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Basic Dental Insurance Basic Dental Insurance Coding and Billing Coding and Billing

Basic Dental Insurance Coding and Billing

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Basic Dental Insurance Coding and Billing. Dental plans do not pay for care rendered to patients who are not eligible to receive benefits. When a subscriber starts a new job, there is usually a 30 – 60 day waiting period before coverage becomes effective. - PowerPoint PPT Presentation

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Page 1: Basic Dental Insurance  Coding and Billing

Basic Dental Insurance Basic Dental Insurance

Coding and BillingCoding and Billing

Page 2: Basic Dental Insurance  Coding and Billing

Dental plans do not pay for care Dental plans do not pay for care rendered to patients who are not rendered to patients who are not eligible to receive benefits.eligible to receive benefits.

When a subscriber starts a new job, When a subscriber starts a new job, there is usually a 30 – 60 day waiting there is usually a 30 – 60 day waiting period before coverage becomes period before coverage becomes effective.effective.

Page 3: Basic Dental Insurance  Coding and Billing

If the subscriber changes jobs, is laid If the subscriber changes jobs, is laid off, or retires, his / her coverage is off, or retires, his / her coverage is usually terminated within 30 days of usually terminated within 30 days of the change in employment. the change in employment.

COBRACOBRA

The rules for eligibility under other The rules for eligibility under other gov’t programs, such as Medicare gov’t programs, such as Medicare and CHAMPUS, and CHAMPUS, vary greatly.vary greatly.

Page 4: Basic Dental Insurance  Coding and Billing

The dental office should The dental office should ALWAYSALWAYS contact the insurance carrier to contact the insurance carrier to verify benefitsverify benefits

BEFORE services are rendered.BEFORE services are rendered.

There is There is no dental coverageno dental coverage under under Medicare !Medicare !

Page 5: Basic Dental Insurance  Coding and Billing

Coverage can change month to Coverage can change month to month for some individuals, so it is month for some individuals, so it is important to verify benefits before important to verify benefits before each visit.each visit.

Know how to read the insurance card Know how to read the insurance card !!

They are all different ! Sometimes They are all different ! Sometimes medical card includes dental; medical card includes dental; sometimes patient has separate sometimes patient has separate cards.cards.

Page 6: Basic Dental Insurance  Coding and Billing

EMPLOYER – buys the coverage as a EMPLOYER – buys the coverage as a benefit for the employees, and benefit for the employees, and negotiates the limitations and negotiates the limitations and benefits of the plan.benefits of the plan.

CARRIER – is responsible for covering CARRIER – is responsible for covering only the level of treatment that is only the level of treatment that is included in the plan purchased.included in the plan purchased.

Page 7: Basic Dental Insurance  Coding and Billing

Information explaining the coverage Information explaining the coverage under a specific plan is found in the under a specific plan is found in the benefits booklet that is supplied to benefits booklet that is supplied to the subscriber (employee). the subscriber (employee).

Ask the patient to bring their benefits Ask the patient to bring their benefits book to the first dental visit so book to the first dental visit so coverage can be reviewed.coverage can be reviewed.

!!

Page 8: Basic Dental Insurance  Coding and Billing

LEAT – Least Expensive Alternative LEAT – Least Expensive Alternative TreatmentTreatment

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

Page 9: Basic Dental Insurance  Coding and Billing

For Example :For Example : The patient needs a replacement for a The patient needs a replacement for a

missing tooth. The treatment choices missing tooth. The treatment choices are a fixed bridge for $6000.00 or a are a fixed bridge for $6000.00 or a removable partial denture for $1200.00. removable partial denture for $1200.00. Under the LEAT rule, the carrier will pay Under the LEAT rule, the carrier will pay benefits only for the partial denture. benefits only for the partial denture.

The patient may have the bridge done The patient may have the bridge done but the carrier will only pay the but the carrier will only pay the $1200.00. The patient must make up the $1200.00. The patient must make up the difference.difference.

Page 10: Basic Dental Insurance  Coding and Billing

Dual CoverageDual Coverage

Dual coverage is when a patient has Dual coverage is when a patient has dental insurance coverage under dental insurance coverage under more than one plan. more than one plan.

When this is the case, it is necessary When this is the case, it is necessary to take steps to be sure that the to take steps to be sure that the correct benefits are paid.correct benefits are paid.

Page 11: Basic Dental Insurance  Coding and Billing

When there is dual coverage you When there is dual coverage you must determine which carrier is must determine which carrier is primary and which is secondary.primary and which is secondary.

There are specific questions on a There are specific questions on a claim form that ask for this claim form that ask for this information.information.

Page 12: Basic Dental Insurance  Coding and Billing

Coordination of Benefits Coordination of Benefits

Husband & Wife both have dental Husband & Wife both have dental insurance coverage for each otherinsurance coverage for each other

If wife is patient, her insurance is If wife is patient, her insurance is primary and her husband’s insurance primary and her husband’s insurance is secondary.is secondary.

If husband is patient, his insurance is If husband is patient, his insurance is primary and his wife’s insurance is primary and his wife’s insurance is secondary.secondary.

Page 13: Basic Dental Insurance  Coding and Billing

Birthday RuleBirthday Rule

If child has insurance coverage from If child has insurance coverage from both mom and dad, you use the both mom and dad, you use the birthday rule to determine who’s birthday rule to determine who’s insurance is billed primary, and insurance is billed primary, and who’s insurance is billed secondary.who’s insurance is billed secondary.

Page 14: Basic Dental Insurance  Coding and Billing

Birthday Rule cont’Birthday Rule cont’

Mother’s BirthdayMother’s Birthday

April 23, 1968April 23, 1968

Father’s BirthdayFather’s Birthday

February 9, 1968February 9, 1968

Who’s insurance is primary ?Who’s insurance is primary ?

Page 15: Basic Dental Insurance  Coding and Billing

TerminologyTerminology

Usual, Customary, and Reasonable Usual, Customary, and Reasonable (UCR)(UCR)

Schedule of BenefitsSchedule of Benefits Fixed FeesFixed Fees

Coinsurance / CopaymentCoinsurance / Copayment DeductibleDeductible

Page 16: Basic Dental Insurance  Coding and Billing

DeductibleDeductible

Individual Deductible – each covered Individual Deductible – each covered family member must meet this family member must meet this amount in covered services before the amount in covered services before the insurance will start paying.insurance will start paying.

Family Deductible – total amount of Family Deductible – total amount of covered services to be paid by family covered services to be paid by family before the insurance will start paying.before the insurance will start paying.

Page 17: Basic Dental Insurance  Coding and Billing

Dependent: A child or spouse of the Dependent: A child or spouse of the subscriber.subscriber.

Eligibility: The process of determining Eligibility: The process of determining whether the patient is eligible for whether the patient is eligible for benefits.benefits.

Exclusions: Services not covered by Exclusions: Services not covered by the dental policy.the dental policy.

Page 18: Basic Dental Insurance  Coding and Billing

Maximum: The maximum dollar Maximum: The maximum dollar amount a benefits plan will pay toward amount a benefits plan will pay toward the cost of dental care over a specific the cost of dental care over a specific period of time (usually one calendar period of time (usually one calendar year)year)

Predetermination of Benefits: Also Predetermination of Benefits: Also known as a pretreatment estimate, is known as a pretreatment estimate, is an admin procedure that may require an admin procedure that may require the dentist to submit a treatment plan the dentist to submit a treatment plan to the insurance company before to the insurance company before treatment begins.treatment begins.

Page 19: Basic Dental Insurance  Coding and Billing

Dental CodingDental Coding

Developed by the American Dental Developed by the American Dental AssociationAssociation

CDT-1CDT-1 19911991

CDT-2CDT-2 19951995

CDT-3CDT-3 20002000

Page 20: Basic Dental Insurance  Coding and Billing

CDT CategoriesCDT Categories

I. DiagnosticI. Diagnostic

D0100 – D0999D0100 – D0999 II. PreventiveII. Preventive

D1000 – D1999D1000 – D1999 III. RestorativeIII. Restorative

D2000 – D2999D2000 – D2999 IV. EndodonticsIV. Endodontics

D3000 – D3999D3000 – D3999

Page 21: Basic Dental Insurance  Coding and Billing

V. PeriodonticsV. Periodontics

D4000 – D4999D4000 – D4999

VI.VI. Prosthodontics, RemovableProsthodontics, Removable

D5000 – D5899D5000 – D5899

VII.VII. Maxillofacial ProstheticsMaxillofacial Prosthetics

D5900 – D5999D5900 – D5999

VIII.VIII. Implant ServicesImplant Services

D6000 – D6199D6000 – D6199

Page 22: Basic Dental Insurance  Coding and Billing

IX. Prosthodontics, fixedIX. Prosthodontics, fixed D6200 – D6999D6200 – D6999

X. Oral SurgeryX. Oral Surgery D7000 – D7999D7000 – D7999

XI.XI. OrthodonticsOrthodontics D8000 – D8999D8000 – D8999

XII.XII. Adjunctive General ServicesAdjunctive General Services D9000 – D9999D9000 – D9999

Page 23: Basic Dental Insurance  Coding and Billing

CDT ExplanationsCDT Explanations

Each code consists of five digitsEach code consists of five digits The first digit is always a The first digit is always a DD which which

indicates that this is a dental procedureindicates that this is a dental procedure The 2The 2ndnd digit is a number that indicates digit is a number that indicates

the category of dental service (I – XII)the category of dental service (I – XII) The remaining numbers indicate The remaining numbers indicate

specific services within each groupspecific services within each group _ _ 999 indicates an “unspecified code”_ _ 999 indicates an “unspecified code”

Page 24: Basic Dental Insurance  Coding and Billing

Example: Code D2150Example: Code D2150

DD indicates that this is a indicates that this is a dentaldental procedureprocedure

22 indicates that this is a indicates that this is a restorativerestorative procedureprocedure

11 indicates that this is an indicates that this is an amalgamamalgam restorationrestoration

5 & 05 & 0 provide details about the provide details about the type of type of restorationrestoration