental license revoked. Not to mention that we believe in providing honest, quality care because of who we are and what we believe. Dishonesty is never permitted in our office.
How Does Individual Dental Insurance Work
How does dental insurance work? By and large, dental insurance plans are pretty straightforward, and with a little information anyone can understand them. In fact, Id bet my two front teeth I can explain how health insurance works in under five minutes. Shall we try? Heres everything you need to know about how dental insurance works.
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Where To Find Your Claim Statements
If you have elected to receive claim statements and other plan documents by mail, you should receive them in the mail after your visit to the dentist if there is a balance due. However, you can also access your claim statements and other documents at any time by logging in to your online account. Your claim statements can be viewed and downloaded as PDFs by navigating to the Plan documents section.
A claim statement will show information related to your dental plan usage, including the date and type of service you received, how much it cost, and your portion of the bill plus what Delta Dental pays.
Mailing Addresses For Claims Processing
Delta Dental Premier® and Delta Dental PPO Claims
Mailing addresses for your Delta Dental Premier and Delta Dental PPO claims.
- Delta Dental of CaliforniaFor the state of CaliforniaDelta Dental of California
- For the states of Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas and Utah
Delta Dental Insurance Company
- For the states of Delaware, Maryland, New York, Pennsylvania, Washington, D.C., and West Virginia
- Mailing addresses for your DeltaCare USA claims.
- AARP Dental Insurance Plan Claims
Mailing addresses for your AARP Dental Insurance Plan claims.
AARP Dental Insurance Plan c/o Delta Dental Insurance CompanyP.O. Box 2059
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Common Ways Insurance Companies Deny Dental Claims
TThis article originally appeared in Dental Office Manager Digest e-newsletter.
EVER HEARD OF WARREN BUFFET, the man who made most of his fortune by heavily investing in the insurance industry? Of course, you have. His net worth is said to be somewhere in the area of $100 billion. Understanding the business model of insurance companies, Mr. Buffet took a gamble and came out one of the richest men in history. You see, insurance companies are in the business of making money, not spending it.
One of the most common ways insurance companies ensure that their profits soar is to collect monthly premiums from their members , then deny as many claims as possible by referring to the literature in a patients contract, specifically the exclusions, limitations, or frequency provisions. Exercising their right to deny payment of claims based on this literature ultimately results in decreased payouts and increased profits for the insurance company.
Now that you have a better understanding of the insurance company business model, you need to think like an insurance company. Be sure to dot your is and cross your ts before you send out any dental claims for processing.
Here are three most of the most common ways insurance companies deny dental claims, and some ways in which you can avoid them.
Lack of information from the provider
Limitations, exclusions, frequencies
What Is Dental Insurance
Simply put, individual dental insurance is a contract between you and your health benefits carrier in our case, Delta Dental of Washington. When you enroll in an individual dental plan, you have entered into a contract. This means that you are responsible to pay your premiums and follow the rules of the plan and were responsible to pay your dentist for covered services at agreed upon reimbursement levels.Dental plans vary, so the reimbursement level or portion that the benefits carrier pays – depends on the plan you choose.
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How Do I Bill Dental Claims To Health Insurance
And for good reason. Dental to medical cross-coding can cause administrative headaches and gridlock access to necessary dental services. All in all your patients medical plan will in many cases augment their dental benefits. Keep in mind that dental insurance is more easily positioned to cover preventative treatment.
Health & Dental Insurance Faq
Every province and territory will have a different health insurance plan check your health ministry’s website for details but most may not cover:
- Prescription drugs
- Vision care
- Semi-private or private hospital rooms
- Registered specialists and therapists such as Acupuncturists, Chiropodists, Chiropractors, Naturopaths, Osteopaths, Physiotherapists, Podiatrists, Psychologists/Psychotherapists, Registered Massage Therapists, Speech Pathologists/Therapists
- Health-related products such as orthotics, hearing aids, prosthetics and medical equipment
- Health-related services such as ambulance, homecare and nursing, medical coordination and second medical opinions
Yes, if your employment is ending and you are losing group benefits, you can convert your group health and dental benefits to an individual policy.
The FollowMe Health Plan Insurance for CARP Members was specifically designed to provide members with a plan that provides them with many of the same health benefits they enjoyed with their group plan. If applying within 90 days of losing their group coverage, no medical questionnaire or exam is required at time of application and their acceptance is guaranteed, once eligibility has been confirmed and their initial payment has been received.
You have 12 months from the date you were charged for a health and dental service to submit your claim for reimbursement.
To access your receipt at that time:
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Q: What Does Ppo Mean
A: PPO means Preferred Provider Organization. Dentists and other healthcare professionals simply fill out forms and sign a contract stating that they will accept a certain fee for each service performed. For example a doctor may say a procedure costs $150, but the insurance company will pay $100 for it. Dentists and other healthcare professionals who are PPOs or in-network accept this discounted fee in exchange for being listed as a PPO for that insurance company. Its great for patients because it helps to keep costs low. Its great for doctors because they get an opportunity to see new patients!
Prior Authorization For Nonurgent Dental Care
If your request for prior authorization isnt urgent, Florida Blue will respond to your request within a reasonable time thats appropriate to the clinical circumstances of your case. Well typically respond within 15 business days of receiving your request. We may extend our response time for an additional 15 business days if we cant respond within the first 15 business days or if its due to circumstances beyond our control. If this happens, well let you know before the end of the first 15 business days. Well tell you why were extending our response time and when we expect to make a decision. If we need more information, well let you know and give you at least 45 business days to provide it to us.
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Q11 What Types Of Leave Without Pay Are Covered Under The Dependants’ Dental Care Plan
If you go on authorized LWOP for any of the following reasons, employer-paid coverage will be extended to you for the total period of absence:
- maternity leave
- parental leave
- academic or technical training when it is in the interests of the CF and the LWOP is authorized.
If you proceed on any other type of LWOP, employer-paid coverage will continue during the first three consecutive calendar months of leave. Following this period, if you would like to maintain your DDSP coverage, you must pay contributions quarterly in advance, starting with the fourth month of your leave of absence and continuing for the duration of the LWOP, including the month you return to work. An example of this type of LWOP is as follows:
You take LWOP for Spousal Accompaniment from 1 August 2013 until 31 July 2016, and return to work 1 August 2016. You have employer-paid DDCP coverage through the first three full months of LWOP . This employer-paid coverage will cease on 31 October 2013. You must remit contributions in advance on a quarterly basis for the period beginning 1 November 2013 if you wish to have continued DDCP coverage throughout the remaining period of LWOP. Contributions would be required for November 2013 through August 2016 as employer-paid coverage would not be reinstated until December 1, 2012 (the first of the month following your return to work.
Dental Insurance Claims Processing 101
Dental claims processing entails all aspects of giving care to patients, starting from the moment a patient is registered until the explanation of benefits and payments are completed. Dental insurance claims are submitted via paper and electronically.
Electronic transactions are where clearinghouses such as the Smart Data Stream Clearinghouse come in.
Clearinghouses give dental practices the tools and access necessary to submit, receive and request information from different payers. A quality clearinghouse is one that successfully provides a seamless data exchange between dental care providers and insurance payers.
Dental claims are complex, but understanding the workflow can help businesses identify areas to reduce cost and speed up turnaround time.
Steps in Dental Insurance Claims Processing
The first step in the dental claims process is to ensure that the patient has been seen and received care. After a patient has visited a dental provider, claims go through several steps before patients receive their final bill:
What is a Dental Insurance Claims Clearinghouse?
Q: Do You Take My Insurance
A: The answer is probably! We are a Preferred Provider for Aetna, Blue Cross Blue Shield of Alabama, Cigna, Delta Dental, Guardian, MetLife, Southland, SunLife and United Concordia. We can file insurance for select Medicare patients who have dental policies with one of the above companies. We are also in network with the militarys Active Duty Remote Program as well as the VA Community Care Network. We will file most insurance with out of network benefits on your behalf.
But heres the most important part: did you know that most PPO dentists who take your dental insurance accept the exact same fee for service? The insurance company pays the doctor a set amount and the patient, when applicable, pays a set amount. Thats why its so important for you to select a dentist and a dental office that meets your personal needs. When you have insurance, you often pay the same price no matter which PPO office you select, so why not pick someone you trust in an office where you feel comfortable?
Peterson Dental does not accept Medicaid at this time.
What If The Insurance Company Doesnt Pay What They Promised
In this case, you have the right to know why your claim payout was lowered or denied. If you believe that you deserve a higher payout, your best option is to consult a lawyer who can talk to the insurer on your behalf. In some states, you may be able to take your insurer to small claims court to get the money youre entitled to.
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How Will The Npi Affect Other Numbers I’ve Used In The Past
The NPI replaces other identifying numbers used in electronic transactions, such as:
- Enter your patients name and choose Existing .
- Select the patient, then select the Submit Claim icon in the Actions menu.
- Next, in the Type of Transaction menu, choose Pre-Treatment Estimate.
- Complete the claim information, select Continue, then Submit Claim.
Use the My Claims tool to see Delta Dentals estimated payment and the patients portion .
Or, you may mail a paper claim to Delta Dental. Include all required x-rays, documentation and/or written narratives. You will receive by mail a pre-treatment estimate showing the amount Delta Dental is estimated to pay and the amount of the patients responsibility. Unfortunately, we cannot provide pre-treatment estimates by telephone.