What Is A Dental Insurance Claim
Were going back to the basics, with an answer to a common question: what is a dental insurance claim? plus some good-to-know info on how these types of claims work.
In its simplest terms, a dental insurance claim is a request for payment made by a dental practice to an insurance provider. If the claim is approved, the insurance provider will issue funds to the practice for the service provided.
Sounds simple enough, right? Sometimes it is, however there are lots of complexities built into the dental insurance claim and payment process, and they can put a lot of stress on a dental offices front desk not to mention their profits. Thats why dental insurance claims processing pros like us exist, to ease the burden and make sure claims get processed as smoothly as possible.
How Much Is Dental Insurance
The cost to have dental insurance varies based on your coverage, where you live, and other factors such as:
- Is it an individual or family policy?
- Is the dental insurance provided through an employer?
- What are the annual maximums?
- What are the annual deductible and the copays?
Affordable dental insurance plans might pay for preventive care but not pay as high of a percentage for major services. If you need thousands of dollars of work done for crowns or a bridge, a higher-cost dental plan might pay for itself.
Overall, monthly premiums range between $39 per month for an individual to $139 per month for a family . FAIR Health has a handy calculator for dental costs, which you can use to estimate the cost of specific dental services.
What Are The Benefits Of Having Dental Insurance
The benefits of dental insurance can include:
- Lower out-of-pocket costs for non-preventive dental care. Without dental insurance you end up paying the full cost for dental treatments and procedures. Your insurance company negotiates with the dentists in its network to offer you lower costs. This is how a dental plan helps protect you from the high cost of dental care.
- $0 preventive dental care. Most dental plans cover you 100% for routine, preventive dental care. These plans include a dental exam, cleaning, and some X-rays every six months. For children it may also include fluoride and other pediatric preventive dental care.
- Good dental health impacts other health, too. Good dental health can help you identify health problems before they become major. During your regular oral exam, your dentist not only cleans and polishes your teeth, but they also check your whole mouth, throat, and tongue for cancer and other potentially serious issues. Keeping teeth and gums healthy can also help avoid serious health problems like heart disease. For existing health problems, poor oral health can actually worsen things like diabetes and coronary artery disease.1
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Tip : Have A List Of Appeal Information For Each Insurance Company
Every insurance company is a bit different regarding their appeals process. This, of course, is another way to make appeals more difficult and for offices not to follow through with the process.
For example, some insurance companies want a new claim with additional information. Some want the original Explanation of Benefits accompanied with additional information. Some want the new claim and/or original EOB sent to a different address than where initial claims are sent.
Some want them sent directly through their web portal.Gathering this information for each insurance company and cataloging it will shorten the time needed to submit each appeal.
Directors And Officers Insurance
Also known as D & O insurance, directors and officers liability insurance covers the costs associated with protecting your directors or officers in the event they wind up in legal trouble. This protects the members of your board as well as those in a position of leadership from being sued personally, as opposed to a company being sued.
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Is General Liability Coverage Enough Protection
Typically, no. General liability is not quite enough coverage for medical professionals as they are exposed to a wide range of risks that this type of insurance does not cover. For instance, it does not cover any sort of crime or cyber liability. Unfortunately, a medical professional and business owner can’t rely on just a general liability insurance policy to be adequately protected. To find out what other insurance products you need for complete coverage, talk to our brokers today.
Who Can I Lean On For Support To Help My Dental Practice Transition To Fee
Dental ClaimSupport has been able to help dental providers through this discussion and handling of dental claims to support those considering going out-of-network. Getting higher reimbursement rates is the main goal of the provider, but getting the providers claims paid is the ultimate goal for Dental ClaimSupport.
If you are considering going FFS and you are looking for more insights, consider joining a mastermind group with other dental providers just like you. Hear from others about what they have done, how they have done it, and how to deal with all around insurance stress.
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Using Your Individual Dental Insurance Plan
When you are ready to use your dental insurance plan, find a dentist in your plans network. In our case, our dentists can join two networks. Dentists in the Delta Dental PPO Network often have agreed to accept lower fees than dentists in the Delta Dental Premier® Network. Dentists who choose to not join one of our networks are called Non-Participating Dentists. You may choose any dentist to provide services under almost all of our individual plans . However, your out-of-pocket costs may be substantially higher if you use a Non-Participating Dentist than with a Delta Dental PPO or Delta Dental Premier Dentist. You will be responsible for payment of any balance remaining after the DDWA benefit is paid. Many dental insurance plans no longer issue physical cards. Not to worry. If a dentist is in your plans network, he or she has a direct line to the insurance company. The receptionist or billing specialist can look you up in our system to verify your coverage and benefits.
Tip : Don’t Accept No For An Answer
The majority of offices dont follow through on claim research and will accept from insurance what they are given. Most of the time, the first appeal will overturn the original decision and benefits or in some cases additional benefits will be paid out.When working through denials, no pays, and your insurance aging report, if you dont agree with the decision, appeal it!
Do not let insurance companies dictate your dentistry.
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What Is The Difference Between A Submitted Fee And An Accepted Fee
You may notice a difference on your dental benefits summary between the submitted fee and the accepted fee. The submitted fee is the amount that the dental office charges for your service and submits to Delta Dental. The accepted fee is the amount your dentist agrees to accept from Delta Dental as full payment for your dental service. Log in to your account to access your documents.
How To Read Your Explanation Of Benefits
After a visit to the dentist, you will receive a document in the mail called a dental benefits summary. You may also see this called an explanation of benefits . What is it and how can you read it?
A dental benefits summary or EOB is not a bill. Instead, its a document that breaks down the care youve already received, what portion is covered by your plan and what portion you may owe to your dentist. Watch this video for a detailed look at the different parts of this document. Log in to your account to access your documents.
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What Is Claims Processing
Once the insurance company receives the filed claim, it will need to be processed. Claims processing is simply reviewing the services or treatments that were performed and making any payments according to the plan benefits. Most benefit payments are made directly to the dentists office.
For example, lets say a member has a dental plan with benefits for general exams covered at 100%. Once the member has their dental exam, the dentist will file the claim with the insurance company. The carrier then processes the claim and makes a payment for 100% of the allowed charges filed by the dentist. The carrier then sends a payment back to the dentist, and also sends an Explanation of Benefits to the member.
How Do You Apply For Dental Insurance
There are a couple of ways you can get dental insurance:
- Your employer may offer you dental coverage as part of your employment benefits. If so, you can apply for that during annual open enrollment. There may be different types of dental plans you can choose from that can help cover the type of dental care you expect to need.
- If your employer doesnt offer dental insurance, or if you lose a job or work for yourself, you can buy a dental plan on your own. You can do this either through a state health exchange or directly from a health insurance company like Cigna.
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How To Submit A Claim Electronically
Use Provider Tools for free real-time claims with digital attachments and pre-treatment estimates. Youll see Delta Dentals payment and the patient portion when the claim or pre-treatment estimate processes, often within moments .
First, log in to Provider Tools. From there, you can transmit claims, digitized attachments and pre-treatment estimates with either of these tools:
- Submit Claim: transmission is quick and efficient.
- My Patients: your current patients are listed here and we add new patients as their claims are processed. Patient information is automatically entered on your pre-treatment estimate or claim.
You can also use FastAttach®, a service available through National Electronic Attachment, Inc. , to electronically transmit digitized x-rays, periodontal charts, Explanation of Benefits documents, photos and narratives.
If you are not submitting claims electronically, talk with your practice management system vendor about activating your systems electronic claims component.
Are You Considering Out
Most providers are asking themselves this question: Can I go out-of-network with Delta Dental? Most are asking this question because a high percentage of their patient base is either Delta Dental PPO or Dental Dental Premier, and the fees are extremely low .
Delta Dental has almost created a hybrid version of scenarios 2 and 3 above, but not the providers choice. The office is fee-for-service but still wants to be reimbursed for their services by the insurance company.
Delta Dental has decided that if you go out-of-network with them, they will send the reimbursement check directly to the patient when allowed by state law, no matter what you do on the claim form in item 37. Collecting from patients in this scenario can be very difficult because the patient is not prepared to pay for their services in full at their time of service, while they also tend to cash their checks from Delta Dental and decide not to reimburse the office .
Delta Dental is creating more work for the office while the office is trying to operate normally by reimbursing the office . This tends to be a difficult decision to make for most providers, and as much as providers dislike the low PPO reimbursement rates, they also want to be reimbursed for their services. Unfortunately for most, its a catch 22.
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How Do I Get Dental Office Insurance
The best way to get dental office insurance is by reaching out to a qualified, licensed broker such as the team at Morison Insurance. Our brokers are highly experienced, and will shop around on your behalf to find the best insurance policy for your needs. We’re dedicated to helping our clients get the coverage they need at competitive quotes.
How Does Dental Insurance Work
Dental insurance can pay for things like annual cleanings, minor oral health fixes, or big-dollar dental claims for crowns and bridges. In general, dental coverage is broken out by preventive, basic and major services:
- Preventive dental care includes diagnostic and preventive services like regular oral exams, teeth cleaning, and x-rays. It may also include fluoride treatments and sealants . In many cases, dental plans include 100% of the cost of preventive care.
- Basic dental care includes office visits, extractions, fillings, periodontal treatment , and root canals. Your insurance company might pay anywhere from 60 to 80% of the cost for these services, with you covering the rest of the cost. But if you’re paying a lower percentage of the costs, you may have a high-dollar copay.
- Major dental care covers crowns, bridges, dentures, and inlays. Inlays are something between a filling and a crown: Your tooth might have extensive decay and need a more substantial filling, but it may not be in bad enough shape to require a crown. Meanwhile, crowns completely cover the tooth. Some dental insurance plans include root canals under “major” dental care, while others categorize them as “basic.” The cost of major dental care is higher, and most insurance plans cover about 50% of the fee.
There are two main types of dentail insurance plans:
The Provider Does File Dental Claims But Wants The Dental Insurance Company To Reimburse The Patient
In this second scenario, a dental practice may choose to file the claims on the patient’s behalf, leaving box 37 unchecked on the 2019 ADA Dental Claim Form. The dental practice is going to collect the full fee from the patient before sending the claim to the insurance.
With box 37 unchecked, the insurance payer is going to send all Explanation of Benefits to the patient. The dental office is likely not going to receive any notification of payment or denial from the insurance company.
In this case, the dental practice then has a couple options of how they follow up on claims and when they decide to close the claim in their dental software. If the office is not expecting to be paid from insurance, the open claim would then need to be closed immediately in the dental software.
To follow up on outstanding claims, the office can either follow up on claims regularly, or wait for a patient request. If the patient is responsible for their own claim follow-up, they may run into denial issues, resubmission issues, or even timely filing issues.
With the patients receiving the EOBs, the dental insurance is not required to give any information regarding the claim or payment information to anyone besides the patient. For example, the dental practice can call to check the status of a claim, but the insurance may not give any information regarding whether a claim was paid, or how much was paid on the claim to the patient.
Electronic Encounter Forms For Deltacare Usa
Save time and money while helping the environment by electronically submitting your encounter forms to DeltaCare USA.
- Saving money by eliminating printing, copying and mailing costs.
- Saving time by submitting electronic encounter forms daily, which can eliminate the need to spend more time running monthly reports.
- Receiving prompt notification of any invalid data, allowing you to make the necessary corrections and re-submit right away.
- Receiving reports of all successfully transmitted encounter forms, reducing follow-up on unpaid submissions.
DeltaCare USA’s payer identification number for encounter forms is DDCA3.
For more information about electronic encounter form submission, please email our .
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Why Choose Morison Insurance
When it comes to selecting a broker, it’s essential that you choose someone who has your best interests at heart and is prepared to grow with you as your needs change. The team at Morison Insurance always puts our customer’s interests first. Unlike agents, we don’t work for one insurance providerâwe work for you. So, you can trust that we’ll do our best to find you the most comprehensive coverage at a competitive rate. We have built relationships with all of Ontario’s top insurance companies and know how to find our clients the best insurance possible.
Furthermore, our company is family owned and operated. We bring this family mindset to all our clients. When you choose Morison Insurance, you choose to be part of our extended family! We will always make sure you are protected so that you don’t have to worry about the future.
If you are interested in learning more about what our Morison Insurance brokers can do for you, then we invite you to give us a call today at 1-800-463-8074. Alternatively, you can fill out the online form on our website. We look forward to providing excellent insurance solutions.
How To Easily Read An Eob
Lets dig in to the components of an EOB to explain how to properly understand it. When you receive an EOB for dental treatments, there are a few things you can check to make sure the claim was processed correctly.
The first thing you can do is to make sure that all the procedures and services that you received are shown on the EOB. Then you can check the charges and allowed amounts for each procedure to see how the carrier paid the claim. Typically most dental plans will pay a percentage for each charge depending on the category the service falls in.
Lastly, youll want to make sure the patient responsibility amount thats listed at the bottom of the EOB matches the amount the provider is billing you. This way you can know that youre paying the correct amounts to the dentist office.
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