DA117PRACTICE

MANAGEMENTDental Insurance

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

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

Spouse – Husband or wife of the insured

Primary Insurance – Insurance of the employed

Secondary Insurance – Insurance of the spouse

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

Birthday Rule – A method for choosing whether the mother’s or father’s insurance will be primary insurance for the dependentBased on whose birthday comes first in the

yearExample – Mother born February 1960 Father born December 1955Mother’s insurance is billed first

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

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

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

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

PRE-TREATMENT ESTIMATE A treatment plan submitted on an

insurance form to insurance company for estimation of payment before dental services are completed.

ELECTRONIC CLAIMS Due to the increase in practice

management software, more offices are submitting claims electronically, through the insurance company website or a clearing houseA 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.

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.

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.

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.