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The NationalInsurance Guide
compiled by the SAO and approved by the AAO
401 North Lindbergh, St. Louis, MO 63141800.424.2841 or 314.993.1700
AAOmembers.org
Revised 2008
SAO OFFICE INSURANCE GUIDE
2
CONTENTS
PrefacePrefacePrefacePrefacePreface 3 3 3 3 3
ChaptChaptChaptChaptChapter 1: Hister 1: Hister 1: Hister 1: Hister 1: Histororororory of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefitsitsitsitsits 5 5 5 5 5
ChaptChaptChaptChaptChapter 2: Ter 2: Ter 2: Ter 2: Ter 2: Types of Dental Rypes of Dental Rypes of Dental Rypes of Dental Rypes of Dental Reimbureimbureimbureimbureimbursementsementsementsementsement 8 8 8 8 8
ChaptChaptChaptChaptChapter 3: Plan Designer 3: Plan Designer 3: Plan Designer 3: Plan Designer 3: Plan Design 1111144444
ChaptChaptChaptChaptChapter 4: Claims Aer 4: Claims Aer 4: Claims Aer 4: Claims Aer 4: Claims Administrationdministrationdministrationdministrationdministration 1919191919
ChaptChaptChaptChaptChapter 5: HIPer 5: HIPer 5: HIPer 5: HIPer 5: HIPAAAAAAAAAA 3333311111
ChaptChaptChaptChaptChapter 6: Orer 6: Orer 6: Orer 6: Orer 6: Orthodontic Codesthodontic Codesthodontic Codesthodontic Codesthodontic Codes 3333333333
ChaptChaptChaptChaptChapter 7er 7er 7er 7er 7: Of: Of: Of: Of: Offffffices of Sices of Sices of Sices of Sices of Stattattattattate Insurance Commissionere Insurance Commissionere Insurance Commissionere Insurance Commissionere Insurance Commissionersssss 3535353535
ChaptChaptChaptChaptChapter 8: Glossarer 8: Glossarer 8: Glossarer 8: Glossarer 8: Glossary of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefit Tit Tit Tit Tit Terminologyerminologyerminologyerminologyerminology 3636363636
ChaptChaptChaptChaptChapter 9: Fer 9: Fer 9: Fer 9: Fer 9: Frequently Askrequently Askrequently Askrequently Askrequently Asked Insurance Questionsed Insurance Questionsed Insurance Questionsed Insurance Questionsed Insurance Questions 4444477777
ADDENDUM: POLICIES, FADDENDUM: POLICIES, FADDENDUM: POLICIES, FADDENDUM: POLICIES, FADDENDUM: POLICIES, FORMS, AND LETTERS (separatORMS, AND LETTERS (separatORMS, AND LETTERS (separatORMS, AND LETTERS (separatORMS, AND LETTERS (separate PDF)e PDF)e PDF)e PDF)e PDF)
PrivPrivPrivPrivPrivacy Pacy Pacy Pacy Pacy Policy (4 itolicy (4 itolicy (4 itolicy (4 itolicy (4 items)ems)ems)ems)ems)
Filing InfFiling InfFiling InfFiling InfFiling Information (2 itormation (2 itormation (2 itormation (2 itormation (2 items)ems)ems)ems)ems)
InfInfInfInfInformation on Third Pormation on Third Pormation on Third Pormation on Third Pormation on Third Parararararties (1 itties (1 itties (1 itties (1 itties (1 item)em)em)em)em)
Sample PSample PSample PSample PSample Policy and Leolicy and Leolicy and Leolicy and Leolicy and Lettttttttttererererers (3 its (3 its (3 its (3 its (3 items)ems)ems)ems)ems)
What YWhat YWhat YWhat YWhat You Should Knoou Should Knoou Should Knoou Should Knoou Should Know About Yw About Yw About Yw About Yw About Your Orour Orour Orour Orour Orthodontic Insurance Benefthodontic Insurance Benefthodontic Insurance Benefthodontic Insurance Benefthodontic Insurance Benefit (11 itit (11 itit (11 itit (11 itit (11 items)ems)ems)ems)ems)
FleFleFleFleFlexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Accounts/DR (7 itccounts/DR (7 itccounts/DR (7 itccounts/DR (7 itccounts/DR (7 items)ems)ems)ems)ems)
Sample FSample FSample FSample FSample Forms torms torms torms torms to File Complaints (2 ito File Complaints (2 ito File Complaints (2 ito File Complaints (2 ito File Complaints (2 items)ems)ems)ems)ems)
RRRRReporeporeporeporeport on Insurance Rt on Insurance Rt on Insurance Rt on Insurance Rt on Insurance Refusal/Refusal/Refusal/Refusal/Refusal/Request fequest fequest fequest fequest for Aor Aor Aor Aor Additional Infdditional Infdditional Infdditional Infdditional Information (1 itormation (1 itormation (1 itormation (1 itormation (1 item)em)em)em)em)
SAO OFFICE INSURANCE GUIDE
3
PREFPREFPREFPREFPREFAAAAACECECECECE
The idea to produce an office manual
related to Third Party issues in orthodontics came
as a result of an SAO survey that revealed signifi-
cant office confusion and frustration with insur-
ance claims administration. Recurrent problems
common to all practices prompted the SAO
Executive Committee to authorize an Insurance
Committee whose charge was to assemble as
much helpful information on this subject as
possible and make it available in a usable form
for office staff.
The purpose of the manual is to educate,
instruct, troubleshoot, and heighten staff aware-
ness to the responsibilities of data processing
patient care in a Third Party environment. As it is
time dated to issues that are constantly changing,
updates and revisions must necessarily follow as
needed.
There is an inherent bias evident in
sections dealing with self-funded dental benefit
plans like Direct Reimbursement (DR), Direct
Assignment (DA), and Flexible Spending Accounts
(FSA). No apologies are necessary when years of
documented facts speak for themselves. Orga-
nized Dentistry, with good reason, has favored,
supported, and promoted this type of benefit for
many years. With Third Party intervention both as
a collector of funding and a payer of claims, one
must expect differences in outcome for value
received against dollar paid. The integrity of the
orthodontic profession depends on our under-
standing of and independence from Third Party
involvement and on our understanding of and
dependence on the ethical care of patients.
There is always opportunity for the
orthodontist’s and staff’s knowledge to be a
decisive factor in CEOs’, HR personnel, benefit
managers’, and patients’ decisions regarding
dental benefits. At the very least, the AAO and
ADA provide a wealth of resource information for
prospective purchasers of dental benefits to
analyze and evaluate. Nothing but ill will is
created when the doctor or staff degrades a
patient’s insurance. Their benefit package is a
significant ‘perk’ and must be respected regard-
less of its worth or effectiveness. Our job is to
help patients understand the benefits of orth-
odontic treatment, provide that service in a
professionally competent environment, and
facilitate Third Party transactions into the daily
practice of orthodontics.
Hopefully, this office guide will improve
the management of reimbursement and support
the profession’s effort to deliver superior service
to an informed public.
AAAAACKNOCKNOCKNOCKNOCKNOWLEDGEMENTWLEDGEMENTWLEDGEMENTWLEDGEMENTWLEDGEMENTSSSSS
Compiling the material for this manual
would not have been possible without the willing
permission granted by various contributors. We
have directly quoted, paraphrased, and copied
parts of their content as it appeared in various
forms. We did not attempt this challenge as any
type of original work nor did we seek to re-invent
any wheel that was already rolling. The idea was
to gather as much usable and useful information
related to Third Party intervention into the daily
practice of orthodontics between two covers —
hoping that it would educate office staff and
facilitate the challenging job of keeping a smooth
efficient operation with Third Party payers. Fortu-
nately, this has been less of a problem in orth-
odontics than in general dentistry and in no way
has dentistry been as adversely impacted as
medicine. To its great credit the AAO has always
been at the forefront in the dental benefit arena
and has kept alive and viable the alternatives to
Insurance control of the profession. The Council
on Health Care and Council on Insurance and
AAOPAC have been watchdogs who bark, growl,
and bite when necessary. One has to begin with
appreciation expressed to Dr. Kelly Carr who in
the 1960’s originated the concept of Direct
Reimbursement and never wavered in his convic-
tion that it was a better idea. In spite of all the
expected opposition, he convinced enough key
people in the AAO that DR is now a household
word in the benefits lexicon. We have borrowed
extensively from AAO and ADA brochures and
SAO OFFICE INSURANCE GUIDE
4
information. We have benefited from information
supplied by the Mr. John Stoner Organization in
St. Petersburg, FL who was a key developer of
Direct Assignment Plans and from Mr. Roger
Shultz who contributed much to the art of selling
Direct Reimbursement. Mr. Bob Macdonald of
the Florida Dental Association’s Dental Benefits
Department has been a tremendous help in
allowing us to use material in his Dental Office
Guide For Understanding Dental Benefits Pro-
grams, a course he presents to the University of
Florida College of Dentistry. We were already far
along with our work when we learned of its
existence, but it helped us reshape our ideas and
relate his presentation to orthodontists. Copy-
righted material from the ADA and other sources
required permission.
The AAO has been a driving force behind
the growth of and respect for self-funded dental
benefit plans across the nation.
The SAO is appreciative of the contribu-
tions of Dr. John Harrison in determining and
gathering the materials that should be included in
the original Guide and this Update. His counsel
was invaluable. Dr. Harrison has served honor-
ably as the SAO representative to the AAO Council
on Health Care for 8 years.
The SAO Board of Directors is to be
commended for encouraging the project because
of the need expressed in the membership survey.
Lastly, an expression of thanks goes to Dr. Steve
Tinsworth who was insistent that a manual
dealing with insurance issues be undertaken by
the SAO. We appreciate the willingness of every-
one involved to do whatever is necessary to help
people understand dental needs and the services
that provide that care.
We are appreciative of the offices who
assisted in reviewing and suggesting comments
to add to the content of this updated Guide. In
particular, we would like to thank the staffs of Dr.
Beth Faber and Dr. Michael Rogers.
DISCLAIMERDISCLAIMERDISCLAIMERDISCLAIMERDISCLAIMER
The SAO Insurance Office Guide is pre-
sented for informational purposes only. Legal
advice requires an attorney, and this guide should
not be relied on as legal advice or as a substitute
for a personal attorney. Laws, facts, and condi-
tions change as well as conclusions based on
them. The SAO Insurance Committee will update
information as needed to keep our members
current with practice implications as related to
orthodontic benefits in the market place. The
guide is not intended to offer or challenge any
philosophy of practice related to Third Party
payers. We have attempted to be responsibly
objective with descriptions and definitions. The
content of this guide has come from many reli-
able sources and we have liberally used the
statements and ideas they expressed.
SAO OFFICE INSURANCE GUIDE
5
ChaptChaptChaptChaptChapter 1: er 1: er 1: er 1: er 1: History of Dental Benefits
Insurance can generally be defined as a group of people
pooling resources to reimburse one of its members who suffers a
financially catastrophic and unpredictable loss. “Dental Insur-
ance”, then, is somewhat of a misnomer in that its losses are
extremely predictable and are not generally catastrophic. Never-
theless, “dental insurance” developed, and it is useful to under-
stand why.
The early 1960s generally marks the advent of dental
insurance. Unrelated economic, political, and dental phenomena
occurred at roughly the same time which acted as a stimulus to
prompt the development of this insurance. It is important to
examine each of these separately to understand their impact.
The first phenomenon involved the federal government.
There were those in Congress who felt that access to health care
was limited and that, to some extent, this lack of access was
related to the number of available practitioners and to the costs
involved. The government’s solution to this problem was to use the
economic “supply and demand” principle. It was felt that by
stimulating an increased supply of practitioners, the lack of avail-
ability would be met on the one hand, and increased competition
would meet the problem of cost on the other. Therefore, programs
were developed to stimulate more graduates from our health care
professional schools.
During this period there was a dramatic increase in the
number of dental school graduates, so much so that there became
known the term “busyness problem”. Fees were not reduced but
stabilized. Dental incomes did not keep pace with inflation for
approximately 15-years. The law of supply and demand failed in
this instance since the percentage of the public receiving dental
treatment did not increase.
The second phenomenon also occurred in the early 1960s.
The labor force in this country began demanding more in the
way of fringe benefits. The insurance industry was quick to recog-
nize this opportunity and designed a dental insurance system
without any significant guidance or consultation with the dental
profession. These dental plans were designed using the industry’s
medical insurance experience as a model.
It was clear to some at that time that the economics of
dentistry and medicine were very different and that the medical
model would not suffice. It was also known that providing a dental
benefit was extremely predictable in terms of cost. However,
“dental insurance” promised to solve the “busyness” problem
dentists were facing, so not much opposition was raised regarding
its development.
The third phenomenon began to occur in the 1970s and
extended into the 1980s. Overall costs in health care began to rise
disproportionately—greater than the general inflation rate or cost of
living index. The insurance industry felt great pressure from their
AAO STATEMENT
OF POSITION
In consideration of the role oforthodontics in health care forthe American people, themembers of the AmericanAssociation of Orthodontistsbelieve that:
• Orthodontics is anintegral part of oralhealth and that oralhealth is an importanthealth care service.Orthodontic carecontributes to thepatient’s overallhealth, quality of lifeand self-esteem.
• All American patientsshould continue tohave the freedom toselect qualified dentalhealth care providersof their choice. Thefreedom of patients toselect their dentalhealth care provider is
What are Dental BenefWhat are Dental BenefWhat are Dental BenefWhat are Dental BenefWhat are Dental Benefits?its?its?its?its?
(1) The amount payable by a
third party toward the cost of
various covered dental services
(2) The dental service or proce-
dure covered by the plan.
Source: AAO Policies on Dental
Benefits Programs
Who Are Third PWho Are Third PWho Are Third PWho Are Third PWho Are Third Parararararties?ties?ties?ties?ties?
•Employers/ Third Party
Administrators (TPA)
•Insurance Company
•Dental Service Corporation
•Prepaid Dental Plan
•Independent Practice
Association
SAO OFFICE INSURANCE GUIDE
6
clients to contain costs. The overabundance of dentists and the
“busyness” problem made dentistry a prime candidate for man-
aged care devices even though dentistry did not account for very
much in the rise in health care costs.
Commercial insurance carriers turned the success they
were having controlling medical costs through development of
Health Maintenance Organizations (HMOsHMOsHMOsHMOsHMOs) toward dentistry. The
basic indemnity plans were ratcheted down into several hybrid
alternatives. Dental Health Maintenance Organizations (DHMOsDHMOsDHMOsDHMOsDHMOs)
began to appear as “prepaid” dental plans. It features a
“gatekeeper” function where everyone is assigned a general practi-
tioner who determines if referrals to dental specialists are neces-
sary.
The DHMO is an exclusive provider plan, which provides
care to prepaid enrollees who receive care only from contracted
providers. These plans are popular because of their low cost
monthly premiums and non-employer involvement. They are
known as “capitation” plans because the provider dentists receive
a monthly payment per “head” (patient) to care for the patient
regardless of whether the patient was seen for any dental services
that month. Usually that amount is 60% of the monthly premium.
Another option presented was Preferred Provider Organiza-
tions (PPOsPPOsPPOsPPOsPPOs). The “capitation” and “gatekeeper” function is re-
moved; patients can select from a list of providers and can receive
care out of network although out-of-pocket expenses for the patient
will be higher than the plan allows for reimbursement. PPOs have
higher monthly premiums and cover more services. Large insur-
ance corporations offer a variety of dental plans (indemnity, PPO,
and DHMO) but inherently oppose self-funded plans such as Direct
Reimbursement (DRDRDRDRDR) because they are competitive alternatives to
“traditional” insurance products.
The coalescence of these three phenomena at roughly the
same time changed the face of the dental profession dramatically.
No longer can the individual dentist make all decisions regarding
his patients and practice independently. The Third Party now plays
a prominent role in that process.
To counter the intrusion of third parties, organized dentistry
became a Third Party in California: California Dental Services gave
birth to Delta DentalDelta DentalDelta DentalDelta DentalDelta Dental, a Dental Service Organization run by dentists
which became a giant provider not unlike the major players in the
dental prepayment marketplace.
Concerns with Delta prompted interest in independent
practice associations (IPIPIPIPIPAsAsAsAsAs). Dental IPAs allowed dentists to own a
corporation that controlled the quality and type of care delivered
under a contract to employer groups. The dentists were at risk for
the success of the venture, not a Third Party. IPAs can design a
variety of plans from fee-for-service to capitation. The dentists
were the stockholders and the providers and thus have the opportu-
nity to be competitive and profitable.
The other alternative to managed care developed by orga-
nized dentistry to return to the basics of dental care delivery are the
employer self-funded plans of Direct Reimbursement (DRDRDRDRDR) and
a fundamental Ameri-can right. The personalrelationship betweendentist and patient isthe foundation ofeffective treatment andquality health care.
• The advantages of fee-for-service dentalhealth care and ben-efits systems should bemaintained because oftheir high quality andcost effectiveness. Allemployers, govern-mental and private,should be encouragedto provide dental andorthodontic coverageas a benefit of employ-ment. Direct reim-bursement is thepreferred benefit plandesign due to itssimplicity of adminis-tration and cost effec-tiveness.
• All dental health plans,including publiclyfunded plans, shouldinclude patient protec-tion principles includ-ing, but not limited to:freedom of choice ofprovider, third partyaccountability, elimina-tion of gag rules, andself-referred access tospecialists.
• Benefits for orthodon-tic treatment should beincluded in privately-funded dental healthcare plans, but mustbe designed to pro-mote quality care.Both publicly andprivately-funded plansshould provide orth-odontic benefits toachieve correction ofcongenital anomaliessuch as those associ-ated with cleft lip/palate or traumaticinjuries to the teethand/or orofacial struc-
SAO OFFICE INSURANCE GUIDE
7
Direct Assignment (DDDDDAAAAA). These are truly fee-for-service, freedom of
choice of dentists, cost-based not procedure-based options that
give back control and responsibility for dental health to the patient,
not a Third Party.
Many state dental associations have taken a pro-active
role in promoting self-funded dental benefit plans by directing
informational advertising to target markets and cooperating with
insurance agents capable of initiating or converting dental plans to
a self-funded model. This partnership was the stimulus needed to
make a product like Direct Reimbursement viable and sellable to
skeptic of human resource personnel. They inherently trusted the
agents’ role of providing information and options more than that of
dentists. Naturally they were suspicious of dental self-interest and
self-righteous indignation over insurance cost cutting; plus dentists
were only offering a concept, not the nuts and bolts needed to put
a plan in place. Without a knowledgeable commissioned sales
force subsidized by dentists, self-funded plans would have re-
mained stagnate. Phenomenal growth occurred because of this
cooperative effort. Much credit must be given to the AAO for its
commitment and dedication to counter balance the cost saving
limited service of Managed Care with dollar enhancing, free choice,
responsible dentist / patient relationship dental care. The AAO
because of their 30+ years experience has provided critical assis-
tance to insurance agents unfamiliar with cost-analysis of self-
funded plans and also to state dental associations. The AAO
promoted its own brand of Direct Reimbursement nationwide until
2004, when the DR baton was passed on to the ADA for implemen-
tation and marketing. Like any alliance, a partnership is only as
good as it continues to meet the self-interest of all parties, noble
causes notwithstanding. Working with “beasts” who can harm you
and devour you takes skill, diligence, and resolve. We have seen
what happened so quickly to the Medical Profession. Dentistry, on
the other hand, has in place a better “mousetrap” with a promising
future.
tures. Publicly-fundedplans should provideorthodontic benefits forindigent and “specialneeds” individuals,regardless of age, ifthey do not receivedental/orthodonticbenefits from theiremployer.
• The tax deductibility ofdental health carebenefits, includingorthodontic care,should be retained.Self-employed indi-viduals should be ableto deduct the full costof dental health carebenefits for themselvesand their families.
HISTORY OF DENTAL BENEFITS
1950s/1960s Dental Service Corporation (CDS)
1970s Delta, Blues, Indemnity Plans, Direct Reimbursement, Closed
Panels
1980s Managed Care Plans (PPOs), DHMOs, Prepaid Plans), IPAs
1990s Direct Assignment, Dental Referral Plans, Point of Service
2000s Consumer-Directed Benefit Plans (HRA, MSA, FSA)
SAO OFFICE INSURANCE GUIDE
8
ChaptChaptChaptChaptChapter 2: er 2: er 2: er 2: er 2: Types of Dental Reimbursement
There are a variety of dental payment mechanisms offered
in the market place. They can generally be categorized as fee-for-
service, indemnity, discount managed care, self-funded, payroll pre-
tax funded, and government-funded plans. Each has its own spe-
cific characteristics. The golden rule applies: whoever has the gold
makes the rules.
Fee-for-service means the traditional transaction between two
parties, the patient and the dentist. The dentist performs a service
and is reimbursed according to the payment mechanism agreed to
by the patient and dentist. The patient is at risk for the entire fee.
There is no Third Party involvement. Some insurance plans claim
to be fee-for-service but this is a false, erroneous statement be-
cause it contradicts the true definition.
Indemnity or traditional compensation dental insurance
plans are freedom-of-choice plans offered by state regulated
commercial insurance carriers. They compensate a percentage or a
fixed amount of the total fee. Orthodontic coverage is designated
as a maximum lifetime amount as a co-payment to offset the
entire fee of the insured. Typical amounts are $1000 and $1500,
but the reality is that the plan will only reimburse at one-half the
fee up to the maximum. This is confusing to patients who expect to
always receive their maximum amount. Only if the fee is twice or
more than twice the maximum could the patient expect full indem-
nification. For example, if the orthodontic fee is $2500 on a co-pay
basis, the patient will incur $1250 (50%) expense out-of-pocket. If
the benefit is $1500, the patient will receive only $1250 of the
$1500 stated benefit.
A claim form must be accurately and exactly filed after
diagnostic records have been obtained and the case treatment
planned by the orthodontist. The reimbursement can either be
assigned to the orthodontist or to the patient. If the orthodontist
accepts the fee from the insurance company, this is called assign-
ment of benefit. Some offices never accept assignment of benefit
as stated in their office policy to all patients and other offices
alwalwalwalwalwaaaaays ys ys ys ys accept assignment. Practice philosophy determines how
claims will be handled.
Insurance companies vary in how and when they will
reimburse, but they are legally at risk for the designated amount as
long as they are assured the patient completed treatment. Con-
tinuation of treatment forms are routinely sent to verify the fact.
They are a nuisance factor of Third Party payment and can be
avoided by office policies known to the insured before initiating
treatment (sample letter, PDF supplement). The insured gives
proof of continuing treatment by their receipt of payment or copy of
their canceled check to the orthodontist.
Direct Reimbursement (DR) is a self-funded/ fee-for-service /
INDEMNITINDEMNITINDEMNITINDEMNITINDEMNITY PLANY PLANY PLANY PLANY PLAN
•Issued by third party payer,
insurance carrier, dental service
corporation (DELTA or BC/BS)
who accepts risk
•Guaranteed payment of claims
in exchange for monthly
premium
•Freedom of Choice of Dentist
•Assignment of benefits/
balanced billing
•Reimbursement by UCR or
TOA
DENTDENTDENTDENTDENTAL PAL PAL PAL PAL PAAAAAYMENT MODELSYMENT MODELSYMENT MODELSYMENT MODELSYMENT MODELS
NON-NETWORK:NON-NETWORK:NON-NETWORK:NON-NETWORK:NON-NETWORK:
•Fee-for-Service (FFS)
•Self-Funded Plans
(DR/DA=$ based)
•Self-insured
(100-80-50=Procedure Based)
•Indemnity Plan
(Traditional Insurance)
•Consumer Directed
(HRA, FSA, MSA)
NETWORK:NETWORK:NETWORK:NETWORK:NETWORK:
•Preferred Provider
Organization (PPO)
•Dental HMO/ Point of Service/
EPO/IPA
•Prepaid Dental Plan
•Dental Referral Plan
•Consumer Directed
(HRA, FSA, MSA)
•Closed-Panel (Salaried)
SAO OFFICE INSURANCE GUIDE
9
freedom-of-choice plan that reimburses patients according to
dollars spent on dental care, not type of treatment received. In-
stead of paying monthly insurance premiums, employers pay a
percentage of actual fees-for-service. The design of the DR DR DR DR DR plan is
selected by the employer to fit the company’s budget and will vary
among companies. Commonly, a two- or three-tiered structure will
be encountered whereby 100% of the first $200 of dental expense
will be reimbursed, 50-80% of the next tier, and or 50% of the third
tier up to the maximum. Totals may be individual or family maxi-
mums. The financial obligation is the patient’s responsibility since
there is no insurance company involved; the employer is the Third
Party. An ADA claim form or receipt of payment is required by the
employer to reimburse the employee. Pure DRDRDRDRDR is very popular with
informed human resource personnel because their employees may
choose their own dentist and are free to elect any dental procedure
without restriction.
The downside of DR/DA is the lag time between the time the
patient paid the provider and the time the employer processes
payment to the employee.
Every dollar spent goes toward dentistry, thus avoiding the
25-35% retention associated with fully insured products.
Variations of DR DR DR DR DR were developed to facilitate introducing
this novel plan into the market place. Third Party Administrators
(TPAs) have been enlisted by organized dentistry to promote,
market, and manage this unique approach. Remuneration for their
effort and success is a commission typically 10-15% of premiums
paid, still well below conventional insured products.
A more flexible direct reimbursement plan, Direct Assign-
ment (DA), was developed by organized dentistry, adding an
assignment of benefits feature so the patient does not have the up-
front cost due at the time of treatment. Stop-loss insurance is
available to protect the employer from over-utilization of the plan
(adverse selection) when the plan is initially brought into service.
Some DA plans include another feature, “co-pay”: an office
visit charge, which is collected by the TPA and withheld from the
check back to the dentist for the administrative service charge. The
dentist/orthodontist has also agreed to subsidize the plan (dis-
count the fee) $5 for every billable service; therefore, for orthodon-
tists, quarterly or semi-annual billing prevents an unnecessary $5/
month service charge or withhold from the plan administrator. This
co-payment shared by patient and dentist pays the TPA for the cost
of plan administration and lowers the premium cost, thus making
it more competitive in the marketplace. Patients not utilizing the
plan are not subsidizing those in the group that are and the dentist
/orthodontist is getting a patient they would not have gotten except
for this type of plan. Typically, stop loss is not necessary in spite of
the fear of over-utilization. As long as the plan is funded, experi-
ence has shown that DR/DA plans do not need stop-loss as an
added expense. The dentists will still receive 98% of the fee
similar to credit card financing.
Dental SerDental SerDental SerDental SerDental Service Corvice Corvice Corvice Corvice Corporation (Delta) and Prefporation (Delta) and Prefporation (Delta) and Prefporation (Delta) and Prefporation (Delta) and Preferred Prerred Prerred Prerred Prerred Prooooovider Organi-vider Organi-vider Organi-vider Organi-vider Organi-
DIRECTDIRECTDIRECTDIRECTDIRECT• REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT
•Freedom of choice of dentist
•Fee-for-service
•Self-funded (ERISA)
•Dollar Tiered Benefits
•Simple administration
•No predetermination or prior
authorization
•Few restrictions, limitations,
exclusions
DIRECT ASSIGNMENTDIRECT ASSIGNMENTDIRECT ASSIGNMENTDIRECT ASSIGNMENTDIRECT ASSIGNMENT
•Freedom of choice of dentist
•Self-funded (ERISA)/stop-loss
insurance
•Fee-for-service/balanced
billing
•Option: assignment of benefits
•Dollar Tiered Benefits
•Simple administration
•No predetermination or prior
authorization
•Few restrictions, limitations,
exclusions
SAO OFFICE INSURANCE GUIDE
10
zations (PPO’s)zations (PPO’s)zations (PPO’s)zations (PPO’s)zations (PPO’s) are large discount managed care organizations
that reimburse by a table of maximum allowances or fee schedule.
Delta offers a cafeteria of plan models to compete with all forms of
plans. An orthodontist agrees to be a Delta or PPO network pro-
vider by agreeing to Delta’s or the PPO’s fee schedule which could
differ considerably from his regular fee-for-service. There is no
allowance for any additional charges (“balanced billing”) beyond
the schedule for a network provider. The fee schedule will vary
from region to region because of variations in demand for services
and utilization of the plan. Cost containment through discounted
fees and other limitations are supposedly offset by the argument of
large patient enrollment to fill up empty chairs and increased
business.
Patients should not believe the notion that a “preferred
provider” is somehow specially selected because of their out-
standing ability or superiority over a “non-preferred” provider. This
is an insurance marketing term to make the product seem attrac-
tive to the public. Their preferred provider is subject to annual
review and can be “deselected” without due process if his stan-
dards of treatment vary outside the parameters set by the organi-
zation.
Some PPOs allow the option for a patient to go out of
network (Delta); others may impose some monetary penalty. Billing
the patient for the balance due to the difference between the fee
schedule and the orthodontist’s customary fee may or may not be
allowable (balanced billing).
Dental Health MaintDental Health MaintDental Health MaintDental Health MaintDental Health Maintenance Organizationsenance Organizationsenance Organizationsenance Organizationsenance Organizations (DHMOs)DHMOs)DHMOs)DHMOs)DHMOs) are managed
care discount plans that base their reimbursement on “prepaid”
“capitation” (dollars per month per head). These limited plans are
not encountered in orthodontics. The dentist receives a fixed
payment each month for providing no charge services outlined in
the plan regardless of whether the patient is seen or not seen. Non-
covered procedures preformed by the dentist are highly discounted
and requires payment by the patient. Obviously it is to the dentist’s
advantage to perform as little treatment as possible or to diagnose
only major procedures. Ethical and professional concerns are
realities in this type of arrangement. They are the least expensive
dental plans.
Prepaid LimitPrepaid LimitPrepaid LimitPrepaid LimitPrepaid Limited Health Sered Health Sered Health Sered Health Sered Health Service Organization (PLHSO) vice Organization (PLHSO) vice Organization (PLHSO) vice Organization (PLHSO) vice Organization (PLHSO) is another
type of managed care program sold primarily to groups, but also to
individuals on voluntary enrollment. Participating specialists,
orthodontists, are placed into the network by agreement to provide
services for all procedures and services at a 25% discount. If the
plan requires pre-authorization prior to referral, the specialist must
agree to the subscriber’s (patient’s) discounted schedule of ben-
efits. American Dental Plan American Dental Plan American Dental Plan American Dental Plan American Dental Plan andandandandand Or Or Or Or Oral Health Seral Health Seral Health Seral Health Seral Health Services vices vices vices vices (now known
as ComComComComComp Dentp Dentp Dentp Dentp Dent) are examples. Since there is no verification of the
authenticity of the discount unless non-plan fees are posted, this is
a dubious honor system at best.
A PLHSO is a characteristic capitation model with a
PREFERRED PRPREFERRED PRPREFERRED PRPREFERRED PRPREFERRED PROOOOOVIDERVIDERVIDERVIDERVIDER
ORORORORORGGGGGANIZAANIZAANIZAANIZAANIZATION (PPO)TION (PPO)TION (PPO)TION (PPO)TION (PPO)
•Dentists contract with plan to
join network
•Discount fee schedule
(15%-30%)
•Dentists at risk
•Enrollees may select dentist in
network or pay a higher fee for
non-participating dentists
•Plan reimbursement based on
fee schedule
DENTDENTDENTDENTDENTAL HMO/AL HMO/AL HMO/AL HMO/AL HMO/
PREPPREPPREPPREPPREPAID PLANAID PLANAID PLANAID PLANAID PLAN
•Dentists contract to join
network
•Insureds select from network
dentists
•Network dentist receives
monthly capitation fee per
covered enrollee
•Dentist at risk
•Discounted fee schedule of
40%-50%
DHMO/POINT OF SERDHMO/POINT OF SERDHMO/POINT OF SERDHMO/POINT OF SERDHMO/POINT OF SERVICEVICEVICEVICEVICE
•Visit designated primary care
network dentist (Gatekeeper)
•Verify dental services needed
•Select any dentist and have
dental treatment
•Pay dentists FFS and plan
reimburses up to limits
SAO OFFICE INSURANCE GUIDE
11
monthly fee (premium) that covers preventative and diagnostic
services at no charge. The member dentist (not orthodontist) is
paid 60% of the monthly premium to provide all the no charge
services provided by the plan. Forty percent is retained by the
PLHSO. Other basic and major dental procedures are scheduled at
highly discounted fees and require payment by the subscriber. The
subscriber “believes” (has been informed) that they will encounter
25% higher specialists’ fees if they seek treatment out of network.
This is not necessarily true, nor is it usually true since there is no
valid comparison unless the documented fee estimate is 25% less
than an out-of-network specialist documented fee estimate. There
is no treatment reimbursement from the plan, except for the
capitated premium; nor is balanced billing in a prepaid capitation
plan allowed. Incentive commissions are very high (15%) for
brokers selling these “Certificates of Benefits” to subscribers
because the PLHSO takes no risk, and they have such a large share
of the market. These plans are aggressively marketed to the public
and are popular with large employers because there is no contribu-
tion or hassle on their part, and it is the simplest way to offer
“perceived” access to dental care to a public that is always ready
for a bargain. Issues could be raised with ethical standards where
quality and treatment could be compromised with “least expensive
alternatives”.
Medicaid Medicaid Medicaid Medicaid Medicaid is the major government funded dental program. Dentists
who participate must complete an application form and have an
approved provider number from the state. Reimbursement is
limited and fixed, and there can be no balanced billing for the usual
fee charged by the orthodontist. Many orthodontists who partici-
pate do so as an act of charity or benevolence.
CHAMPUSCHAMPUSCHAMPUSCHAMPUSCHAMPUS is the military dependent program that contracts with
dentists to provide services to eligible patients.
VVVVVocational Rocational Rocational Rocational Rocational Rehabilitation and Wehabilitation and Wehabilitation and Wehabilitation and Wehabilitation and Worororororkkkkkererererers’ Compensations’ Compensations’ Compensations’ Compensations’ Compensation are other
governmental programs that provide dental care to the public.
Independent Practice Associations (IPIndependent Practice Associations (IPIndependent Practice Associations (IPIndependent Practice Associations (IPIndependent Practice Associations (IPAs) As) As) As) As) are exclusive provider
corporate networks consisting of dentist stockholders who treat the
insured under contract. They can operate under various plan
designs and can insert whatever restrictions are needed to be
competitive in their bidding process.
FleFleFleFleFlexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Accounts (FSccounts (FSccounts (FSccounts (FSccounts (FSAs)As)As)As)As) are a win-win situation for
everyone: reduced payroll taxes for the employer, a significant
health care tax deduction for the employee, and prompt payment
to the dentist. These plans allow for employee payroll contributions
for a menu of health care benefit options with pre-tax dollars. Both
income tax and Social Security taxes are avoided. An individual in a
30% income tax bracket, coupled with Social Security and Medi-
care at 7.65%, realizes a 37.65% reduction on his orthodontic fee
INDEPENDENT PRAINDEPENDENT PRAINDEPENDENT PRAINDEPENDENT PRAINDEPENDENT PRACTICECTICECTICECTICECTICE
ASSOCIAASSOCIAASSOCIAASSOCIAASSOCIATIONTIONTIONTIONTION
•Exclusive Provider Network
•Capitation or Discounted Fees
•Restrictions, Limitations and
Exclusions
•More Competitive than DHMO/
Prepaid Plans in the market
MEDICMEDICMEDICMEDICMEDICAL SAL SAL SAL SAL SAAAAAVINGSVINGSVINGSVINGSVINGS
AAAAACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTS (MSS (MSS (MSS (MSS (MSA)A)A)A)A)
•Employer Funded
•Limited to self-employed and
small employers (50 or less
employees)
•Requires high deductible
insurance policy ($1,600 to
$2,400) with 65% deductible
•Covers payment for health
care services
•Like IRA (15% penalty for early
withdrawal) before 65 years old
HEALHEALHEALHEALHEALTH STH STH STH STH SAAAAAVINGSVINGSVINGSVINGSVINGS
AAAAACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTS (HSS (HSS (HSS (HSS (HSA)A)A)A)A)
•Employer/Employee Funded
•Non-taxable
•Requires high deductible
health insurance plan
•Covers payment for health
care services
•Owned by the individual like
an IRA
SAO OFFICE INSURANCE GUIDE
12
in real money.
Flex plans operate on a 12-month plan, and once a deter-
mined amount is elected, it is irrevocable. Any money left in the
account at year’s end is forfeited. This “use it or lose it” feature is
not a factor with predictable dental expenses which are ideal for
this mechanism. There is an employer determined maximum,
usually $1000-$2500 each year. Dental practitioners should
encourage their employed patients to take advantage of this
benefit.
Employers, however, are not always eager to implement this
plan and may need some convincing from their employees. The
pre-tax savings to patients are considerable.
Medical SaMedical SaMedical SaMedical SaMedical Savings Avings Avings Avings Avings Accounts (MSccounts (MSccounts (MSccounts (MSccounts (MSAs)As)As)As)As)
Regardless of who manages resources for health care (insurance
company, employer, or patient), the incentive is to spend the least
amount. The patient should have the right to decide how much to
spend and for what. This insures that the interests of the patient
remain paramount. Health care managed by an insurance com-
pany or government has two strikes against it: high overhead costs
and profit-driven health care decisions. Health care insurance adds
to the total cost of health care and often obstructs the rendering of
optimal health care by denial of coverage on the basis of cost
control. Furthermore, insurance never provides for full reimburse-
ment. First dollar costs are prohibitively expensive for any insur-
ance. MSAs provide the means for funding employee health care
benefits with regular pre-tax dollars that accumulate and grow in
invested funds. The annual “use it or lose it” feature of Flex Plans
does not allow for any roll-over into the next fiscal year, nor does it
allow the participants to retain control of the unused balance in
their account. Patients need to accumulate assets to pay for
routine care (first dollar costs) and insurance premiums (last dollar
costs).
MSAs are completely portable and are the property of the
individual regardless of job changes or loss of health insurance.
Many Americans are uninsured short-term (less than six months)
because they are between jobs. Unfortunately, current MSA law
discourages offering these plans by limiting the total number of
plans allowable and limits them to small businesses of less than
50 employees.
MSAs are politically opposed by members in Congress who
favor national health care. Organized Dentistry and Organized
Medicine need to unite and actively seek to eliminate the restric-
tions and limited availability of MSAs.
Major benefits to all Americans are:
1. Minimizing the role of insurance
2. Enabling patients to participate more fully in decisions about
their health care
3. Giving patients a better opportunity to choose the best quality
of care
4. Reducing over utilization
5. Encouraging prevention and early intervention
MEDICMEDICMEDICMEDICMEDICAL SAL SAL SAL SAL SAAAAAVINGSVINGSVINGSVINGSVINGS
AAAAACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTS (MSS (MSS (MSS (MSS (MSA)A)A)A)A)
•Employer Funded
•Limited to self-employed and
small employers (50 or less
employees)
•Requires high deductible
insurance policy ($1,600 to
$2,400) with 65% deductible
•Covers payment for health
care services
•Like IRA (15% penalty for early
withdrawal) before 65 years old
CAUTION
A strategy still used by insur-
ance companies to reduce
reimbursement is called “Blind
PPOs” or “Silent PPOs”. If the
orthodontist ever signed a
contract that gave a deep
discount, your name can be
passed to other PPOs (Silent).
You may be on a “resell” list that
tells the insurance company
what discount you have agreed
to give, and the insurance
company will process your bill
as a provider for the cheapest
PPO possible, thus reducing
your reimbursement and giving
extra profit to the insurance
company at your expense.
Unless you know what fee to
expect, you may not know this is
happening to you. Refuse to join
a PPO that will allow your name
to be released, and be sure you
know what your full payment
should be.
SAO OFFICE INSURANCE GUIDE
13
6. Relieving health providers of dealing with insurance matters
7. Reducing fraud
8. Decreasing the cost of health care
9. Providing a strong alternative to national health care
10. Allowing participants to retain control of the unused balance in
their accounts
Attached is an addendum of the IRS Publication 969 which
describes HSAs, MSAs, FSAs, and HRAs regulations, or you may
download a copy at www.irs.gov/pub/irs-pdf/p969.pdf. The follow-
ing websites may be useful: www.heritage.org, www.ncpa.org,
www.galen.org
Health RHealth RHealth RHealth RHealth Reimbureimbureimbureimbureimbursement Arrangements (HRAs).sement Arrangements (HRAs).sement Arrangements (HRAs).sement Arrangements (HRAs).sement Arrangements (HRAs). These are ac-
counts to reimburse medical expenses under IRS Section 213(d)
provided and financed by employer contributions for their employ-
ees. There is no allowable contribution by the employee. Unused
credits may be carried over to subsequent years and may be
coordinated with flexible spending accounts (FSAs). The potential
for savings with tax exempt medical expenses and growth from
unspent funds rolling over from year-to-year plus the ability to
select any doctor and consumers’ incentive to ration their own
health care is a big deal and could signal the end of “stuffing
employees into unpopular HMOs”. Over time, participants could
build up sizable accounts with which to meet future health care
expenses. Already prototype plans have seen huge drops in health
care costs. Aetna and Humana are selling such policies to major
U.S. corporations.
CAUTION
Usual, customary and reasonable fees (UCR) per zip code are quoted by insurance compa-
nies as the basis for their fee structure, but this has often been proven to be an erroneous
statement. Patients need to be informed that UCR is each insurance company’s computer
derived payment for each procedure that will still be profitable to the company in the trans-
action. It has no relationship to fees charged by dentists. There is high variability in the
determination of UCR and updating fees. Often a poor correlation exists with the reality of
fees in any given geographical area. A dentist’s/orthodontist’s fee may be higher or lower
than an insurance company’s UCR for many valid reasons and patients must be educated
beforehand that insurance companies determine their own fees for procedures. Problems
arise when the insured is informed that their dentist’s fee is much higher than their UCR
reimbursement, thus putting the dentist in an adversarial position.
FFFFFee Financing,ee Financing,ee Financing,ee Financing,ee Financing, basically a loan granted to a qualified patient where by the entire fee less the com-
mission (7.5%), is paid to the orthodontist upfront, and the patient pays the lending company over
time with 10-18% interest charges. Orthodontic Fee Plan (OFP) is such an entity. The main advan-
tage is that it helps the traditional fee-for-service orthodontist compete with the no down payment
(no initial fee) advertised by some corporate orthodontic entities. Some orthodontists believe that a
high initial fee discourages patient acceptance since it has been reported that 77% of American
consumers would bounce a $500 check. Another advantage is that it takes any collection problem
out of the office. There is a strong buying mentality in America that is accustomed to monthly pay-
ments.
HINT
HRAs and FSAs can be coordi-
nated so that participants can
be covered by both
HEALHEALHEALHEALHEALTH REIMBURSEMENTTH REIMBURSEMENTTH REIMBURSEMENTTH REIMBURSEMENTTH REIMBURSEMENT
ARRANGEMENT (HRA)ARRANGEMENT (HRA)ARRANGEMENT (HRA)ARRANGEMENT (HRA)ARRANGEMENT (HRA)
•Employer Funded (funding
pool)
•Non-taxable employee benefit
•Pay health care premiums, co-
insurance payments, cost of
health care services
•Limited to qualified health
care services
•Can be used as a defined
contribution retirement benefit
plan to pay health care costs
and Medicare supplements
SAO OFFICE INSURANCE GUIDE
14
ChaptChaptChaptChaptChapter 3: er 3: er 3: er 3: er 3: Plan Design
Lack of insurance is the top reason people give for not
visiting the dentist, yet not all dental plans are a good buy. Premi-
ums paid by the patient plus co-payment paid by the patient over a
period of time against the actual claims paid by insurance compa-
nies often exceed the actual dollar cost of the dentistry supplied.
As an example, $1000 could be paid out by the insured in one year
when the total dental bill was $800. Insurance works because of
under-utilization. Approximately 50% of employees with dental
insurance will not use it in any given year; therefore, the reservoir of
money accumulates for the insurance company. The ADA states
that the average annual dental expense per person in the USA is
very low. Obviously, orthodontic, oral surgery, periodontal, endo-
dontic, and cosmetic expenses are much higher than the average
for general dentistry. Critics of dental insurance believe we should
only insure against a risk we do not anticipate or against a cata-
strophic loss that we could not handle financially.
Routine basic dental expenses over time are very predict-
able, and there are alternatives to insurance for higher dental
expenses such as flexible spending accounts and medical savings
accounts (where legal). They allow tax-free dollars to be deducted
from payroll, thus providing a significant discount at government
expense, not the dentist’s expense. In one sense they become an
interest free loan since the entire allocation set aside for dental
care can be drawn the first month the plan is in effect. By fully
utilizing all the features of a Flex Plan, it is actually possible to
achieve a $5,347.50 tax savings over 3 years for a prospective
patient’s parents in a 28% tax bracket. That would more than pay
for a $4,000 orthodontic fee without any insurance benefit.* (John
Stoner TPA) Surprisingly, this is not a well-known fact, nor are flex
plans as popular as they should be.
Insurance products add to the cost of dentistry because of
the profit that must be made by the insurance company, adminis-
tration /management costs, incentives and commissions to bro-
kers, and marketing/promotions costs. The upside is that dental
fees are higher because of insurance than in pre-insurance days.
The downside is that insured orthodontic benefits in 1971 were
$1,000 and many are still $1,000 in 2008 in spite of increasing
premiums and increased costs delivering orthodontic services.
Plan design makes quite a difference to both patient and
dentists alike, and decisions are necessary regarding the positives
and negatives of how each office will respond to various types. Not
all dental plans include orthodontic treatment, or the terms may be
different, and some plans have an age limit of 18. Most conven-
tional orthodontic insurance is a fixed lifetime maximum allow-
ance— typically $1,000-$1,500 paid at 50% of the charge up to the
maximum or whichever is less. UCR is meaningless because the
amount of the fee has no relation to the fixed benefit.
Managed Care Plans work from a fixed fee schedule at a
DENTDENTDENTDENTDENTAL BENEFITAL BENEFITAL BENEFITAL BENEFITAL BENEFITS MARKETS MARKETS MARKETS MARKETS MARKET
Presented at National Dental
Benefit Conference sponsored by
the ADA in 2007
•162,500,000 people enrolled
in dental benefit plans
--50% have PPO coverage
--26% have Indemnity plans
--15% have DHMO coverage
--9% have Discount dental plans
•Enrollment in dental plans has
increased by 8% in the last 10
years
•Key dental industry trends are:
--Costs have been shifting to
consumers and employees are
paying a larger % of premiums
--Rising costs are forcing
carriers into new territories such
as the discount dental market
--Administration costs have
decreased by about 3% since
2003
• New innovations in dental
plan benefits are:
--Hybrid dental benefit products
--Modified designs to older plans
such as annual maximum roll-
overs
•2,000,000 persons covered by
other plans (2%)
SAO OFFICE INSURANCE GUIDE
15
reduced fee that the provider orthodontist must adhere to without
billing for any increased cost due to complexities (no balanced
billing). If the patient chooses to go out of the network of provid-
ers, reimbursement is either denied or subject to conditions. The
orthodontist’s option to work with managed care plans carries the
lure of high volume to offset the lower cash flow. There are no
marketing- referral worries with the patients supplied. The fee-for-
service orthodontist must be willing to accept the burdens of
making their practice attractive to more independent clients who
value freedom of choice and who are not financially dependent on
low cost or insurance products. There is a large market share of the
population, approximately 50%, who will probably never purchase
dental insurance. There are reputable ethical orthodontists on both
sides of the managed care issue and some in the middle who
incorporate both fee-for-service and managed care patients in their
practice.
Cost-containment features of both Indemnity Plans and Man-
aged Care Plans are: waiting periods, deductibles, office visit
charge, co-payment by insured of 20%-50% of fee, UCR, table of
allowances, balanced billing, predetermination of benefits, prior
authorization, coordination of benefits, least expensive alternate
treatment (LEAT), limitations, restrictions, exclusions, time limita-
tions between procedures (radiographs, cleanings, crown replace-
ments etc.) and pre-existing conditions (See Glossary for definition
of terms). Fortunately, orthodontics has not been as burdened by
these encumbrances as has general dentistry, and obviously,
orthodontics is always a pre-existing condition before a plan goes
into effect. Exclusions are procedures not covered by the dental
plan such as implants, TMJ treatment, Orthognathic Surgery,
orthodontics, and cosmetic dentistry. Major Medical Insurance
may or may not cover TMJ treatment or Orthognathic Surgery,
excluding the orthodontic component.
It is important to understand that insurance carriers have a
customary fee (average) for a given geographical area (zip code’s
first three numbers) for every dental procedure in order to base the
reimbursement on a percentage of the customary fee. All proce-
dures are identified by specific categories in the ADA CDT-7 Code of
Dental Nomenclature. It is important that patients understand that
dental benefits only pay a portion of any fee charged. There are
many problems created when insurance carriers tell their insured
that the fees they are paying for dental services are above the
customary rate for the area. To avoid any impression that the
patient is being overcharged, it would be best to explain how
insurance carriers actually arrive at what they misleadingly refer to
as usual, customary, and reasonable.
Rarely, if ever, are orthodontists required to submit radio-
graphs or photographs to an insurance company to gain prior
approval for coverage.
Coordination of benefits is an issue when an insured has more
than one dental plan or when there is an accident that will cover
Dollar-Based Plan HighlightsDollar-Based Plan HighlightsDollar-Based Plan HighlightsDollar-Based Plan HighlightsDollar-Based Plan Highlights(presented by Regence Blue
Shield)
•No procedure classes or
exclusions except cosmetic and
orthodontic orthodontic orthodontic orthodontic orthodontic procedures
•No deductible
•6-month waiting period
•No network
Plan will pay:
--100% of first $150 of care
--80% of next $500 of care
--50% of remaining care until
Annual Benefit Maximum is
reached ($750, $1000, $1250,
$1500 annual maximum
choices)
Rates:
$44 Adult
$24 Child
$50 65+
Procedure-Based PlanProcedure-Based PlanProcedure-Based PlanProcedure-Based PlanProcedure-Based Plan
HighlightsHighlightsHighlightsHighlightsHighlights (presented by
Regence Blue Shield)
•$50 deductible waived if
patient has at least one prophy
and exam per year
•No waiting periods
•No network
•Benefits increase based upon
length of enrollment
Rates:
$32 Adult
$25 Child
SAO OFFICE INSURANCE GUIDE
16
dental fees under another type of insurance policy (e.g., workers
compensation, auto insurance, personal injury protection). It is a
criminal act if reimbursement exceeds 100% of the total charges.
The dental office is obligated to inform both insurance companies
in situations where there is double coverage and it is the obligation
of the insurance companies involved to settle the monetary issue
between them.
Assignment of Benefits is another issue as to whether or not an
orthodontic office chooses or refuses to accept assignment of
benefits which means that the insurance claim will either reim-
burse the orthodontist or the patient. Accepting assignment does
create various bookkeeping problems as the office deals directly
with insurance representatives and continued requests for docu-
mentation. Wasted time on hold with insurance companies’
inadequate customer service agents is a major complaint from
most offices accepting assignment. Nevertheless, it may be a
necessity to assist the patient’s payment for treatment and may
actually enhance the dentist-patient relationship.
Not accepting assignment creates a wall of independence
for the orthodontist from insurance ownership and its inherent
problems and seems to help the patient and their employer be
more responsible for the plan that they accepted, especially when
there are irritating hassles. The entire fee is paid by the patient,
the same as a fee-for-service. The orthodontic office is out of the
loop as to when and how much the patient is reimbursed. Finan-
cial accounting and monthly reporting is much less of a problem
for the office staff. It is worth mentioning that at the beginning of
the 21st Century approximately 70% of the orthodontists in the
SAO accepted assignment and 30% strongly held to not accepting
assignment. This percentage may have changed since the original
survey. There are happy patients and orthodontists in both camps
and so it will remain.
An ideal plan design would have these features:
• Easy to understand
• Amount of reimbursement known before visiting the orthodon-
tist
• No complex forms
• Freedom to choose orthodontist
• No exclusions, restrictions
• No pre-authorization
• More dollars for actual treatment
• Reimbursement based on dollars spent, not procedures
• Reduced administrative expenses
• Funds budgeted to pay claims stay with employer
• Cost-effective
• Helps patient become a better dental consumer and involved in
their treatment
• Flexibility as needs change (ortho, oral surgery, perio, endo,
reconstructive)
HELPFUL HINTS FOR
CONSIDERING PLAN DESIGN
• Does the employer have
access to sufficient
information to make a
decision?
• How many dentists have
accepted the plan, and
what is the geographical
distribution?
• Are there enough den-
tists to adequately serve
the group?
• How many dentists
withdrew from the plan?
• What are the criteria for
selecting dentists to
participate?
• What is the utilization
rate for patients in the
plan?
• What is the average
waiting period for an
initial appointment?
• What is the average
period between appoint-
ments?
• What are the benefits
for patients requiring a
specialist’s care?
• How are specialists
selected and compen-
sated?
• Does the plan have
adequate specialists’
participation?
• Are dentists limited to
contracted specialists?
• Does the plan provide
for emergency treat-
ment?
• What provisions are in
the program for emer-
gency care away from
home?
• What provisions are
made for unforeseen
circumstances or diffi-
cult cases?
• What percent of the
premium is used for
SAO OFFICE INSURANCE GUIDE
17
Self-funded dental plans such as Direct Reimbursement (DR),
Direct Assignment (DA), and Flexible Spending Accounts (FSAs)
allow the beneficiary freedom of choice of orthodontist and fee-for-
service. They reimburse according to dollars spent, not procedures.
The plan is designed by the employer, usually with the assistance of
a Third Party Administrator (TPA). Cost estimations that have
proven to be exceptionally accurate are provided by the AAO, ADA,
state dental associations, and TPAs. Recognized actuaries compile
national dental treatment data.
Basic plan design for DR or DA would pay 100% of the first
$200, 80% of the next $500, and 50% of the remaining dollars up
to the annual maximum of $1,000. There is no distinction as to
what type of dental service is rendered. In DR the patient pays the
dentist and is reimbursed by the employer according to plan design
with submission of a receipt of payment or standard ADA form.
To compete with other models DA encourages the dentist to
accept assignment, thus lowering the office visit cost to the patient
in the hope that this feature favors acceptance of treatment. Plan
reimbursement back to the dentist is normally within two weeks.
Some DA plans have a dentist-patient co-payment feature per
claim to offset the administrative cost so as to compete more
favorably with lower cost managed care plans. This feature is not
desirable in an orthodontic practice with monthly billing; therefore,
it is advisable to file a claim quarterly or semi-annually to reduce
the number of claim withholds that the dentist and patient contrib-
ute on each claim ($5/claim/dentist-$10/claim/patient).
The idea behind the dentist/patient co-pay/claim is that only
those who benefit from dental services pay for the administration
whereas, in other models, patients are paying for plan administra-
tion whether used or not. It was a reasonable way to lower the
premium on a plan favorable to employer, employee, and dentist so
that fee-for-service could be competitive in a managed care envi-
ronment and not compromise or limit benefits. One must remem-
ber that in managed care the dentist is in reality subsidizing the
plan by agreeing to a 20-25% discounted fee. DA allows for a $5
per claim subsidy from the dentist and a $10 per claim subsidy
from the patient as a cost of business to run the plan. The dentist
always receives 95- 97% of his fee, not really different from the
cost of accepting credit cards for payment. This feature may not be
as critical an issue as it once was when managed care growth was
causing great anxiety in the profession and there was a need to
compete. That is one reason DA was developed. The other reason
DA was developed was an attempt to overcome some of the objec-
tions to DR and make it more attractive in the marketplace. The
30-year history to keep DR alive and well in the face of overwhelm-
ing opposition from insurance companies is one of heroic relent-
less tenacity by organized dentistry at all levels. Substantial gains
for DR/DA as a percentage of the total covered patients over the
last five years are very encouraging and significant.
Self-funded dental plans are not regulated by the Department
of Insurance. These plans are administered under federal ERISA
HELPFUL HINTS FOR
CONSIDERING PLAN DESIGN
continued
administration?
• Is freedom of choice of
dentist important?
• Is freedom to decide
what dental options you
have important?
• What data has been
used to establish the
UCR fee?
• How often are the fee
levels updated?
• At what percentile is
payment made?
• What percentage of
claims has the plan
denied patient cover-
age?
• How quickly are claims
paid?
• What is the difference
between the table of
allowances and a typical
fee?
• What dental procedures
are excluded?
• What are the restrictive
limitations?
• Is the terminology
consistent with the
ADA’s Current Dental
Terminology?
• What is the percent to
premium commission
paid to brokers?
• Does your insurance
consultant receive a
rebate from the insur-
ance company selected?
• How will the plan be
administered, and how
well will it be adminis-
tered?
• What safeguards are in
place?
• How well does the
benefits manager
understand dental care
–preventative, mainte
SAO OFFICE INSURANCE GUIDE
18
laws. To offset any supposed risk to the employer who establishes
a self-funded dental plan, TPAs can secure stop-loss coverage to
cover any potential excess claims over premiums. This is another
feature added by DA to make DR more acceptable to employers
who thought self-funding was too risky. As history has proven, very
few plan managers opt for the added expense of stop-loss because
it is rarely necessary unless there is significant adverse selection
(employees never had a dental plan or employees had significant
dental problems and all of them sought complete treatment the
first year of the plan), not a likely scenario but a reasonable fear of
employers.
Managed care model plans use a network of provider orthodon-
tists and discounted fee schedules. There are two types: PPOs
(Preferred Provider Organizations) and HMOs (Health Maintenance
Organizations). These plans have many limitations, restrictions,
and exclusions. Dental Maintenance Organizations (DMOs) and
Prepaid Limited Health Service Organizations (PLHSOs) are charac-
teristic of capitation models whereby the dentist is paid a minimal
monthly payment per capita (head) to provide preventative and
diagnostic services at no charge to patient. The patient pays a
monthly premium for this service to the HMO. Orthodontic service,
if included, is contracted by willing orthodontists who will discount
their “Customary Fee” 25%. Unless the customary fee is docu-
mented and posted for the insured to compare the fee quoted,
there is no check and balance for validation of a true 25% discount
from specialists contracting with the HMO or PLHSO. There is
reason for questioning this arrangement especially if fees are
quoted without including records, retention, breakage, missed
appointments, home care instructions, nutrition counseling,
cleanings etc.
These types of plans are heavily marketed and are popular with
employers because there is no contribution or participation of their
part and they have provided a dental benefit to their employees.
They comprise a large share of the market, and brokers for these
plans are paid much higher commissions than is the case with
alternatives, so it should be no surprise that they have had phe-
nomenal growth. They appeal to the consumer because they
appear to be a bargain.
We need to be diligent in educating patients, human resource
personnel, benefits managers, financial consultants, and executive
officers about possible improvements in benefit designs that
deliver improved performance per dollar spent and give back to
individuals their responsibility and ownership for care decisions.
The better we educate, the closer we will come to the ideal plan
design.
HELPFUL HINTS FOR
CONSIDERING PLAN DESIGN
continued
nance, major?
• How well does the
insured understand the
dental benefit?
• Is there Peer Review of
complaints?
• Will the employer
implement a flex-plan?
• Is balanced billing
permitted?
• Does the insured know
out-of-pocket costs for
each procedure?
• Is the insured knowl-
edgeable about what
the insurance does not
cover?
• What is the procedure
for dismissing a provider
from a plan?
• On what basis can a
provider be dismissed?
TTTTTrends of Dental Industrrends of Dental Industrrends of Dental Industrrends of Dental Industrrends of Dental Industryyyyy
Presented at National Dental
Benefit Conference sponsored by
the ADA in 2007
•The correlation that the
insurance industry draws
between periodontal disease
and systemic health conditions
will be important for
orthodontists to watch as it
demonstrates the payer’s
recognition of cause and effect.
•New Dollar-Based individual
plans may exclude orthodontic
treatment based on viewpoint
that ortho is “for cosmetics
only” and an unnecessary
“luxury” instead of sound
actuarial decision based on
adverse selection and inherent
risk.
Please refer to “Frequently Asked Questions” for informationabout Flexible Spending Accounts in Chapter 9.
SAO OFFICE INSURANCE GUIDE
19
ChaptChaptChaptChaptChapter 4: Claims Aer 4: Claims Aer 4: Claims Aer 4: Claims Aer 4: Claims Administrationdministrationdministrationdministrationdministration
In order to allow for prompt re-imbursement from an
insurance company to the patient or the dentist, a current uniform
dental claims form must be completed and submitted to the plan
administrator. Every office should have the ADA Current Dental
Terminology Manual (CDT-7) for the current 2 years. CDT Manuals
are revised every 2 odd-numbered years. CDT 7 is valid until July1,
2009. All Codes on Dental Procedures and nomenclature are
included with numerical codes and descriptors. Orthodontic Codes
(D8000 – D8999) as well as others: Diagnostic, Radiographic,
Imaging, Study Models, Preventive, Non-orthodontic appliances,
etc. will be used when filing a claim form. The manual was
adopted by the ADA in conjunction with the insurance industry. The
CDT is divided into XII major categories, one of which (XI) describes
orthodontic procedures. Procedures not depicted in the CDT or
unusual circumstances must be classified under unspecified
orthodontic code D8999 with a narrative report attached for review
by the plan administrator. Additional documentation may be
requested by the Third Party payer when coded D8999 “by report”.
Be advised, use of 999 codes will result in claim denial.
Orthodontists are not limited to Orthodontic Codes for
services rendered, in fact, it may be to the patient’s advantage to
have records such as radiographs and imaging D0210 – D0350,
diagnostic casts D0470, preventive services D1110 –D1351, and
passive appliances (space maintenance) D1510 –D1550 sepa-
rated from the orthodontic treatment form. Reimbursement to the
patient will maximize their dental insurance benefit when this
advantage is utilized. (NOTE: This practice may not be permissible
in states with orthodontic specialty laws). Other codes describe
splints, stents, night-guards, mouth-guards, bleaching trays, oc-
clusal equilibration, and other procedures used by orthodontists.
The manual is essential for flawless claims administration.
On the standard dental claim form, there are 58 spaces
requesting information. Incomplete or incorrect information can
delay payment to either patient or dentist; however, box #37, is
completed only if the orthodontist is accepting assignment.
The orthodontist’s social security number or tax ID number (T.I.N.)
is nononononot t t t t required under IRS legislation if the patient is reimbursed by
the insurance company. Authorization of assignment of benefits to
the orthodontist (box #37) must be negated by the patient; other-
wise, the reimbursement will be sent to the dentist or the form
returned for the T.I.N. It is worthwhile to stamp or use a sticker
on the form at the appropriate box ( copy of ADA claim form at end
of chapter). The correct response for a misdirected reimbursement
is to return the check to the insurance company with a copy of the
original form clearly indicating the insurance company’s mistake
and also notification to the patient that the insurance company is
delaying his/her reimbursement.
There is no pre-authorization required with orthodontics;
nor is submission of records a requirement. Patients either have or
don’t have orthodontic coverage. NoNoNoNoNo form should be sent until the
DO NOT ACCEPT
ASSIGNMENT OF BENEFITS
SSSSStamp or stictamp or stictamp or stictamp or stictamp or stickkkkker ter ter ter ter to placeo placeo placeo placeo place
on claim fon claim fon claim fon claim fon claim formormormormorm
CAUTION
A dental office has an obligation
to the insurance company to
prove that it has made every
effort to collect the co-payment
portion of the fee that the
patient is responsible for paying.
Records must clearly indicate in
detail the effort made to collect
It is a felony to waive co-pay-
ment for an insured patient and
accept the insurance check as
full payment. The doctor is
guilty of a serious offense even
if his office staff permitted this
to occur to “help” a financially
strapped “loyal” patient without
his/her knowledge. The insur-
ance company must be notified
if the office intends to lower its
fee for any reason so that they
can reduce their reimburse-
ment.
CAUTION
HINT
Randomly check orthodontic
software against a patient
contract to make sure billing/
payments match the contract
terms.
COMMON CCOMMON CCOMMON CCOMMON CCOMMON CAAAAAUSES OFUSES OFUSES OFUSES OFUSES OF
PPPPPAAAAAYMENT DELAYMENT DELAYMENT DELAYMENT DELAYMENT DELAYYYYYS:S:S:S:S:
•Lack of information
•Incorrect coding
•Incorrect or unlabeled
radiographs
•Failure to submit pre-
determination of benefits
SAO OFFICE INSURANCE GUIDE
20
orthodontist has diagnosed, planned treatment, and determined a
total fee for the case. AAAAAccuratccuratccuratccuratccurate, complee, complee, complee, complee, complettttte fe fe fe fe filing with signatures,iling with signatures,iling with signatures,iling with signatures,iling with signatures,
serserserserservices, codes, and datvices, codes, and datvices, codes, and datvices, codes, and datvices, codes, and dates is essential in order tes is essential in order tes is essential in order tes is essential in order tes is essential in order to ao ao ao ao avvvvvoid delaoid delaoid delaoid delaoid delayyyyyededededed
papapapapayment tyment tyment tyment tyment to patient or oro patient or oro patient or oro patient or oro patient or orthodontist. Lacthodontist. Lacthodontist. Lacthodontist. Lacthodontist. Lack of infk of infk of infk of infk of information orormation orormation orormation orormation or
incorrect infincorrect infincorrect infincorrect infincorrect information is the most common cause of paormation is the most common cause of paormation is the most common cause of paormation is the most common cause of paormation is the most common cause of paymentymentymentymentyment
deladeladeladeladelay and may and may and may and may and may also pry also pry also pry also pry also prompt an inompt an inompt an inompt an inompt an invvvvvestigation bestigation bestigation bestigation bestigation by the insurancey the insurancey the insurancey the insurancey the insurance
carriercarriercarriercarriercarrier. NPI number. NPI number. NPI number. NPI number. NPI numbers bos bos bos bos box #5x #5x #5x #5x #54 are a ne4 are a ne4 are a ne4 are a ne4 are a new requirement fw requirement fw requirement fw requirement fw requirement for reim-or reim-or reim-or reim-or reim-
burburburburbursement.sement.sement.sement.sement.
Some orthodontic offices provide a “SUPER BILL” as an
attachment to the insurance form that explains treatment and fee.
The AAO provides printed Superbills for a nominal charge. They are
a handy record of services rendered.
Reporting incorrect treatment dates for the purpose of
obtaining benefits, false appointments, non-existent treatment,
unnecessary services, and w w w w waivaivaivaivaiver of co-paer of co-paer of co-paer of co-paer of co-payment byment byment byment byment by the patient arey the patient arey the patient arey the patient arey the patient are
willful fraudulent violationswillful fraudulent violationswillful fraudulent violationswillful fraudulent violationswillful fraudulent violations for which the dentist will be found
guilty of unethical and criminal practice even if unknowledgeable
about the conspiracy. If the dentist treats a close friend or relative
with insurance and notifies the insurance company that co-pay-
ment was forgiven and gives reason; then, there is no ethical
violation and the insurance company will base reimbursement on
their percent of their fee for that code. If a dentist is not participat-
ing in managed care, but wishes to treat patients covered by these
plans, it is ethical for the dentist to choose to lower his usual fee
and accept the discounted fee reimbursed by the dental plan.
It is unethical for a dentist to increase a fee to a patient
because they are covered by insurance. It is unethical if the dentist
incorrectly describes a dental procedure so as to make it appear to
be covered under a dental plan or does any unnecessary dental
care. See the AAO Code of Ethics at the end of this chapter. One
erroneous claim form to benefit either patient or dentist by a few
hundred dollars could never be worth losing the license to practice
orthodontics.
Filing claims electronically is fast becoming the standard
practice in dental offices. It is a faster, more efficient (less office
time) and reimbursement turn- around time is reduced. Any error
is immediately identified and correctable instantly. However, this
practice can only be used in offices that accept assignment. Paper
forms must be submitted if the office doesn’t accept assignment.
Another future benefit to electronic claims will be immediate
transfer of funds into the orthodontist’s bank account, thus assur-
ing prompt payment. The downside of electronic claims transmis-
sion is that the orthodontic office is then under allallallallall Federal HIPAA
Rules and Regulations; whereas, offices that submit paper claims
are exempt (for the time being) unless that office has outsourced
claims management to a clearinghouse to convert to electronic
billing. The minimum fee is now $35/month for 80 claims or less
– above 80 claims its $0.35/claim, less than the postage for a
paper claim. Dr. Scott Trapp, a general dentist from Omaha, devel-
oped a spreadsheet that showed his office saved over $200/week
by filing 48 claims electronically instead of by paper. Reimburse-
ment was transferred to his account in seconds.
CAUTION
WHEN DISPUTING A CLAIM:
Always keep a phone log of
date, time and person spoken to
when calling insurance compa-
nies. Ask for the name of their
licensed dental consultant and
how he/she is qualified to be an
orthodontic consultant. If
possible, record the conversa-
tion and tell them before hand
that in your opinion you are
seeking to prove the company
has abused the claim and you
are reporting them to the State
Department of Insurance--then
do it!
CAUTION
On the standard dental claim
form, complete boxes #41 and
#45 only if the orthodontist
accepts assignment of benefits.
HINT
Check with the patient annually
to make sure that the employer
has retained the same dental
insurance plan.
COST CONTCOST CONTCOST CONTCOST CONTCOST CONTAINMENTAINMENTAINMENTAINMENTAINMENT
FEAFEAFEAFEAFEATURES:TURES:TURES:TURES:TURES:
•Restrictions, limitations,
exclusions
•Deductibles
•Co-payment
•Predetermination of
benefits
•Prior Authorization
•Annual Maximums
•Least Expensive Alternate
Treatment
•UCR or Table of Allowances
SAO OFFICE INSURANCE GUIDE
21
SAO OFFICE INSURANCE GUIDE
22
SAO OFFICE INSURANCE GUIDE
23
SAO OFFICE INSURANCE GUIDE
24
SAO OFFICE INSURANCE GUIDE
25
SAO OFFICE INSURANCE GUIDE
26
ADA Principles of ETHICS and Code of PROFESSIONAL CONDUCT
PPPPPAAAAAYYYYYOR ISSUES TOR ISSUES TOR ISSUES TOR ISSUES TOR ISSUES TO REPORT ARE:O REPORT ARE:O REPORT ARE:O REPORT ARE:O REPORT ARE:
•Payment denial /Pre-Treatment authorization denial
•No direct pay to non-participating provider
•Benefit denial
•Delay in payment(s)
•Change in code to less complex or less expensive procedure
•Combined procedure(s) resulting in lower benefit
•Problems with/lack of coordination of benefits
•Requests for additional treatment information/records
•Loss of patient claims or additional treatment information
•Other (please explain)
NOTE: See Forms PDF for templates. Copy the AAO with complaints submitted to the state
insurance commissioner.
SAO OFFICE INSURANCE GUIDE
27
ElectrElectrElectrElectrElectronic Claims Tonic Claims Tonic Claims Tonic Claims Tonic Claims Transmission—Transmission—Transmission—Transmission—Transmission—To Be Or Noo Be Or Noo Be Or Noo Be Or Noo Be Or Not Tt Tt Tt Tt To Beo Beo Beo Beo Be
bbbbby Dry Dry Dry Dry Dr. James F. James F. James F. James F. James Fergusonergusonergusonergusonerguson
Insurance is a thorny
issue in all of our offices. We all
have at least one employee who
spends their entire work time or
the best part of it dealing with
insurance problems. When I
began my practice in 1973, I
had no patients with orthodon-
tic coverage. Now in 2008,
about 90% of the patients I
treat have some form of orth-
odontic coverage. I have heard
some say that the best way to
handle insurance is to fill out
the forms and give them to the
parents and let them handle it.
I disagree. We are all con-
cerned with public relations and
advertising. What kind of image
do we present to the public
when we say, “We will fill out
your insurance forms for you but
you have to deal with your
insurance company?” The
parents are not educated and
equipped to deal with insurance
companies. Our insurance
clerks are. What better PR than
to handle the insurance prob-
lems for the parents and see to
it that the claims are paid? Yes,
it is a hassle, but the trouble
may be worth it in terms of PR.
Are you tired of your
insurance clerks spending hours
of their time printing paper
claims that require envelopes
and postage to be sent into the
insurance company and be-
cause they are paper claims, the
insurance companies deal with
them last? Now you get to wait
four or five weeks to be paid or
to find out that something was
not filed properly and the
process begins again. Elec-
tronic claims transmission is the
answer.
What’s that you say,
“You don’t have a computer”?
No problem! You can send the
paper claims in a batch to a
middleman (e.g. WebMD) and
they will file them electronically
for you. The cost is 35 cents per
claim. If the data is incorrect,
they will let you know right away
and may possibly make the
corrections right over the phone.
If you already own a
computer and you are using it to
produce the paper claims,
WebMD can map the output of
your program and instead of
printing a paper claim, you
direct the computer to print to a
file and then you transmit the
file to WebMD over a phone line.
If you have standard
practice management software,
it already has the map of your
data and it will be very simple to
set up electronic claims trans-
mission.
There are other compa-
nies like WebMD, but I am not
familiar with them. They should
all be similar, but price shop-
ping is in order. WebMD is the
only company that will map non-
standard office management
software (something other than
Orthosoft, Orthochart, etc.).
I have been filing elec-
tronic claims for about five
years and I am very pleased.
The staff member who files the
insurance claims spends about
1/3 the time she used to spend
dealing with claims filing. We
know immediately if some
information is not correct
because the claims will be
rejected before they can be filed
and the program will tell you
where the error occurred. You
make a simple fix and immedi-
ately resubmit it. The turn
around in terms of how quick
you get your money is usually 7
to 14 days. No envelopes and
postage are required and if you
add up the time saved and
utilized doing something else,
the savings are tremendous.
As far as I know all
insurance companies accept
electronic claims. If you elec-
tronically file a claim on a
company that does not yet
accept electronic transmission,
WebMD will file a paper claim
for you. There is a minimum fee
paid to WebMD every month of
$35. This base fee gives you 80
claims a month. Claims in
excess of 80 are billed at 35
cents per claim.
I think we all need to
realize that insurance is here to
stay and we had better learn to
deal with it. I am NOT saying
join capitation programs or
DMOs or PPOs or any of that
other stuff. I am saying learn
how to effectively and efficiently
file claims and receive payment
as quickly as possible. I think
the target date for all electronic
filing has been pushed back,
but electronic claims is by far
the quickest way for you to get
paid.
What equipment do yWhat equipment do yWhat equipment do yWhat equipment do yWhat equipment do you need tou need tou need tou need tou need tooooo
begin Electronic Tbegin Electronic Tbegin Electronic Tbegin Electronic Tbegin Electronic Trrrrransmissionansmissionansmissionansmissionansmission
of Insurof Insurof Insurof Insurof Insurance Claims?ance Claims?ance Claims?ance Claims?ance Claims?
1. Any computer sold currently
is more than sufficient to file
electronic claims. I file my
claims on a computer running
windows 98.
2. Get as much ram as you can
reasonably afford—at least 512,
SAO OFFICE INSURANCE GUIDE
28
but preferably 1 gig.
The speed of the ram is signifi-
cant and is dependent on the
motherboard you choose.
3. You will have to have a phone
line modem or a high speed
internet connection to do
electronic claims. Any pre-made
system should come with an
Ethernet connector used for
high speed internet. Either DSL
or cable modems can be used
to transmit insurance data at
this time and they are prefer-
able to a phone line modem.
4. A system you pick should
have a 10/100 /1000 Ethernet
port. This port will allow you to
connect your computers over an
intra-office network and connect
to a high speed internet connec-
tion.
5. The video card in a computer
is very important not only in that
it transmits the video signal to
the monitor, but also it is the
one place the entire computer
can be slowed down or brought
to a halt. The video card should
have at least 32 mb. of ram and
64 would be better.
6. The computer should have
CD-R/RW. This is a CD-ROM
device that will write data to a
blank CD. Writeable CDs are
cheap (about $0.10) and they
will hold 650 mb of data. It is
an excellent storage and archive
media because it is not mag-
netic and the data will not
degrade over a short time. DVD-
R-RW holds more data and the
data will not degrade as quickly.
7. The computer will have one or
two floppy drives. A 3.5” 1.4 mb
floppy disk drive is standard. A
zip drive that holds up to 250
mb of data is a bonus. These
drives store data in a magnetic
format and are good for daily
backups that are over written
once a week. They are not good
for permanent storage because
the magnetic data will degrade
with time. They can also be
erased by a magnetic field.
8. The keyboard and mouse are
just data entry devices unless
you are the person using them.
These two items cause more
carpal-tunnel syndrome than
any other part of a computer.
You should have an ergonomic
keyboard and mouse.
9. The monitor should be large
enough to be seen easily. There
are CRT (cathode ray tube)
monitors that require depth and
LCD (liquid crystal display)
monitors, which take little desk
space. Prices are: 15” CRT is
about $50 while a 19” LCD is
$200.
10. Who do you call? Not Ghost
Busters! Call WebMD in Atlanta.
If enough people are interested
in using WebMD, perhaps we
can get some kind of group rate.
Once you have your computers
installed and you network
running, then you are ready to
take the leap into the world of
electronic insurance claims
filing.
You will need to investigate
those companies that provide
clearinghouse services for
electronic insurance claims
transmission. There are many
such companies and they can
be found in the phone book and
on the Internet. Some will be
local in you area and some will
be remote. I live in middle
Tennessee and use a company
in Atlanta, GA. Location is not
an issue. Price and service are
the issues. Some of the compa-
nies that I have heard of are:
1. WebMD in Atlanta. They
used to be named Mede
America before they
were bought out.
2. Executive Office Alterna-
tives
3. D&M Medical Billing
Service
4. Foothills Medical Billing
I use WebMD and I found the
others by using Search on the
Internet browser. I had a conver-
sation with WebMD on Thursday
August 1, 2002 and after
jumping through several hoops,
I learned the following:
1. They no longer will send
out stand-alone software
to those who do not
have practice manage-
ment software. You will
have to have some kind
of practice management
software. Talk to your
friends and learn from
their experiences. Call
all of the companies
(there are fewer and
fewer every day) and ask
a lot of questions.
2. They will still map1 non-
standard software
(software written espe-
cially for you – software
other than Ortho-soft,
Orthochart, etc.; how-
ever, they do this on a
case-by-case basis. It
depends on what output
the software delivers). I
did this when I started
with MedeAmerica
SAO OFFICE INSURANCE GUIDE
29
(WebMD) and it takes a
little time because you
have to work with the
technician over the
phone to get everything
set up properly. My
guess is that if you have
non-standard software,
you either wrote it or you
are very familiar with
how it works. So you
should have no trouble
working with the techni-
cian. I did this 10 years
ago and if memory
serves me correctly, it
took about an hour of
my time to get it run-
ning.
3. They already have the
maps for all of the
standard Orthodontic
software programs on
the market. Therefore, if
you use Orthosoft,
Orthochart or some
other standard software,
all you have to do is sign
up and start sending
electronic claims.
1 1 1 1 1 A map is a diagrA map is a diagrA map is a diagrA map is a diagrA map is a diagram of the data yam of the data yam of the data yam of the data yam of the data your comour comour comour comour computputputputputer outputser outputser outputser outputser outputs
when y when y when y when y when you print an insurou print an insurou print an insurou print an insurou print an insurance fance fance fance fance form (what inform (what inform (what inform (what inform (what information isormation isormation isormation isormation is
put int put int put int put int put into what space). Electronic claims look liko what space). Electronic claims look liko what space). Electronic claims look liko what space). Electronic claims look liko what space). Electronic claims look like papere papere papere papere paper
claims without the titles t claims without the titles t claims without the titles t claims without the titles t claims without the titles to the fo the fo the fo the fo the fields.ields.ields.ields.ields.
CAUTION
Be sure to ask your orthodontic
software provider to certify that
the software is HIPAA compli-
ant.
When you file your first insur-
ance claim electronically, you
immediately become liable for
all of the tenants of HIPAA. If
you have ever filed an electronic
insurance claim in the past, you
are subject to HIPAA. Even if
you don’t file electronic insur-
ance claims now, you may
eventually become subject to
HIPAA. So do you hide from
HIPAA and give up the speed
and convenience and cost
savings of electronic claims or
do you jump in and figure HIPAA
will find you eventually anyway?
CAUTION
How To Treat Patients, Get Paid and Not Feel Guilty
By Dr. Harold Enoch
Recently, I needed some
bodywork done on my car. I
went to a highly recommended
repair shop and got an esti-
mate. Since I wanted my
vehicle to look nice again and I
felt the estimate was reason-
able and affordable, I had the
work done. Upon completion, I
looked over the work, paid the
bill, and drove off happy in my
beautiful car.
Do you think the techni-
cian felt guilty about taking my
money for a job well done? No,
he did not…because that is his
business.
My staff and I feel the
same way about orthodontics.
People come to us to repair
improper tooth alignment and
occlusions as well as to modify
poor skeletal and neuromuscu-
lar growth patterns. We give
them a quote on how much
treatment (including follow-ups)
will cost, and if the patient
decides the estimate is reason-
able and affordable, they ask us
to proceed. The treatment is
completed, the bill is settled,
and the patient drives off happy
with a beautiful smile and an
improved bite.
We don’t feel guilty for a
job well done…because that’s
our business. And, we don’t feel
badly because our office doesn’t
accept insurance. That is not
our business.
There are four common
“assignment-or-die” myths held
by most orthodontic offices:
• “We won’t get paid for our
work without insurance.”
(Not true. Patients come to
your office because of the
expertise available, not your
price list.)
• “We won’t attract patients
otherwise.” (Not true. Most
patients are referred to your
office by their dentists, not
your insurance policy.)
• “We are responsible for
making payment for our
services easier for our
patients.” (Not true. You’re
only responsible to provide
the best orthodontic care
possible, period!)
• “We might as well accept
insurance assignments,
most of our competitors do.”
(Not true. You’d be sur-
prised how many offices in
SAO OFFICE INSURANCE GUIDE
30
your area do not. Go ahead,
please call around.)
Insurance, per se, is not bad.
In fact, for some patients, it is
the difference between afford-
ing orthodontic work or not.
However, your office is in no way
required to accept insurance
and/or responsible for handling
the corresponding paperwork.
And you shouldn’t feel guilty for
operating that way. Here’s why:
o You practice orthodontics
and only orthodontics.
You treat patients; they pay
you for your services. If they
have insurance, they com-
plete a claim form, submit
it, and are reimbursed. A
quick, clean, simple pro-
cess.
o You shouldn’t have to
worry about who is cov-
ered and how much.
Patients either have insur-
ance or they don’t. And, in
most cases, insurance only
covers 50% of orthodontic
care up to a certain dollar
amount (usually $1500),
with the patient responsible
for the difference in costs.
o You don’t have to run your
office like a medical
practice. Medical insur-
ance is a doctor-to-insurance
company system. Contracts
ensure that if an MD follows
an established diagnosis/
treatment protocol, he or
she receives a pre-agreed
payment. A patient simply
contributes a co-payment;
the doctor is responsible for
obtaining reimbursement.
Dental insurance is a pa-
tient-to-insurance company
system. Generally, orth-
odontists are not contracted
to insurance companies.
They receive payment from
the patient; the patient is
responsible for obtaining
reimbursement. (However,
you can make it easier for
the patient by providing an
Attending Orthodontic
Statement that notes the
problem, required treat-
ments, and fees.)
o You have no leverage with
insurance companies.
Insurance companies
respond to their customers
or your patient’s employers.
They do not respond to you.
Thus, the best person to
handle an insurance prob-
lem (should one develop) is
your patient’s human
resource professional. He or
she can leverage the “make-
us-happy-or-we’ll-look
elsewhere-at-renewal-time”
position.
o You don’t have the time,
staff, or resources to
manage insurance paper-
work and inevitable
difficulties. Your office is
designed to provide the best
possible patient care.
Accepting assignment
means substantial addi-
tional paperwork, extra
billing, intricate accounting,
exhausting phone calls,
disgruntled patients, and an
additional employee or two,
an extra computer or two,
and office space to handle
all of this adequately.
o You can keep fees down.
Accepting assignment
means extra work. Extra
work means higher over-
head. Higher overhead
means higher fees.
Now then, how can you
educate your patients about
your insurance policy and help
them understand that it’s to
their best advantage to reim-
burse personally their insurance
claims?
Simply…
ü ENSURE a treatment
coordinator meets with
each new patient to review
and explain all office
policies.
ü EXPLAIN the insurance
policy in terms that promote
how advantageous it is for
the patient to work with the
insurance company directly
rather than through you, i.e.,
it is easier, faster, and the
patient has a better lever-
age position, etc.
ü PRESENT the patient with a
letter at initial consultation
that explains all office
policies, including the
insurance guidelines.
ü PROVIDE a brief statement
about insurance policy on
your website.
ü OFFER a “super bill” that
explains treatment and
provides cost breakdown for
attachment to insurance
form the patient submits for
reimbursement. (In orth-
odontics, patients only need
to submit one claim once.
The insurance company
then sets up an automatic
payment schedule.)
ü CONSIDER using a software
program that automatically
generates insurance forms
for patients to submit.
Remember, people come to
you to make their smiles beauti-
ful or to improve their bite.
Don’t hesitate to be up front
about insurance, do your job
well, and don’t feel guilty that
your office doesn’t accept
insurance assignment.
Incidentally, my car looks
great!!!
SAO OFFICE INSURANCE GUIDE
31
ChaptChaptChaptChaptChapter 5: er 5: er 5: er 5: er 5: HIPHIPHIPHIPHIPAAAAAAAAAA
The Health Insurance Portability and Accountability Act of 1996
(HIPAA) is federal law that applies to healthcare providers. It
provides for insurance portability, privacy and the security of
healthcare information, and imposes administrative regulations on
healthcare providers. Orthodontists who transmit insurance claim
forms electronically are providers who must be in compliance.
1. One intent is to improve the efficacy and effectiveness of the
health care system by establishing standards and requirements
for electronic transmission of health information to realize
significant cost savings.
2. The sending and receiving of electronic health care transac-
tions requires privacy and security standards for plans, individu-
als, employers, and providers.
3. Being out of compliance means risk of federal criminal fines
($50,000-$250,000) and penalties (1-10 years in jail).
4. Final rules state that health plans, clearing-houses, and provid-
ers that transmit any health information in electronic form in
connection with a covered transaction must be in compliance.
In addition, other individuals/organizations who perform a
function or activity on behalf of a covered entity may by “exten-
sion” be designated as a “business associate” and therefore
must be in compliance. CDT-7 Dental Procedure Codes must be
used. SNODENT codes have been abandoned thanks to AAO
efforts.
5. Each dentist will apply for and receive a National Provider
Identifier (NPI). Your NPI, Social Security number, and Tax ID
number will be needed for any claim to any payee.
6. Providers must obtain a patient’s written consent before using
or disclosing the patient’s health information for purposes of
treatment, payment, or healthcare operations (TPO). This form
is different from and separate from an informed consent to
treatment.
7. The Privacy Rule grants patients rights on use and disclosure of
their protected health information (PHI, see glossary) and
recourse to patients whose privacy is violated. It addresses the
need for patient education about their rights and written
explanations that must be supplied and available to patients.
PHI may be disclosed without patient consent under certain
specific legal/criminal situations.
8. A “privacy officer” must be designated in your office to imple-
ment the policies and procedures, train staff, and protect PHI
from disclosures.
9. Physical safeguards for security in safeguarding health informa-
tion and the building they reside in must be documented for the
maintenance and/or destruction of documents and records.
10. The regulation may impose data encryption and other restric-
tions for telephone and Internet transactions (open networks).
Security is not yet final.
CAUTION
CAUTION
If an orthodontic office has ever
filed an electronic claim for
reimbursement, that office must
be HIPAA compliant even if it
was to stop immediately and
return to paper-filed claims. It is
too late!
We have addressed the advan-
tages of electronic claims filing,
but offices may want to think
twice about instituting this fast,
efficient method because of the
requirements to be totally
compliant with HIPAA.
HIPHIPHIPHIPHIPAA COAA COAA COAA COAA COVERED ENTITIESVERED ENTITIESVERED ENTITIESVERED ENTITIESVERED ENTITIES
•A health care provider that
conducts certain transactions
in electronic form
•A health care clearinghouse
•A health plan
SAO OFFICE INSURANCE GUIDE
32
HIPAA is a complex law. Legal counsel and AAO/ADA updates
will provide advice and explanation for issues that arise in your
practice. For more information, access website: www.hhs.gov/ocr/
hipaa
ADA developed a Privacy Kit that will give you the facts and
tools needed for compliance. It is available for $125. To purchase
a kit, call (800) 947-4746 or visit the ADA’s Web site, www.ada.org.
Basic requirements fBasic requirements fBasic requirements fBasic requirements fBasic requirements for compliance with HIPor compliance with HIPor compliance with HIPor compliance with HIPor compliance with HIPAA RAA RAA RAA RAA Rules:ules:ules:ules:ules:
1. Designate a privacy officer for your practice.
2. Protect confidential information and practice privacy precau-
tions.
3. Train staff about HIPAA requirements.
4. Write your practice’s privacy notice.
5. The minimum-necessary rule requires an inventory and cat-
egory for confidential information your practice discloses.
6. Use new Consent, Authorization Forms.
7. Comply with the seven core HIPAA patients’ rights policies and
procedures.
8. Develop forceful employee sanctions for violations to deter
violations.
9. Sign written contracts with business associates sharing confi-
dential information.
* “Ensure Compliance with HIPAA Privacy, Confidentiality Rules” by
James M. Barclay, J.D. Today’s FDA, Volume 14, NO.6.
AAO members may download HIPAA GUIDE TO PATIENT PRI-
VACY RULES and HHS forms on the AAO member website under
Legal & Advocacy- HIPAA
http://www.aaomembers.org/legal/loader.cfm?url=/commonspot/
security/getfile.cfm&PageID=1274
CAUTION
If an orthodontic office has
never filed an electronic claim
for reimbursement and does not
ever intend to, then that office
does not have to be HIPAA
compliant unless that paper
claim form has to be sent to a
clearinghouse for electronic
encyption. This will likely
become the standard procedure
in time with all insurance claims
since this is the objective.
QUESTIONS FQUESTIONS FQUESTIONS FQUESTIONS FQUESTIONS FOR ORTH-OR ORTH-OR ORTH-OR ORTH-OR ORTH-
ODONTIC MANAODONTIC MANAODONTIC MANAODONTIC MANAODONTIC MANAGEMENTGEMENTGEMENTGEMENTGEMENT
SOFTSOFTSOFTSOFTSOFTWWWWWARE VENDORSARE VENDORSARE VENDORSARE VENDORSARE VENDORS
WHICH PRWHICH PRWHICH PRWHICH PRWHICH PROCESS CLAIMSOCESS CLAIMSOCESS CLAIMSOCESS CLAIMSOCESS CLAIMS
•What are the hardware
and software requirements?
•Can the system transmit
graphics (e.g. charts)?
•Can the system be
updated?
•What are the fees for
electronic claim
processing?
•Does the clearinghouse
have direct access to your
payers?
•What is the expected
turnaround time?
SAO OFFICE INSURANCE GUIDE
33
ChaptChaptChaptChaptChapter 6: Orer 6: Orer 6: Orer 6: Orer 6: Orthodontic Codesthodontic Codesthodontic Codesthodontic Codesthodontic Codes
The use of codes is a result of a joint effort of the ADA and
the Third Party Payers (insurance industry) to come to terms with
how dentistry wants to provide dental health care and what the
insurance companies are willing to reimburse.
There are 9999 possibilities for much mischief when the
insurance industry demands codes for every billable service or
procedure in dentistry. There is tension, frustration, confusion and
exasperation in these marathon meetings to clarify and accurately
define dental procedures so that they are acceptable to both
parties. Nevertheless, there are many areas of ambiguity and
shortcomings in each version of CDT (Current Dental Terminology)
and it will be just as true with CDT- 7 which was the standard in
January 2007.
Codes are always a work in progress and each ADA mem-
ber dentist has a right to submit ideas and reasons for improve-
ments. Codes are the proprietary copyright of the ADA and cannot
be published without their permission and payment, but it is
essential for each office to have the latest copy and abide by them
faithfully in any kind of insured transaction; otherwise, there will be
no reimbursement. The existence of a code does not necessarily
mean that the procedure is a covered or reimbursed benefit in a
dental benefit plan since plans differ in coverage.
Orthodontic offices should be grateful that our specialty
has such few codes and it is to the AAOs councils and committees
credit that such is the case. The insurance industry and the federal
government (HIPAA) always demand more codes for each and
every orthodontic procedure and more paper work to prove we
actually do straighten teeth.
Orthodontic codes are primarily extended treatment
descriptions, not the a la carte per visit codes typical of other
dental fields. The “powers that be” would like to change this
unique expression of our services and have historically attempted
to quantify and qualify what degree of malocclusion would be a
covered entity. Fortunately for our patients, all the scoring
schemes have failed. The Council on Health Care (COHC) of the
AAO has refused to liberalize and expand our codes in meetings
with the ADA and the insurance industry because of the very
implications and impact they have had in other areas of dentistry.
This refusal to bend has frustrated the plans of those who desire to
control all of health care with a system of numbers.
Be advised that there is a wealth of information in the
current issue (CDT –7) that will clarify many issues and answer
questions concerning the ADA Dental Claim Form. Front desk staff
should quickly become familiar with the Glossary of Dental Benefit
Terminology and new clinical staff will benefit from the Glossary of
Common Dental Terms. As an example: some orthodontists might
prefer to do circumferential fiberotomies on rotated teeth rather
than refer to a periodontist and may find it difficult to find the
appropriate code D7291 (transseptal fiberotomy, by report). See
Code Reference Guide on page 101 for proper nomenclature.
HINT
HINT
HINT
HINT
HINT
Code TMJ by using a medical
claim form and AMA Procedure
Codes.
Since orthodontic treatment is a
necessary part of Orthognathic
Surgery and essential to a
successful outcome, it is worth
the effort to include the orth-
odontic treatment as part of the
medical claim. Some carriers
will pay.
To maximize orthodontic ben-
efits, consider procedures that
could be classified and billed
under dental procedures.
The most commonly used codes
used in filing insurance: D8080,
D8070, D8090, D8670.
Some insurance companies
require the original orthodontic
code when filing continuation of
treatment. EXAMPLE: need to
use D8080 every filing rather
than D8670 or in conjunction
with D8670.
SAO OFFICE INSURANCE GUIDE
34
It may be helpful to patients to code records separately
from the orthodontic treatment by using Diagnostic Codes D0100 -
D0999 for casts, imaging and radiographs. And not check Box #40
as orthodontic treatment -diagnostic data collection is not treat-
ment.
The issue is interpreting box #40. Taking Diagnostic records
is not technically treatment. It could be reimbursed under the
patients dental benefit instead of the maximum orthodontic
benefit. This attempt to maximize the ortho benefit is not an ethical
issue but an attempt to place procedures in their proper categories.
Likewise, the fees for extractions, exposure of canines or place-
ment of TAD’s should not be deducted from the limited orthodon-
tics benefit. These ongoing issues are not resolved with Third Party
Payees. It is in the Third Party Payees financial interest to invade
the orthodontic benefit with all adjunctive procedures related to
orthodontic treatment.
Preventive Codes D1000 - D1999 may be appropriate on
occasion as well as Prosthetics Codes D5951 – D5999.
Miscellaneous Services D9910 – D9999 will be frequently
utilized in orthodontic treatment: mounted cases, athletic
mouthguards, occlusal splints, occlusal adjustments, external
bleaching to name a few.
All this is to say that proper coding for procedures will
provide each patient with their maximum benefit under most third
party plans.
The American Medical Associations’ Current PrCurrent PrCurrent PrCurrent PrCurrent Proceduraloceduraloceduraloceduralocedural
TTTTTerminology Codes erminology Codes erminology Codes erminology Codes erminology Codes –7th edition (CPT–7CPT–7CPT–7CPT–7CPT–7) could be utilized for TMJ
services if denied under a dental plan. Exams, consultations,
diagnostic, physical therapy, equilibration, and splint therapy might
be better addressed through Medical Insurance. Oral Surgeons
make use of these codes routinely.
Remember the 9999 possibilities and think about what if
dentistry had diagnostic codes like medicine. Such is the case with
SNODENT (Systemized Nomenclature of Dentistry) developed by
the ADA for defining dental disease in an electronic environment
and waiting in the wings in case government financing of dental
health care demands it. At present, on paper, there are some
4,000 new codes that could be put into effect unless organized
dentistry draws some lines in the sand and stops this ad nauseas
assault of minutia. For the time being, SNODENT is a non-issue,
but HIPAA regulations are just beginning and the intentions of Third
Party intervention is always more codes, more paperwork, and
more control similar to medicine.
If the ADA succumbs to federal government pressure for
diagnostic codes because of HIPAA legislation, then we could suffer
the consequences. Support of the AAOPAC allows proponents to
advocate for issues that assure orthodontists can treat patients
with the highest standard of care.
To order the ADA CDT Code
Book, call (800) 947-4746
SAO OFFICE INSURANCE GUIDE
35
ChaptChaptChaptChaptChapter 7er 7er 7er 7er 7: : : : : Offices of State Insurance Commissioners
ALABAMAALABAMAALABAMAALABAMAALABAMA
Alabama Dept. of Insurance
201 Monroe St. Suite 1700
Montgomery, AL 36104
In State: 1-800-433-3966
Phone: 334-269-3550
Fax: 334-241-4192
Website: aldoi.org
FLFLFLFLFLORIDORIDORIDORIDORIDAAAAA
Florida Dept. of Insurance
200 East Gaines Street
Tallahassee, FL 32399-0300
In State: 1-800-342-2762
Phone: 850-413-3100
Fax: 850-413-2950
Website and/or E-Mail:
www.doi.state.fl.us
GEORIGGEORIGGEORIGGEORIGGEORIGAAAAA
Georgia Insurance and Safety
Fire Commissioner’s Office
Dept. of Consumer Services
Two Martin L. King, Jr. Drive
716 West Tower
Atlanta, GA 30334
Toll Free: 1-800-656-2298
Phone: 404-656-2070
Fax: 404-657-8542
Website and/or E-Mail:
www.inscomm.state.ga.us
KENTUCKYKENTUCKYKENTUCKYKENTUCKYKENTUCKY
Kentucky Dept. of Insurance
PO Box 517
215 West Main St.
Frankfort, KY 40602-0517
Toll Free: 1-800-595-6053
Phone: 502-564-6034
Fax: 502-564-6090
Website and/or E-Mail:
www.doi.state.ky.us
LLLLLOUISIANAOUISIANAOUISIANAOUISIANAOUISIANA
Louisiana Dept. of Insurance
PO Box 94214
Baton Rouge, LA 70804-9214
In State: 1-800-259-5300
Phone: 225-342-0895
Fax: 225-342-3078 or 225-342-
0895
Website and/or E-Mail:
www.ldi.state.la.gov
MISSISSIPPIMISSISSIPPIMISSISSIPPIMISSISSIPPIMISSISSIPPI
Mississippi Dept. of Insurance
Consumer Service Division
PO Box 79
Jackson, MS 39205-0079
In State: 1-800-562-2957
Phone: 601-359-3569
Fax: 601-359-1077
Website and/or E-Mail:
www.doi.state.ms.us
NORTH CNORTH CNORTH CNORTH CNORTH CARARARARAROLINAOLINAOLINAOLINAOLINA
North Carolina Dept. of Insur-
ance
PO Box 26387
Raleigh, NC 27611
In State: 1-800-546-5664
Phone: 919-733-2032
Fax: 919-733-0085
Website and/or E-Mail:
SOUTH CSOUTH CSOUTH CSOUTH CSOUTH CARARARARAROLINAOLINAOLINAOLINAOLINA
South Carolina Dept. of Insur-
ance
PO Box 100105
Columbia, SC 29202-3105
In State: 1-800-768-3467
Phone: 803-737-6160
Fax: 803-737-6231
Website and/or E-Mail:
TENNESSEETENNESSEETENNESSEETENNESSEETENNESSEE
Tennessee Dept. of Commerce
and Insurance
Volunteer Plaza
500 James Robertson Parkway
Nashville, TN 37243-0574
In State: 1-800-342-4029
Phone: 615-741-2218
Fax: 615-532-7389
Website and/or E-Mail:
www.state.tn.us
VIRVIRVIRVIRVIRGINIAGINIAGINIAGINIAGINIA
Virginia State Corporation
Commission
Bureau of Insurance
PO Box 1157
Richmond, VA 23218
In State: 1-800-552-7945
Phone: 804-371-9691
Fax: 804-371-9944
Website and/or E-Mail:
www.state.va.us\scc
WEST VIRWEST VIRWEST VIRWEST VIRWEST VIRGINIAGINIAGINIAGINIAGINIA
West Virginia Office of the
Insurance Commissioner
PO Box 50540
Charleston, WV 25305-0540
Toll Free: 1-800-642-9004
Phone: 304-558-3354 x 2
Fax: 304-558-0412
Website and/or E-Mail:
www.state.wv.us
Each state has a law governing
the turn around time for reim-
bursement once an accurate,
complete claim form has been
received. Florida now has a 14-
workday turn around law; a 28-
45 day law is common in other
states. Ten percent interest can
be charged againsst any insur-
ance company for delinquent
days of reimbursement. Prob-
lems of any nature can best be
addressed if a complaint is filed
with the state insurance com-
missioner with copies sent to
the patient and insurance
company. Insurance companies
do not like to be reported and it
is a disservice to the profession
by not taking advantage of this
redress of grievances.
HINT
SAO OFFICE INSURANCE GUIDE
36
procedure whereby a benefi-
ciary/patient authorizes the
administrator of the program to
forward payment for a covered
procedure directly to the treat-
ing dentist.
Attending Dentist’s State-
ment: Also known as the ADA
Dental Claim Form. A form
used to report dental proce-
dures to a third-party payer, the
claim form was developed by
the American Dental Associa-
tion.
Audit: An examination of
records or accounts to check
their accuracy. A post-treat-
ment record review or clinical
examination to verify informa-
tion reported on claims.
BBBBB
BAC: Business Associate
Contract under HIPAA.
Bad Faith Insurance Prac-
tices: The failure of an insur-
ance company to deal with a
beneficiary of a dental benefit
plan fairly and in good faith; an
activity which impairs the right
of the beneficiary to receive the
appropriate benefits of a dental
benefit plan or to receive them
in a timely manner.
Some ExSome ExSome ExSome ExSome Examamamamamples of bad faithples of bad faithples of bad faithples of bad faithples of bad faith
insurinsurinsurinsurinsurance prance prance prance prance practices include:actices include:actices include:actices include:actices include:
evaluating claims based on
standards which are signifi-
cantly at variance with the
standards of the community;
failure to properly investigate a
claim for benefits; and unrea-
sonably and purposely delaying
and/or withholding payment of
a claim.
ChaptChaptChaptChaptChapter 8: Glossarer 8: Glossarer 8: Glossarer 8: Glossarer 8: Glossary of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefy of Dental Benefit Tit Tit Tit Tit Terminologyerminologyerminologyerminologyerminology(used with permission of the American Dental Association)(used with permission of the American Dental Association)(used with permission of the American Dental Association)(used with permission of the American Dental Association)(used with permission of the American Dental Association)
A
Administrator: One who
manages or directs a dental
benefit program on behalf of
the program’s sponsor. (See
Third Party Administrator).
Administrative Costs: Over-
head expenses incurred in the
operation of a dental benefit
program, exclusive of costs of
dental services provided.
Administrative Services Only
(ASO): An arrangement under
which a third party, for a fee,
processes claims and handles
paperwork for a self-funded
group. This frequently includes
all insurance company services
(actuarial services, underwrit-
ing, benefit description, etc.)
except assumption of risk.
Adverse Selection: A statisti-
cal condition within a group
when there is a greater demand
for dental services and/or more
services necessary than the
average expected for that group.
Allowable Charge: The maxi-
mum dollar amount on which
benefit payment is based for
each dental procedure.
Alternate Benefit: A provision
in a dental plan contract that
allows the third-party payer to
determine the benefit based on
an alternative procedure that is
generally less expensive than
the one provided or proposed.
Alternative Benefit Plan: A
plan, other than a traditional
(fee-for-service, freedom-of-
choice) indemnity or service
corporation plan, for reimburs-
ing a participating dentist for
providing treatment to an
enrolled patient population.
Alternative Delivery System:
An arrangement for the provi-
sion of dental services in other
than the traditional way (e.g.,
licensed dentist providing
treatment in a fee-for-service
dental office).
American Association of
Orthodontists (AAO): an
advocate group for orthodon-
tists. about 95 % of US orth-
odontists are members. Orth-
odontists are specialists in the
diagnosis, prevention and
treatment of orthodontic prob-
lems. Orthodontists are required
to complete a minimum of two
academic years of study in an
accredited orthodontic resi-
dency program after dental
school.
American Dental Association
(ADA): An advocacy group that
promotes Oral Health Care to
the public while representing
the dental profession. The ADA
is the world’s largest and oldest
national dental association.
Any Willing Provider: Legisla-
tion that requires managed care
organizations (MCOs), such as
health maintenance organiza-
tions (HMOs) and preferred
provider organizations (PPOs) to
contract with any providers,
from physicians and hospitals to
pharmacists and chiropractors,
who are willing to meet the
terms of the contract.
Assignment of Benefits: A
SAO OFFICE INSURANCE GUIDE
37
Balance Billing:Balance Billing:Balance Billing:Balance Billing:Balance Billing: Billing a
patient for the difference
between the dentist’s actual
charge and the amount reim-
bursed under the patient’s
dental benefit plan.
Beneficiary: A person who
receives benefits under a dental
benefit contract. (See also
CoCoCoCoCovvvvvered Pered Pered Pered Pered Pererererersonsonsonsonson, InsuredInsuredInsuredInsuredInsured,
MemberMemberMemberMemberMember, SubscriberSubscriberSubscriberSubscriberSubscriber).
Benefit: The amount payable
by a third party toward the cost
of various covered dental
services or the dental service or
procedure covered by the plan.
Benefit Booklet: A booklet or
pamphlet provided to the
subscriber, which contains a
general explanation of the
benefits and related provisions
of the dental benefit program.
Also known as a SummarSummarSummarSummarSummary Plany Plany Plany Plany Plan
DescriptionDescriptionDescriptionDescriptionDescription.
Benefit Plan Summary: The
description or synopsis of
employee benefits required by
ERISA to be distributed to the
employees.
Birthday Rule: Coordination of
benefits regulation stipulating
that the primary payer of ben-
efits for dependent children is
determined by the parent’s date
of birth. Regardless of which
parent is older, the dental
benefit program of the parent
whose date of birth falls first in
a calendar year is considered
primary. (May not apply to self-self-self-self-self-
funded prfunded prfunded prfunded prfunded programsogramsogramsogramsograms).
Bundling of Procedures: The
systematic combining of distinct
dental procedures by third-party
payers that results in a reduced
benefit for the patient/benefi-
ciary.
Business Associate: A person
who performs or assists in the
performance of a function or
activity involving the use or
disclosure of individually identi-
fiable health information.
“Business Associate” includes
legal, actuarially, accounting,
consulting, data aggregation,
management, administrative,
accreditation, or financial
services. Functions of business
associates include: (1) claims
processing or administration,
(2) data analysis, processing, or
administration, (3) utilization
review, (4) quality assurance, (5)
billing, (6) benefit management,
(7) practice management, (8)
repricing.
By Report: A narrative descrip-
tion used to report a service
that does not have a procedure
code or is specified in a code as
“by report”; may be requested
by a third-party payer to provide
additional information for
claims processing.
C
Cafeteria Plan: Employee
benefit plan in which employees
select their medical insurance
coverage and other nontaxable
fringe benefits from a list of
options provided by the em-
ployer. Cafeteria plan partici-
pants may receive additional,
taxable cash compensation if
they select less expensive
benefits. (Sometimes FleFleFleFleFlex Planx Planx Planx Planx Plan
or 50or 50or 50or 50or 501c3a1c3a1c3a1c3a1c3a)
Capitation: A capitation
program is one in which a
dentist or dentists contract with
the programs’ sponsor or
administrator to provide all or
most of the dental services
covered under the program to
subscribers in return for pay-
ment on a per-capita basis.
Carrier: See Third PThird PThird PThird PThird Pararararartytytytyty.
Case Management: The
monitoring and coordination of
treatment rendered to patients
with specific diagnoses or
requiring high cost or extensive
services.
Centers for Medicare and
Medicaid Services (CMS,
formerly HCFA): federal
agency within the Department
of Health and Human Services
(HHS) whose mission is to
ensure effective, up-to-date
health care coverage and to
promote quality care for benefi-
ciaries covered by Medicare and
Medicaid programs.
Certificate Holder:
1) The person, usually the
employee, who represents the
family unit covered by the
dental benefit program; other
family members are referred to
as “dependents.”
2) Generally refers to a sub-
scriber of a traditional indem-
nity program.
3) In reference to the program
for dependents of active-duty
military personnel, the certifi-
cate holder is called the spon-
sor. (See SubscriberSubscriberSubscriberSubscriberSubscriber).
Claim:Claim:Claim:Claim:Claim:
1) A request for payment under
a dental benefit plan.
2) A statement listing services
rendered, the dates of
services, and itemization of
costs. Includes a statement
signed by the beneficiary
and treating dentists that
services have been ren-
SAO OFFICE INSURANCE GUIDE
38
bursed; and
2) contracts between a dental
benefit organization and a
group plan sponsor. These
contracts typically describe
the benefits of the group
plan and the rates to be
charged for those benefits.
Contract Dentist: A practitio-
ner who contractually agrees to
provide services under special
terms, conditions and financial
reimbursement arrangements.
Contract Fee Schedule Plan:
A dental benefit plan in which
participating dentists agree to
accept a list of specific fees as
the total fees for dental treat-
ment provided.
Contract Practice: Dental
practice in which an employer or
third-party administrator con-
tracts directly with a dentist or
group of dentists to provide
dental services for beneficiaries
of a plan (See Closed PClosed PClosed PClosed PClosed Panelanelanelanelanel).
Contract Term: The period of
time, usually 12 months, for
which a contract is written.
Contributory Program: A
dental benefit program in which
the enrollee shares in the
monthly premium of the pro-
gram with the program sponsor
(usually the employer). Gener-
ally done through payroll deduc-
tion.
Coordination of Benefits
(COB): A method of integrating
benefits payable for the same
patient under more than one
plan. Benefits from all sources
should not exceed 100% of the
total charges.
Co-payment: Beneficiary’s
dered. The completed form
serves as the basis for
payment of benefits.
Claimant: Person who files a
claim for benefits. May be the
patient or the certificate holder.
Claim Form: The form used to
file for benefits under a dental
benefit program; includes
sections for the patient and the
dentist to complete.
Claims Payment Fraud: The
intentional manipulation or
alteration of facts submitted by
a treating dentist resulting in a
lower payment to the benefi-
ciary and/or the treating dentist
than would have been paid if
the manipulation had not
occurred.
Claims Reporting Fraud: The
intentional misrepresentation of
material facts concerning
treatment provided and/or
charges made, in that this
misrepresentation would cause
a higher payment.
Closed Panel: A closed panel
dental benefit plan exists when
patients eligible to receive
benefits can receive them only if
services are provided by den-
tists who have signed an agree-
ment with the benefit plan to
provide treatment to eligible
patients. As a result of the
dentist reimbursement methods
characteristic of a closed panel
plan, only a small percentage of
practicing dentists in a given
geographical area are typically
contracted by the plan to pro-
vide dental services.
Coinsurance: A provision of a
dental benefit program by which
the beneficiary shares in the
cost of covered services, gener-
ally on a percentage basis. The
percentage of a covered dental
expense that a beneficiary must
pay (after the deductible is
paid). A typical coinsurance
arrangement is one in which the
third party pays 80% of the
allowed benefit of the covered
dental service and the benefi-
ciary pays the remainder of the
charged fee. Percentages vary
and may apply to table of
allowance plans; usual, custom-
ary, and reasonable plans; and
direct reimbursement pro-
grams.
COBRA (Consolidated Omni-
bus Budget Reconciliation
Act): Legislation relative to
mandated benefits for all types
of employee benefit plans. The
most significant aspects within
this context are the require-
ments for continued coverage
for employees and/or their
dependents for 18 months who
would otherwise lose coverage
(30 months for dependents in
the event of the employee’s
death).
Contract: A legally enforceable
agreement between two or
more individuals or entities that
confers rights and duties on the
parties. Common types of
contracts include:
1) contracts between a dental
benefit organization and an
individual dentist to provide
dental treatment to mem-
bers of an alternative
benefit plan. These con-
tracts define the dentist’s
duties both to beneficiaries
of the dental benefit plan
and the dental benefit
organization, and usually
define the manner in which
the dentist will be reim-
SAO OFFICE INSURANCE GUIDE
39
share of the dentist’s fee after
the benefit plan has paid. Can
also be an up front office visit
charge.
Cost Containment: Features
of a dental benefit program or
of the administration of the
program designed to reduce or
eliminate certain charges to the
plan.
Cost Sharing: The share of
health expenses that a benefi-
ciary must pay, including the
deductibles, co-payments,
coinsurance, and charges over
the amount reimbursed by the
dental benefit plan.
Coverage: Benefits available to
an individual covered under a
dental benefit plan.
Covered Charges: Charges for
services rendered or supplies
furnished by a dentist that
qualify as covered services and
are paid for in whole or in part
by the dental benefit program.
May be subject to deductibles,
co-payments, coinsurance,
annual or lifetime maximums,
as specified by the terms of the
contract.
Covered Person: An individual
who is eligible for benefits
under a dental benefit program.
Covered Services: Services for
which payment is provided
under the terms of the dental
benefit contract.
Current PrCurrent PrCurrent PrCurrent PrCurrent Procedural Tocedural Tocedural Tocedural Tocedural Terminologyerminologyerminologyerminologyerminology
(CPT)(CPT)(CPT)(CPT)(CPT): A listing of descriptive
terms and identifying codes
developed by the American
Medical Association (AMA) for
reporting practitioner services
and procedures to medical
plans and Medicare.
Customary Fee: The fee level
determined by the administrator
of a dental benefit plan from
actual submitted fees for a
specific dental procedure to
establish the maximum benefit
payable under a given plan for
that specific procedure. (See
also Usual FUsual FUsual FUsual FUsual Feeeeeeeeee and RRRRReasonableeasonableeasonableeasonableeasonable
FFFFFeeeeeeeeee).
D
Deductible: The amount of
dental expense for which the
beneficiary is responsible before
a third party will assume any
liability for payment of benefits.
Deductible may be an annual or
one-time charge, and may vary
in amount from program to
program. (See FFFFFamily Deduct-amily Deduct-amily Deduct-amily Deduct-amily Deduct-
ibleibleibleibleible).
Dental Benefit Plan: Entitles
covered individuals to specified
dental services in return for a
fixed, periodic payment made in
advance of treatment. Such
plans often include the use of
deductibles, coinsurance, and/
or maximums to control the
cost of the program to the
purchaser.
Dental Insurance: A plan that
financially assists in the ex-
pense of treatment and care of
dental disease and accidents to
teeth.
Dental Prepayment: A
method of financing the cost of
dental services prior to their
receipt.
Dental Service Corporation:
A legally constituted, non-for-
profit organization that negoti-
ates and administers contracts
for dental care. Delta Dental
Plans and Blue Cross/Blue
Shield Plans are such plans.
Dependents: Generally spouse
and children of covered indi-
vidual, as defined by terms of
the dental benefit contract.
Direct Billing: A process
whereby the dentist bills a
patient directly for his/her fees.
Direct Reimbursement: A
self-funded program in which
the individual is reimbursed
based on a percentage of
dollars spent for dental care
provided, and which allows
beneficiaries to seek treatment
from the dentist of their choice.
Downcoding: A practice of
third-party payers in which the
benefit code has been changed
to a less complex and/or lower
cost procedure than was re-
ported.
Dual Choice Program: A
benefit package from which an
eligible individual can choose to
enroll in either an alternative
dental benefit program or a
traditional dental benefit pro-
gram. By state statute in
Florida, employers must offer
this program.
E
Eligibility Date: The date an
individual and/or dependents
become eligible for benefits
under a dental benefit contract.
Often referred to as effective
date.
Eligible Person: (See BenefBenefBenefBenefBenefi-i-i-i-i-
ciarciarciarciarciaryyyyy).
Enrollee: Individual covered by
SAO OFFICE INSURANCE GUIDE
40
the program.
G
Gate Keeper System: A
managed care concept used by
some alternative benefit plans,
in which enrollees select a
primary care dentist, usually a
general practitioner or pediatric
dentist, who is responsible for
providing nonspecialty care and
managing referrals, as appropri-
ate, for specialty and ancillary
care.
H
Health Maintenance Organi-
zation (HMO): A legal entity
that accepts responsibility and
financial risk for providing
specified services to a defined
population during a defined
period of time at a fixed price.
An organized system of health
care delivery that provides
comprehensive care to enrollees
through designated providers.
Enrollees are generally as-
sessed a monthly payment for
health care services and may be
required to remain in the pro-
gram for a specified amount of
time.
Health Insurance Portability
and Accountability Act
(HIPAA): Federal legislation
which (1) protects health insur-
ance coverage for workers and
their families when they change
or lose their jobs and (2) re-
quires the establishment of
national standards for elec-
tronic health care transactions
and national identifiers for
providers, health insurance
plans, and employers.
Health Reimbursement
Arrangements (HRAs): Ac-
a benefit plan. (See BenefBenefBenefBenefBenefi-i-i-i-i-
ciarciarciarciarciaryyyyy).
ERISA (Employment Retire-
ment Income Security Act): A
federal act, passed in 1974, that
established new standards and
reporting / disclosure require-
ments for employer-funded
pension and health benefit
programs. To date, self-funded
health benefit plans operating
under ERISA have been held to
be exempt from state insurance
laws. This exemption is cur-
rently under review.
Exclusions: Dental services
not covered under a dental
benefit program.
Exclusive Provider Organiza-
tion (EPO): See PrefPrefPrefPrefPreferrederrederrederrederred
PrPrPrPrProoooovider Organizationvider Organizationvider Organizationvider Organizationvider Organization
Explanation of Benefits: A
written statement to a benefi-
ciary, from a third-party payer,
after a claim has been reported,
indicating the benefit/charges
covered or not covered by the
dental benefit plan.
Extension of Benefits: Exten-
sion of eligibility for benefits for
covered services, usually de-
signed to ensure completion of
treatment commenced prior to
the expiration date. Duration is
generally expressed in terms of
days.
F
Family Deductible: A deduct-
ible that is satisfied by com-
bined expenses of all covered
family members. For example,
a program with $25 deductible
may limit its application to a
maximum of three deductibles,
or $75 for the family, regardless
of the number of family mem-
bers. (See DeductibleDeductibleDeductibleDeductibleDeductible).
Fee-for-Service: A method of
paying practitioners on a ser-
vice-by service rather than a
salaried or capitated basis.
Fee Schedule: A list of the
charges established or agreed
to by a dentist for specific
dental services.
Flexible Benefits: A benefit
program in which an employee
has a choice of credits or dollars
for distribution among various
benefit options, e.g., health and
disability insurance, dental
benefits, childcare, or pension
benefits. (See CafCafCafCafCafeeeeettttteria Plans;eria Plans;eria Plans;eria Plans;eria Plans;
FleFleFleFleFlexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Accountccountccountccountccount,
Also known as 50505050501c3a.1c3a.1c3a.1c3a.1c3a.)
Flexible Spending Account:
Employee reimbursement
account primarily funded with
employee-designated salary
reductions. Funds are reim-
bursed to employee for health
care (medical and/or dental),
dependent care, and/or legal
expenses, and are considered a
nontaxable benefit.
Franchise Dentistry: Refers to
a system for marketing a dental
practice, usually under a trade
name, where permitted by state
laws. In return for a financial
investment or other consider-
ation, participating dentists may
also receive the benefits of
media advertising, a national
referral system, and financial
and management consultation.
Freedom of Choice: A provi-
sion in a dental benefit program
that permits the insured to
choose any licensed dentist to
provide his or her dental care
and receive full benefits under
SAO OFFICE INSURANCE GUIDE
41
counts to reimburse medical
expenses, financed by employer
contributions and which can be
carried over from year-to-year.
Hold Harmless Clause: A
contract provision in which one
party to the contract promises
to be responsible for liability
incurred by the other party.
Hold harmless clauses fre-
quently appear in the following
contexts:
1) Contracts between dental
benefit organizations and an
individual dentist often
contain a promise by the
dentist to reimburse the
dental benefit organization
for any liability the organiza-
tion incurs because of
dental treatment provided
to beneficiaries of the
organization’s dental benefit
plan. This may include a
promise to pay the dental
benefit organization’s
attorney fees and related
costs; and
2) Contracts between
dental benefit organizations and
a group plan sponsor may
include a promise by the dental
benefit organization to assume
responsibility for disputes
between a beneficiary of the
group plan and an individual
dentist when the dentist’s
charge exceeds the amount the
organization pays for the service
on behalf of the beneficiary. If
the dentist takes action against
the patient to recover the
difference between the amount
billed by the dentist and the
amount paid by the organiza-
tion, the dental benefit organi-
zation will take over the defense
of the claim and will pay any
judgments and court costs.
I
Incentive Program: A dental
benefit program that pays an
increasing share of the treat-
ment cost, provided that the
covered individual utilizes the
benefits of the program during
each incentive period (usually a
year) and receives the treat-
ment prescribed. For example,
a 70%-30% co-payment pro-
gram in the first year of cover-
age may become an 80%-20%
program in the second year if
the subscriber visits the dentist
in the first year as stipulated in
the program. Most frequently,
there is a corresponding per-
centage reduction in the
program’s co-payment level if
the covered individual fails to
visit the dentist in a given year
(but never below the initial co-
payment level).
Indemnification Schedule:
See TTTTTable of Alloable of Alloable of Alloable of Alloable of Allowwwwwancesancesancesancesances.
Indemnity Plan: A dental plan
where a third-party payer
provides payment of an amount
for specific services, regardless
of the actual charges made by
the provider. Payment may be
made either to enrollees or, by
assignment, directly to dentists.
Schedule of allowances, table of
allowances, or reasonable and
customary plans are examples
of indemnity plans.
Individual Practice Associa-
tion (IPA): A legal entity orga-
nized and operated on behalf of
individual participating dentists
for the primary purpose of
collectively entering into con-
tracts to provide dental services
to enrolled populations. Den-
tists may practice in their own
offices and may provide care to
patients not covered by the
contract as well as IPA patients.
Insurer: An organization that
bears the financial risk for the
cost of defined categories or
services for a defined group of
beneficiaries. (See Third PThird PThird PThird PThird Pararararartytytytyty).
Insured: Person covered by the
program. (See BenefBenefBenefBenefBeneficiariciariciariciariciaryyyyy).
L
Least Expensive Alternative
Treatment (LEAT): A limitation
in a dental benefit plan that will
only allow benefits for the least
expensive treatment. Also
referred to as Least ExpensivLeast ExpensivLeast ExpensivLeast ExpensivLeast Expensiveeeee
PrPrPrPrProfofofofofessionally Aessionally Aessionally Aessionally Aessionally Acceptablecceptablecceptablecceptablecceptable
AltAltAltAltAlternativernativernativernativernative Te Te Te Te Treatment (LEPreatment (LEPreatment (LEPreatment (LEPreatment (LEPAAAAAAAAAAT)T)T)T)T).
Liability: An obligation for a
specified amount or action.
Limitations: Restrictive condi-
tions stated in a dental benefit
contract, such as age, length of
time covered, and waiting
periods, which affect an
individual’s or group’s coverage.
The contract may also exclude
certain benefits or services, or it
may limit the extent or condi-
tions under which certain
services are provided. (See
ExExExExExclusionsclusionsclusionsclusionsclusions).
M
Managed Care: Refers to a
cost containment system that
directs the utilization of health
benefits by:
1) restricting the type, level
and frequency of treat-
ment;
2) limiting the access to
care; and
3) controlling the level of
reimbursement for
services.
Maximum Allowance: The
SAO OFFICE INSURANCE GUIDE
42
coordination of benefits provi-
sion, because reimbursement
would be limited to the greater
level allowed by the two plans,
rather than a total of 100% of
the charges. Also referred to as
“benefit-less-benefit” or “carve-
out.”
Nonparticipating Dentist:
Any dentist who does not have a
contractual agreement with a
dental benefit organization to
render dental care to members
of a dental benefit program.
O
Open Enrollment: The annual
period in which employees can
select from a choice of benefit
programs.
Open Panel: A dental benefit
plan characterized by three
features:
1) Any licensed dentist may
elect to participate.
2) The beneficiary may receive
dental treatment from
among all licensed dentists,
with the corresponding
benefits being payable to
either the beneficiary or the
dentist.
3) The dentist may accept or
refuse any beneficiary.
Overbilling: Nondisclosure of
waiver of patient co-payment.
Overcoding: Reporting a more
complex and/or higher cost
procedure than was actually
performed.
P
Participating Dentist: Any
dentist who has a contractual
agreement with a dental benefit
organization to render care to
maximum dollar amount a
dental program will pay toward
the cost of a dental service as
specified in the program’s
contract provisions, e.g., UCR,
Table of Allowances. (Also
known as maximum pamaximum pamaximum pamaximum pamaximum payyyyyableableableableable
amountamountamountamountamount.)
Maximum Benefit: The maxi-
mum dollar amount a program
will pay toward the cost of
dental care incurred by an
individual or family in a speci-
fied period, usually a calendar
year.
Maximum FMaximum FMaximum FMaximum FMaximum Fee Scee Scee Scee Scee Schedule:hedule:hedule:hedule:hedule: A
compensation arrangement in
which a participating dentist
agrees to accept a prescribed
sum as the total fee for one or
more covered services.
Medicaid: A federal assistance
program established as Title XIX
under the Social Security Act of
1965 which provides payment
for medical care for certain low
income individuals and families.
The program is funded jointly by
the state and federal govern-
ments and administered by
states.
Medically Necessary Care:
The reasonable and appropriate
diagnosis, treatment, and
follow-up care (including sup-
plies, appliances and devices)
as determined and prescribed
by qualified, appropriate health
care providers in treating any
condition, illness, disease,
injury, or birth developmental
malformations. Care is medi-
cally necessary for the purpose
of: controlling or eliminating
infection, pain, and disease; and
restoring facial configuration or
function necessary for speech,
swallowing or chewing.
Medicare: A federal insurance
program enacted in 1965 as
Title XVIII of the Society Security
Act that provides certain inpa-
tient hospital services and
physician services for all per-
sons age 65 and older and
eligible disabled individuals.
The program is administered by
the Health Care Financing
Administration.
Member: An individual enrolled
in a dental benefit program.
(See BenefBenefBenefBenefBeneficiariciariciariciariciaryyyyy).
N
National Provider Identifier
(NPI): a unique 10-digit identifi-
cation number issued to health
care providers in the United
States by the Centers for Medi-
care and Medicaid Services
(CMS)
Necessary Treatment: A
necessary dental procedure or
service as determined by a
dentist, to either establish or
maintain a patient’s oral health.
Such determinations are based
on the professional diagnostic
judgment of the dentist, and the
standards of care that prevail in
the professional community.
Noncontributory Program: A
method of payment for group
coverage in which all of the
monthly premium for the
program is paid by the sponsor.
Nonduplication of Benefits:
This may apply if a subscriber is
eligible for benefits under more
than one plan. A dental benefit
contract provision relieving the
third-party payer of liability for
cost of services if the services
are covered under another
program. Distinct from a
SAO OFFICE INSURANCE GUIDE
43
eligible persons.
Payer: In health care, generally
refers to entities, other than the
patient, that finance or reim-
burse the cost of health ser-
vices. In most cases, refers to
insurance carriers, other third-
party payers, and/or health plan
sponsors (employers or unions).
Peer Review:
1) A retrospective consider-
ation or an examination by
one or more individuals of
equal standing or rank.
2) A process established to
provide for review by li-
censed dentists of: the care
provided by a dentist for a
single patient; disputes
regarding fees; cases
submitted by carriers,
initiated by patients or
dentists; quality of care and
appropriateness of treat-
ment.
Peer Review Organization
(PRO): An organization estab-
lished by an amendment of the
Tax Equity and Fiscal Responsi-
bility Act of 1982 (TEFRA), to
provide for the review of medi-
cal services furnished primarily
in a hospital setting and/or in
conjunction with care provided
under the Medicare and Medic-
aid programs. In addition to
their review and monitoring
functions, these entities can
invoke sanctions, penalties, or
other corrective actions for
noncompliance in organization
standards.
Percentile: The number in a
frequency distribution below
which a certain percentage of
fees will fall. For example, the
90th percentile is the number
that divides the distribution of
fees into the lower 90% and the
upper 10%, or that fee level at
which 90% of dentists charge
that amount or less, and 10%
charge more.
Point of Service: Arrangements
in which patients with a man-
aged care dental plan have the
option of seeking treatment
from an “out-of-network” pro-
vider. The reimbursement for
the patient is usually based on a
low table of allowances, with
significantly reduced benefits
than if the patient had selected
an “in network” provider.
PHI: Protected Health Informa-
tion under HIPAA privacy rules.
It applies to oral, written, or
electronic “individually identifi-
able information”.
Point of Service (POS): Man-
aged care plan which allows
subscribers to go out of network
to receive service, although the
cost may be higher.
Post-treatment Review: See
AAAAAudituditudituditudit.
Preauthorization: Statement
by a third-party payer indicating
that proposed treatment will be
covered under the terms of the
benefit contract. See also
PrecerPrecerPrecerPrecerPrecertiftiftiftiftificationicationicationicationication, PredePredePredePredePredetttttermina-ermina-ermina-ermina-ermina-
tiontiontiontiontion.
Precertification: Confirmation
by a third-party payer of a
patient’s eligibility for coverage
under a dental benefit program.
See also PreauthorizationPreauthorizationPreauthorizationPreauthorizationPreauthorization,
PredePredePredePredePredettttterminationerminationerminationerminationermination.
Predetermination: An admin-
istrative procedure that may
require the dentist to submit a
treatment plan to the third party
before treatment is begun. The
third party usually returns the
treatment plan indicating one or
more of the following: patient’s
eligibility, guarantee of eligibility
period, covered services, benefit
amounts payable, application of
appropriate deductibles, co-
payment and/or maximum
limitation. Under some pro-
grams, predetermination by the
third party is required when
covered charges are expected to
exceed a certain amount, such
as $200. Also known as
PreauthorizationPreauthorizationPreauthorizationPreauthorizationPreauthorization,
PrecerPrecerPrecerPrecerPrecertiftiftiftiftificationicationicationicationication, PrePrePrePrePretreatmenttreatmenttreatmenttreatmenttreatment
RRRRReeeeevievievievieviewwwww, Prior APrior APrior APrior APrior Authorizationuthorizationuthorizationuthorizationuthorization.
Pre-existing Condition: Oral
health condition of an enrollee
which existed before his/her
enrollment in a dental program.
Orthodontic conditions are
always pre-existing.
Preferred Provider Organiza-
tion (PPO): A formal agree-
ment between a purchaser of a
dental benefit program and a
defined group of dentists for the
delivery of dental services to a
specific patient population, as
an adjunct to a traditional plan,
using discounted fees for cost
savings.
Prefiling of Fees: The submis-
sion of a participating dentist’s
usual fees to a service corpora-
tion for the purpose of establish-
ing, in advance, that dentist’s
usual fees and the customary
ranges of fees in a geographic
area to determine benefits
under a usual, customary, and
reasonable dental benefit
program.
Premium: The amount charged
by a dental benefit organization
for coverage of a level of ben-
efits for a specified time.
SAO OFFICE INSURANCE GUIDE
44
for a service covered by the
contractual arrangement.
Reinsurance: Insurance for
third-party payers to spread
their risk for losses (claim paid)
over a specified dollar amount.
Relative Value System:
Coded listing of professional
services with unit values to
indicate relative complexity as
measured by time, skill, and
overhead costs. Third-party
payers typically assign a dollar
value per unit to calculate
provider reimbursement.
Retail Store Dentistry: Refers
to dental services offered within
a retail, department or drug
store operation. Typically, space
is leased from the store by a
separate administrative group
that, in turn, subleases to a
dentist or dental group provid-
ing the actual dental services.
The dental operation generally
maintains the same hours of
operation as the store and
appointments often are not
necessary. Considered to be a
type of practice, not a dental
benefit plan model.
Retrospective Review: A post-
treatment assessment of
services on a case-by-case or
aggregate basis after the
services have been performed.
Risk Pool: A portion of pro-
vider fees or capitation pay-
ments withheld as financial
reserves to cover unanticipated
utilization of services in an
alternative benefit plan.
S
Schedule of Allowances: See
TTTTTable of Alloable of Alloable of Alloable of Alloable of Allowwwwwancesancesancesancesances.
Prepaid Dental Plan: A
method of financing the cost of
dental care for a defined popu-
lation, in advance of receipt of
services.
Prepaid Group Practice: See
Closed PClosed PClosed PClosed PClosed Panelanelanelanelanel.
Pretreatment Estimate: See
PredePredePredePredePredettttterminationerminationerminationerminationermination.
Prevailing Fee: Term used by
some dental benefit organiza-
tions to refer to the fee most
commonly charged for a dental
service in a given area.
Preventive Dentistry: Refers
to the procedures in dental
practice and health programs
which prevent the occurrence of
oral diseases.
Prior Authorization: See
PredePredePredePredePredettttterminationerminationerminationerminationermination.
PrPrPrPrProof of Loss:oof of Loss:oof of Loss:oof of Loss:oof of Loss: Verification of
services-rendered expenses
incurred by the submission of
claim forms, radiographs, study
models, and/or other diagnostic
material.
Prospective Review: Prior
assessment by a payer or
payer’s agent that proposed
services are appropriate for a
particular patient, and/or the
patient and the category of
service are covered by a benefit
plan. (See PreauthorizationPreauthorizationPreauthorizationPreauthorizationPreauthorization,
PrecerPrecerPrecerPrecerPrecertiftiftiftiftificationicationicationicationication, PredePredePredePredePredetttttermina-ermina-ermina-ermina-ermina-
tiontiontiontiontion, Second-opinion PrSecond-opinion PrSecond-opinion PrSecond-opinion PrSecond-opinion Programogramogramogramogram).
Protected Health Information
(PHI): any information about
health status, provision of
health care, or payment for
health care that can be linked to
an individual.. This is inter-
preted broadly and includes any
part of a patient’s medical
record or payment history.
Purchaser: Program sponsor,
often employer or union, that
contracts with the dental benefit
organization to provide dental
benefits to an enrolled popula-
tion.
Q
Quality Assessment: The
measure of the quality of care
provided in a particular setting.
Quality Assurance: The
assessment or measurement of
the quality of care and the
implementation of any neces-
sary changes to either maintain
or improve the quality of care
rendered.
R
Reasonable and Customary
(R&C) Plan: A dental benefit
plan that determines benefits
based only on “Reasonable and
Customary” fee criteria. (See
Usual FUsual FUsual FUsual FUsual Feeeeeeeeee, CustCustCustCustCustomaromaromaromaromary Fy Fy Fy Fy Feeeeeeeeee, and
RRRRReasonable Feasonable Feasonable Feasonable Feasonable Feeeeeeeeee).
Reasonable Fee: The fee
charged by a dentist for a
specific dental procedure that
has been modified by the nature
and severity of the condition
being treated and by any medi-
cal or dental complications or
unusual circumstances, and
therefore may differ from the
dentist’s “usual” fee or the
benefit administrator’s “custom-
ary” fee.
Reimbursement: Payment
made by a third party to a
beneficiary or to a dentist on
behalf of the beneficiary, toward
repayment of expenses incurred
SAO OFFICE INSURANCE GUIDE
45
Schedule of Benefits: A
listing of the services for which
payment will be made by a
third-party payer, without
specification of the amount to
be paid.
Second-Opinion Program: An
opinion about the appropriate-
ness of a proposed treatment
provided by a practitioner other
than the one making the origi-
nal recommendation; some
benefit plans require such
opinions for selected services.
Self-Funding: The method of
providing employee benefits, in
which the sponsor does not
purchase conventional insur-
ance, but rather elects to pay for
the claims directly, generally
through the services of a TPA.
Self-funded programs often
have stop-loss insurance in
place to cover abnormal risks.
Self Insurance: Setting aside
of funds by an individual or
organization to meet antici-
pated dental care expenses or
its dental care claims, and
accumulation of a fund to
absorb fluctuations in the
amount of expenses or claims.
The funds set aside or accumu-
lated are used to provide dental
benefits directly instead of
purchasing coverage from an
insurance carrier.
Service Corporations: Dental
benefit organizations estab-
lished under non-for-profit state
statutes for the purpose of
providing health care coverage,
e.g., Delta Dental Plans, Blue
Cross and Blue Shield Plans.
Statistically-based Utilization
Review: A system that exam-
ines the distribution of treat-
ment procedures based on
claims information and in order
to be reasonably reliable, the
application of such claims
analyses of specific dentists
should include data on type of
practice, dentist’s experience,
socioeconomic characteristics,
and geographic location.
Stop-Loss: A general term
referring to that category of
coverage that provides insur-
ance protection (reinsurance) to
an employer for a self-funded
plan.
Subscriber: The person,
usually the employee, who
represents the family unit in
relation to the dental benefit
program. This term is most
commonly used by service
corporation plans. Also known
as: Certificate Holder, Enrollee.
Summary Plan Description:
See BenefBenefBenefBenefBenefit Plan Summarit Plan Summarit Plan Summarit Plan Summarit Plan Summaryyyyy.
Surcharge: A stated dollar
amount paid to the dentist by
the beneficiary, in addition to
other reimbursement received
by third-party payer(s).
Systematized Nomenclature
of Dentistry (SNODENT): a
dental diagnostic vocabulary
incompletely integrated in
SNOMED-CT). SNODENT codes
identify diseases, primary and
secondary diagnoses, anatomy,
morphology, risk factors, condi-
tions, and social factors affect-
ing health (such as smoking) in
indicate the necessity of treat-
ment (line #58 of ADA standard-
ized insurance form).
T
Table of Allowances: A list of
covered services with an as-
signed dollar amount that
represents the total obligation
of the plan with respect to
payment for such service, but
does not necessarily represent
the dentist’s full fee for that
service. Also known as ScScScScSched-hed-hed-hed-hed-
ule of Alloule of Alloule of Alloule of Alloule of Allowwwwwancesancesancesancesances, IndemnityIndemnityIndemnityIndemnityIndemnity
ScScScScSchedulehedulehedulehedulehedule.
Tax Equity and Fiscal Respon-
sibility Act of 1982 (TEFRA):
Legislation (Public Law 97-248)
affecting health maintenance
organizations and the Medicare
and Medicaid programs. Pro-
vides regulations for the devel-
opment of HMO risk contracting
with the Medicare program and,
through amendment, estab-
lished new provisions for the
foundation and operation of
peer review organizations.
Termination Date: See Expira-Expira-Expira-Expira-Expira-
tion Dattion Dattion Dattion Dattion Dateeeee.
Third Party: The party to a
dental benefit contract that may
collect premiums, assume
financial risk, pay claims, and/
or provides other administrative
services. Also known as AAAAAdmin-dmin-dmin-dmin-dmin-
istrativistrativistrativistrativistrative Ae Ae Ae Ae Agent, Carriergent, Carriergent, Carriergent, Carriergent, Carrier, Insurer, Insurer, Insurer, Insurer, Insurer,,,,,
UnderUnderUnderUnderUnderwritwritwritwritwritererererer.
Third Party Administrator
(TPA): Claims payer who as-
sumes responsibility for admin-
istering health benefit plans
without assuming any financial
risk. Some commercial insur-
ance carriers and Blue Cross/
Blue Shield plans also have TPA
operations to accommodate
self-funded employers seeking
administrative services only
(ASO) contracts.
Third-Party Payer: An organi-
zation other than the patient
SAO OFFICE INSURANCE GUIDE
46
(first party) or health care
provider (second party) involved
in the financing of personal
health services.
U
Unbundling of Procedures:
The separating of a dental
procedure into component parts
with each part having a charge
so that the cumulative charge of
the components is greater than
the total charge to patients who
are not beneficiaries of a dental
benefit plan for the same
procedure.
Upcode:Upcode:Upcode:Upcode:Upcode: Using a procedure
code that reflects a higher
intensity service than would
normally be used for the ser-
vices delivered.
Usual, Customary and Rea-
sonable (UCR) Plan: A dental
benefit plan that determines
benefits based on “Usual,
Customary, and Reasonable”
fee criteria. (See Usual FUsual FUsual FUsual FUsual Feeeeeeeeee,
CustCustCustCustCustomaromaromaromaromary Fy Fy Fy Fy Feeeeeeeeee, and RRRRReason-eason-eason-eason-eason-
able Fable Fable Fable Fable Feeeeeeeeee).
Usual Fee: The fee that an
individual dentist most fre-
quently charges for a given
dental service. (See also Cus-Cus-Cus-Cus-Cus-
tttttomaromaromaromaromary Fy Fy Fy Fy Feeeeeeeeee and RRRRReasonableeasonableeasonableeasonableeasonable
FFFFFeeeeeeeeee).
Utilization:
1) The extent to which the
members of a covered
group use a program over a
stated period of time;
specifically measured as a
percentage determined by
dividing the number of
covered individuals who
submitted one or more
claims by the total number
of covered individuals.
2) An expression of the num-
ber and types of services
used by the members of a
covered group over a speci-
fied period of time.
Utilization Management: A
set of techniques used by or on
behalf of purchasers of health
care benefits to manage the
cost of health care prior to this
provision by influencing patient
care decision-making through
case-by-case assessments of
the appropriateness of care
based on accepted dental
practices.
Utilization Review, statisti-
cally based: A system that
examines the distribution of
treatment procedures based on
claims information and in order
to be reasonably reliable, the
application of such claims
analyses of specific dentists
should include data on type of
practice, dentist’s experience,
socioeconomic characteristics,
and geographic location.
W
Waiting Period: The period
between employment or enroll-
ment in a dental program and
the date when a covered person
becomes eligible for benefits.
SAO OFFICE INSURANCE GUIDE
47
CHAPTER 9: FREQUENTLCHAPTER 9: FREQUENTLCHAPTER 9: FREQUENTLCHAPTER 9: FREQUENTLCHAPTER 9: FREQUENTLY ASKED INSURANCE QUESTIONSY ASKED INSURANCE QUESTIONSY ASKED INSURANCE QUESTIONSY ASKED INSURANCE QUESTIONSY ASKED INSURANCE QUESTIONS
§ Do mDo mDo mDo mDo my ory ory ory ory ortho beneftho beneftho beneftho beneftho benefits starits starits starits starits start ot ot ot ot ovvvvver if mer if mer if mer if mer if my employ employ employ employ employyyyyer cer cer cer cer changes insurance companies while mhanges insurance companies while mhanges insurance companies while mhanges insurance companies while mhanges insurance companies while myyyyy
ccccchild is in treatment?hild is in treatment?hild is in treatment?hild is in treatment?hild is in treatment?
Your original insurance company ceases to pay and you reapply to the new plan with appropri
ate information about the old plan. Most of the time the new coverage will only pick up where
the prior carrier left off.
§ WhWhWhWhWhy doesn’t my doesn’t my doesn’t my doesn’t my doesn’t my insurance company insurance company insurance company insurance company insurance company pay pay pay pay pay my my my my my ory ory ory ory orthodontic benefthodontic benefthodontic benefthodontic benefthodontic benefits up frits up frits up frits up frits up front?ont?ont?ont?ont?
No insurance company will do this. Only with IRS sanctioned Sec. #125 or #105 payroll
deduction plans is this possible, but not practical with orthodontics because of long duration.
§ Will mWill mWill mWill mWill my insurance continue ty insurance continue ty insurance continue ty insurance continue ty insurance continue to pao pao pao pao pay fy fy fy fy for mor mor mor mor my treatment when I leay treatment when I leay treatment when I leay treatment when I leay treatment when I leavvvvve me me me me my job since treatmenty job since treatmenty job since treatmenty job since treatmenty job since treatment
starstarstarstarstarttttted prior ted prior ted prior ted prior ted prior to mo mo mo mo my leay leay leay leay leaving?ving?ving?ving?ving?
Not unless you opt for COBRA extension at your expense
§ Does insurance paDoes insurance paDoes insurance paDoes insurance paDoes insurance pay fy fy fy fy for replacement, bror replacement, bror replacement, bror replacement, bror replacement, brokokokokoken, or lost reen, or lost reen, or lost reen, or lost reen, or lost retainertainertainertainertainers?s?s?s?s?
Retainers are usually not covered because there is rarely any benefit remaining after paying
for treatment. *Remember the lifetime benefit is usually $1000-$1500, although a few may
pay $2000.
§ Will mWill mWill mWill mWill my insurance pay insurance pay insurance pay insurance pay insurance pay fy fy fy fy for treatment if there is a wor treatment if there is a wor treatment if there is a wor treatment if there is a wor treatment if there is a waiting period and I begin treatment prioraiting period and I begin treatment prioraiting period and I begin treatment prioraiting period and I begin treatment prioraiting period and I begin treatment prior
ttttto the wo the wo the wo the wo the waiting period being up?aiting period being up?aiting period being up?aiting period being up?aiting period being up?
Beginning treatment before waiting period up: The insurance may only pay on the balance
owed at the end of the wait period. Check first and find out.
§ HoHoHoHoHow long do I haw long do I haw long do I haw long do I haw long do I havvvvve te te te te to fo fo fo fo file a claim on serile a claim on serile a claim on serile a claim on serile a claim on services rendered?vices rendered?vices rendered?vices rendered?vices rendered?
File as soon as you have a billable claim.
§ What is “usual and custWhat is “usual and custWhat is “usual and custWhat is “usual and custWhat is “usual and customaromaromaromaromary”?y”?y”?y”?y”?
Usual Fee – fee for service charged by dentist for a procedure
Customary Fee – average fee charged by dentists for a procedure within a specific geographic
region (first 3 numbers of zip code)
Don’t forget: Reasonable Fee – a fee above the usual fee charged by dentist for complex
cases
Example:
Dentists Fee for Procedure $100
Customary Fee for Procedure $ 90
UCR based on 90th % of Customary Fee $ 81
Copayment $ 19
NOTE: Carrier liability based on % of UCR not % of dentist’s fee
§ If mIf mIf mIf mIf my cy cy cy cy child has 2 phases of treatment and I do nohild has 2 phases of treatment and I do nohild has 2 phases of treatment and I do nohild has 2 phases of treatment and I do nohild has 2 phases of treatment and I do not use all of the lift use all of the lift use all of the lift use all of the lift use all of the lifeeeeetime ftime ftime ftime ftime for phase 1 treat-or phase 1 treat-or phase 1 treat-or phase 1 treat-or phase 1 treat-
ment will I gement will I gement will I gement will I gement will I get the remaining beneft the remaining beneft the remaining beneft the remaining beneft the remaining benefits fits fits fits fits for phase 2?or phase 2?or phase 2?or phase 2?or phase 2?
If Phase I is under $3000 for $1000-$1500 maximum, then you have some money left for
Phase II. You should check with your insurance company.
§ What does “fWhat does “fWhat does “fWhat does “fWhat does “fee scee scee scee scee schedule” mean?hedule” mean?hedule” mean?hedule” mean?hedule” mean?
A table of allowances offered by the Plan based on their idea of UCR (see above)
§ Does insurance usually paDoes insurance usually paDoes insurance usually paDoes insurance usually paDoes insurance usually pay fy fy fy fy for records separator records separator records separator records separator records separately?ely?ely?ely?ely?
Up to the Insurance company. Try and put records on patients dental insurance and save
SAO OFFICE INSURANCE GUIDE
48
treatment for orthodontic insurance.
§ What is a dental HMO plan?What is a dental HMO plan?What is a dental HMO plan?What is a dental HMO plan?What is a dental HMO plan?
Dental HMO: a discount plan for participating dentists agreeing to treat for the fixed fee offered
by the Plan. Patients can not go out of network
§ If an insurance companIf an insurance companIf an insurance companIf an insurance companIf an insurance company say say say say says theys theys theys theys they pay pay pay pay pay 50% does that mean they 50% does that mean they 50% does that mean they 50% does that mean they 50% does that mean they pay pay pay pay pay 50% of the ty 50% of the ty 50% of the ty 50% of the ty 50% of the toooootal ftal ftal ftal ftal fee?ee?ee?ee?ee?
It means it pays 50% of fee OR the life-time maximum benefit—whichever is less.
§ What is dual coWhat is dual coWhat is dual coWhat is dual coWhat is dual covvvvverage?erage?erage?erage?erage?
If each parent has an orthodontic plan from different companies, usually both will pay, but one
will be the primary and all records have to be sent to the secondary to receive payment. It is
against most state laws for the 2nd to withhold pay.
• What does non-duplication of benefWhat does non-duplication of benefWhat does non-duplication of benefWhat does non-duplication of benefWhat does non-duplication of benefits mean?its mean?its mean?its mean?its mean?
This means that the primary carrier must not pay as much or more than the secondary would if
they were primary.
Example: #1
Primary pays $1500
Secondary pays $1500- This carrier has the non-duplication clause. It will not pay anything.
Example: #2
Primary pays $750
Secondary pays $1500- Secondary will only pay up to $750. This plan is paying the
difference in what it will pay and what primary pays. (The company with the non-duplication
clause will not pay more than the first company even though the lifetime amount is higher.
Not all companies have this clause. Check the benefit booklet.
• If I am tIf I am tIf I am tIf I am tIf I am told I need eold I need eold I need eold I need eold I need extractions does this come out of mxtractions does this come out of mxtractions does this come out of mxtractions does this come out of mxtractions does this come out of my ory ory ory ory orthodontic lifthodontic lifthodontic lifthodontic lifthodontic lifeeeeetime maximum ortime maximum ortime maximum ortime maximum ortime maximum or
does this come out of mdoes this come out of mdoes this come out of mdoes this come out of mdoes this come out of my regular dental?y regular dental?y regular dental?y regular dental?y regular dental?
Some companies will take this from your lifetime orthodontic maximum and some don’t.
Check with your carrier.
(Dr. Michael Rogers’ office completes the form aove while verifying insurance information.)
INSURANCE VERIFICINSURANCE VERIFICINSURANCE VERIFICINSURANCE VERIFICINSURANCE VERIFICAAAAATION FTION FTION FTION FTION FORMORMORMORMORM
PPPPPAAAAATIENT NAME:TIENT NAME:TIENT NAME:TIENT NAME:TIENT NAME:
INSURED:INSURED:INSURED:INSURED:INSURED:
Insured SS or ID#:Insured SS or ID#:Insured SS or ID#:Insured SS or ID#:Insured SS or ID#:
Place of EmploPlace of EmploPlace of EmploPlace of EmploPlace of Employmentymentymentymentyment:::::
PPPPPatient D.O.B.:atient D.O.B.:atient D.O.B.:atient D.O.B.:atient D.O.B.:
Insured D.O.B.:Insured D.O.B.:Insured D.O.B.:Insured D.O.B.:Insured D.O.B.:
GrGrGrGrGroup #:oup #:oup #:oup #:oup #:
ORTHO BENEFIT INFORTHO BENEFIT INFORTHO BENEFIT INFORTHO BENEFIT INFORTHO BENEFIT INFO:O:O:O:O:
DatDatDatDatDate:e:e:e:e:
TTTTTalkalkalkalkalked ted ted ted ted to:o:o:o:o:
EfEfEfEfEffffffectivectivectivectivective Date Date Date Date Date:e:e:e:e:
Maximum LifMaximum LifMaximum LifMaximum LifMaximum Lifeeeeetime:time:time:time:time:
AAAAAge Limitge Limitge Limitge Limitge Limit:::::
BenefBenefBenefBenefBenefits Used:its Used:its Used:its Used:its Used:
WWWWWaiting Paiting Paiting Paiting Paiting Period:eriod:eriod:eriod:eriod:
% of P% of P% of P% of P% of Paaaaaymentymentymentymentyment:::::
Initial PInitial PInitial PInitial PInitial Paaaaaymentymentymentymentyment::::: AAAAAutututututo?o?o?o?o?
Deductible:Deductible:Deductible:Deductible:Deductible:
SAO OFFICE INSURANCE GUIDE
49
§ What is fWhat is fWhat is fWhat is fWhat is fee fee fee fee fee for seror seror seror seror service?vice?vice?vice?vice?
The fee the dentist decides his service is worth where by the patient makes up the difference
from what the insurance company pays (balanced billing).
§ WhWhWhWhWhy is ory is ory is ory is ory is orthodontic treatment so costly?thodontic treatment so costly?thodontic treatment so costly?thodontic treatment so costly?thodontic treatment so costly?
Looking at the cost per visit and the results of a beautiful smile will seem inexpensive in rela
tion to other Services. It is important to get the message of the AAO public awareness cam
paign across: “Orthodontists have 2-3 years of specialized education beyond dental school to
learn the proper way to align and straighten teeth.”
• Do annual deductibles apply tDo annual deductibles apply tDo annual deductibles apply tDo annual deductibles apply tDo annual deductibles apply to oro oro oro oro orthodontic benefthodontic benefthodontic benefthodontic benefthodontic benefits?its?its?its?its?
Up to the insurance company. The usual deductible is $50-150. It is good to ask the insurance
company when checking the patient’s eligibility.
• My fMy fMy fMy fMy fee is $5500 with a 5% cash deduction. If the patient paee is $5500 with a 5% cash deduction. If the patient paee is $5500 with a 5% cash deduction. If the patient paee is $5500 with a 5% cash deduction. If the patient paee is $5500 with a 5% cash deduction. If the patient pays cash, what fys cash, what fys cash, what fys cash, what fys cash, what fee amount goesee amount goesee amount goesee amount goesee amount goes
on the insurance claim?on the insurance claim?on the insurance claim?on the insurance claim?on the insurance claim?
The ADA insurance claim form states: “I hereby certify that the procedures as indicated by date
are in progress or have been completed.” You should enter $5225 on the insurance claim form
as the total fee. To do otherwise would be to commit fraud.
NOTE: Many offices will only discount 2.5% if paid by a credit card in order to capture the costs
associated with charging on a credit card. The exact amount you charge should be entered on
the insurance claim form.
SAO OFFICE INSURANCE GUIDE
50
QUESTIONS ON FLEXIBLE SPENDING AQUESTIONS ON FLEXIBLE SPENDING AQUESTIONS ON FLEXIBLE SPENDING AQUESTIONS ON FLEXIBLE SPENDING AQUESTIONS ON FLEXIBLE SPENDING ACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTSSSSSQuestions and Answers by John Stoner
What is a FleWhat is a FleWhat is a FleWhat is a FleWhat is a Flexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Account?ccount?ccount?ccount?ccount?
There are two types of Flexible Spending Accounts:
• Health Care Spending AHealth Care Spending AHealth Care Spending AHealth Care Spending AHealth Care Spending Accountccountccountccountccount
This allows employees to set aside pre-tax dollars, for themselves and their dependents, to pay
medical, dental, and vision expenses not covered under current benefit plans. Out-of-pocket
expenses such as deductibles, co-payments, coinsurance, prescriptions and eyeglasses are
eligible and can be paid with pre-tax dollars.
• Dependent Care RDependent Care RDependent Care RDependent Care RDependent Care Reimbureimbureimbureimbureimbursement Asement Asement Asement Asement Accountccountccountccountccount
This allows employees to pay dependent care expenses with the same pre-tax dollars.
With the proper plan, Flexible Spending Accounts can have a significant economic impact.
Health Care Spending AHealth Care Spending AHealth Care Spending AHealth Care Spending AHealth Care Spending Accountccountccountccountccount
This can be used to nearly everyone and pays for many expenses not covered under current medical,
dental, or vision plans. Most common eligible expenses include:
• Health insurance deductibles, co-pays, and coinsurance
• Dental services or expenses not covered under a dental plan
• Vision care expenses such as eyeglasses, contact lens, and lasik surgery
• Hearing aids
• Chiropractic services
• Physical Therapy and Massage
• Acupuncture
• Ambulance service
• Prosthetics
• Wheelchairs
Dependent Care Spending ADependent Care Spending ADependent Care Spending ADependent Care Spending ADependent Care Spending Accountccountccountccountccount
Pays for expenses such as daycare, nursery school and babysitting while you are at work. Those eligible
for dependent care reimbursement are:
• Children under age 13.
• A disabled child, spouse, or parent that qualified as a dependent for tax purposes.
HoHoHoHoHow are Flew are Flew are Flew are Flew are Flexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Accounts funded?ccounts funded?ccounts funded?ccounts funded?ccounts funded?
The employer makes arrangements through Flex Administrative Services to administer this program.
Employees determine how much they want to contribute to their account. This amount will be deducted
from their paycheck and deposited into their accounts.
When an eligible expense is incurred, simply submit a reimbursement request to Flex Administrative
Services along with the Explanation of Benefits from the insurance carrier or an original receipt for
services rendered.
SAO OFFICE INSURANCE GUIDE
51
HoHoHoHoHow much can I contributw much can I contributw much can I contributw much can I contributw much can I contribute?e?e?e?e?
• Health Care Spending Account maximum is employer determined.
• Dependent Care Spending Account maximum is not to exceed $5,000.00
However, for a married couple in which a spouse earns less than $5,000, the maximum contribution is
the total income of the spouse with the lower income. Maximum contribution is $2,500 per year for
married couples filing individual tax returns.
What if I don’t use all the moneWhat if I don’t use all the moneWhat if I don’t use all the moneWhat if I don’t use all the moneWhat if I don’t use all the money in my in my in my in my in my account during the yy account during the yy account during the yy account during the yy account during the year?ear?ear?ear?ear?
Contributions do not roll over from one plan year to the next. Therefore, careful planning is required. It
is very important to estimate the amount of eligible expense you plan to incur so that all funds are
used by the end of each plan year. Most expenditures are controllable and predictable.
The cut-off date for filing claims for services incurred during a plan year is 60 da60 da60 da60 da60 days ys ys ys ys after the plan year-
ends.
Claims must be incurred during the plan year to qualify for reimbursement.
Is it smarIs it smarIs it smarIs it smarIs it smarttttter ter ter ter ter to tako tako tako tako take credit fe credit fe credit fe credit fe credit for dependent care eor dependent care eor dependent care eor dependent care eor dependent care expenses on mxpenses on mxpenses on mxpenses on mxpenses on my income tax ory income tax ory income tax ory income tax ory income tax or
open a Fleopen a Fleopen a Fleopen a Fleopen a Flexible Spending account?xible Spending account?xible Spending account?xible Spending account?xible Spending account?
For qualified dependents, childcare and dependent care expense can be a direct tax credit on your
federal income tax return. For married couples with an adjusted gross income less than $20,000, a
direct tax credit could offer more savings than a Flexible Spending Account.
It’s always best to check with a tax advisor on this issue.
Aren’t medical eAren’t medical eAren’t medical eAren’t medical eAren’t medical expenses considered an eligible deduction fxpenses considered an eligible deduction fxpenses considered an eligible deduction fxpenses considered an eligible deduction fxpenses considered an eligible deduction for income tax puror income tax puror income tax puror income tax puror income tax pur-----
poses? If so, whposes? If so, whposes? If so, whposes? If so, whposes? If so, why do I need a Fley do I need a Fley do I need a Fley do I need a Fley do I need a Flexible Spending Axible Spending Axible Spending Axible Spending Axible Spending Account?ccount?ccount?ccount?ccount?
Non-reimbursed medical expense is considered an eligible deduction when filing long form, itemizing
deductions, and expenses are greater than 7.5 percent of adjusted gross income.
Most people do not incur enough ineligible expense to meet the second requirement. For example,
assuming a $20,000 annual income, $1,500 in incurred ineligible medical expense would be neces-
sary before claiming any deductions. In this case, only expenses above $1,500 can be deducted. For
nearly everyone, a Health Care Spending Account is a better way to save money.
When can I change the contribution amount?When can I change the contribution amount?When can I change the contribution amount?When can I change the contribution amount?When can I change the contribution amount?
Changes may be made once a year at open enrollment for the following plan year. However, qualifying
events, such as a change in marital status, birth or adoption of a child, or death in the immediate
family will allow changes to be made during the plan year.
HoHoHoHoHow do I gew do I gew do I gew do I gew do I get reimburt reimburt reimburt reimburt reimbursed?sed?sed?sed?sed?
Simply mail a request to Flex Administrative Services with the easy-to-complete form. Include expla-
nation of benefits from insurance carrier or receipts for eligible expenses. Claim forms are available
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through your employer at the beginning of each plan year. Some FSA’s require a receipt before pay-
ment will be issued.
What if I sWhat if I sWhat if I sWhat if I sWhat if I stttttop wop wop wop wop worororororking?king?king?king?king?
Health Care Account: Submit claims for expenses incurred through the last day you worked.
Dependent Care Account: Submit claims for expenses you will incur throughout plan year, up to
amount available on deposit.
HoHoHoHoHow do I gew do I gew do I gew do I gew do I get st st st st startartartartarttttted?ed?ed?ed?ed?
Sign up now by completing the Flexible Spending Accounts enrollment form.
DEPENDENT CDEPENDENT CDEPENDENT CDEPENDENT CDEPENDENT CARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAT ARE ELIGIBLE:T ARE ELIGIBLE:T ARE ELIGIBLE:T ARE ELIGIBLE:T ARE ELIGIBLE:
An eligible dependent is any dependent who is less than 13 years old and your dependent under
federal income tax rules. An eligible dependent may also include your mentally or physically impaired
spouse or a dependent who is incapable of caring for himself or herself (for example, an invalid par-
ent). The dependent must spend at least eight hours per day in your home.
Child care services will qualify for reimbursement from the Dependent Care Reimbursement
Account if the meet these requirements.
§ The child must be under 13-years-old and must be your dependent under federal tax rules.
Note: If your child turns 13 during the year, you cannot stop your contribution at that time.
• The services may be provided inside or outside your home, but not by someone who is your
minor child or dependent for income tax purposes (for example, an older child).
• If the services are provided by a daycare facility that cares for six or more children at the same
time, it must be a qualified daycare center.
• The service must be incurred to enable you, or you and your spouse if you are married, to be
employed.
• The amount to be reimbursed must not be greater than spouse’s income or one-half your
income, whichever is lower.
• Services must be for the physical care of the child, not for education, meals, etc. Kindergarten
expenses must separate out the cost of custodial care from education to reimburse.
Allowable Dependent Care expenses include payments to the following when the expenses enable you
to work:
• Child care centers
• Family daycare providers
• Baby-sitters
• Nursery schools
• Caregivers for a disabled dependent or spouse who live with you
• Household services, provided that a portion of these expenses are for a qualifying dependent
incurred to ensure the dependent’s well-being maintenance
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DEPENDENT CDEPENDENT CDEPENDENT CDEPENDENT CDEPENDENT CARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAARE EXPENSES THAT ARE NOT ARE NOT ARE NOT ARE NOT ARE NOT ELIGIBLE:T ELIGIBLE:T ELIGIBLE:T ELIGIBLE:T ELIGIBLE:
• Dependent care expenses that are provided to one of your dependents by a family member,
unless the family member is age 19 or over by the end of the year and will not be claimed as a
dependent
• Expenses for food and clothing
• Educations expenses from Kindergarten and higher
• Health care expenses for your dependents
• Overnight camps
New in 2008- you may “apply” or “carry over” the unused contributions in your FSA to your pharmacy,
to be used for approved medications.
HINT
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54
Analysis of the After Tax Costs to Pay for Dental Services
Income TIncome TIncome TIncome TIncome Tax Bracax Bracax Bracax Bracax Brackkkkkeeeeetststststs 15.00%15.00%15.00%15.00%15.00% 28.00%28.00%28.00%28.00%28.00% 3333311111.00%.00%.00%.00%.00%
7 7 7 7 7.65%.65%.65%.65%.65% 7 7 7 7 7.65%.65%.65%.65%.65% 7 7 7 7 7.65%.65%.65%.65%.65%
___________________________________ ________________________________________ ________________________________________
TTTTToooootaltaltaltaltal 22.65%22.65%22.65%22.65%22.65% 35.65%35.65%35.65%35.65%35.65% 38.65% 38.65% 38.65% 38.65% 38.65%
Amount of UnreimburAmount of UnreimburAmount of UnreimburAmount of UnreimburAmount of Unreimbursed Dental Sersed Dental Sersed Dental Sersed Dental Sersed Dental Servicesvicesvicesvicesvices
AAAAActual Dollar Amountctual Dollar Amountctual Dollar Amountctual Dollar Amountctual Dollar Amount TTTTTax Bracax Bracax Bracax Bracax Brackkkkkeeeeettttt AAAAActual Tctual Tctual Tctual Tctual Taxaxaxaxax TTTTToooootal Costtal Costtal Costtal Costtal Cost
Of Dental ExpenseOf Dental ExpenseOf Dental ExpenseOf Dental ExpenseOf Dental Expense
$ 200.00$ 200.00$ 200.00$ 200.00$ 200.00 22.65% 22.65% 22.65% 22.65% 22.65% $ 45.30 $ 45.30 $ 45.30 $ 45.30 $ 45.30 $ 2 $ 2 $ 2 $ 2 $ 245.3045.3045.3045.3045.30
35.65% 35.65% 35.65% 35.65% 35.65% $ 7 $ 7 $ 7 $ 7 $ 711111.30.30.30.30.30 $ 2 $ 2 $ 2 $ 2 $ 27777711111.30.30.30.30.30
38.65% 38.65% 38.65% 38.65% 38.65% $ 7 $ 7 $ 7 $ 7 $ 777777.30.30.30.30.30 $ 2 $ 2 $ 2 $ 2 $ 27777777777.30.30.30.30.30
$ 600.00$ 600.00$ 600.00$ 600.00$ 600.00 22.65% 22.65% 22.65% 22.65% 22.65% $ 1 $ 1 $ 1 $ 1 $ 135.9035.9035.9035.9035.90 $ 735.90 $ 735.90 $ 735.90 $ 735.90 $ 735.90
35.65% 35.65% 35.65% 35.65% 35.65% $ 2 $ 2 $ 2 $ 2 $ 2111113.903.903.903.903.90 $ 8 $ 8 $ 8 $ 8 $ 8111113.903.903.903.903.90
38.65% 38.65% 38.65% 38.65% 38.65% $ 23 $ 23 $ 23 $ 23 $ 2311111.90.90.90.90.90 $ 83 $ 83 $ 83 $ 83 $ 8311111.90.90.90.90.90
$1$1$1$1$1000.00000.00000.00000.00000.00 22.65% 22.65% 22.65% 22.65% 22.65% $ 226.50 $ 226.50 $ 226.50 $ 226.50 $ 226.50 $1 $1 $1 $1 $1226.50226.50226.50226.50226.50
35.65% 35.65% 35.65% 35.65% 35.65% $ 356.50 $ 356.50 $ 356.50 $ 356.50 $ 356.50 $1 $1 $1 $1 $1356.50356.50356.50356.50356.50
38.65% 38.65% 38.65% 38.65% 38.65% $ 386.50 $ 386.50 $ 386.50 $ 386.50 $ 386.50 $1 $1 $1 $1 $1386.50386.50386.50386.50386.50
$3000.00$3000.00$3000.00$3000.00$3000.00 22.65% 22.65% 22.65% 22.65% 22.65% $ 679.50 $ 679.50 $ 679.50 $ 679.50 $ 679.50 $3679.50 $3679.50 $3679.50 $3679.50 $3679.50
35.65% 35.65% 35.65% 35.65% 35.65% $1 $1 $1 $1 $1069.50069.50069.50069.50069.50 $4069.50 $4069.50 $4069.50 $4069.50 $4069.50
38.65% 38.65% 38.65% 38.65% 38.65% $1159.50 $1159.50 $1159.50 $1159.50 $1159.50 $4 $4 $4 $4 $4159.50159.50159.50159.50159.50
FLEXIBLE SPENDING ACCOUNTS
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FLEXIBLE SPENDING ACCOUNTS
COUNTS
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Southern Association of Orthodontists
Policies, Letters and Forms
Privacy Policy MODEL POLICY PRIVACY NOTICE PRIVACY CONSENT PRIVACY AUTHORIZATION PRIVACY AGREEMENT
Patient Education/ Sample Policy Letters STEP-BY-STEP FILING OF DENTAL INSURANCE FOR MANAGED CARE PLANS PATIENT AND DENTAL BENEFITS INFORMATION INFORMATION ON THIRD PARTIES OFFICE POLICY FOR OUR PATIENTS WHO HAVE ORTHODONTIC “INSURANCE” Policy for Office not Accepting on Orthodontic Insurance (but encouraging FSA) Policy for Office not Accepting Orthodontic Insurance (but encouraging DR)
WHAT YOU SHOULD KNOW ABOUT YOUR ORTHODONTIC INSURANCE BENEFIT SAMPLE LETTERS AND FORMS # 1 Letter to Insurance Company Refusal of Request for Tax Identification Number (from AAO) # 2 Letter to Insurance Company: Refusal of Request for Continuation of Treatment Form #3 Letter to Insurance Company: Refusal of Request for Orthodontic Records (from AAO) #4 Letter to Patient: Doctor’s Refusal to Accept Assignment of Benefits #5 Letter to Patient: Acceptance of Assignment of Benefits as Non-provider for Insurance Companies #6 Helpful Information to Patient Denial of Claims (from AAO) #7 Letter from Patient to Insurance Company: Denial of Claim (from AAO) #8 Letter from Doctor to Patient: Doctor Non-participation in Preferred Provider Plans #9 OFFICE POLICY REGARDING MONTHLY/QUARTERLY CONTINUATION OF TREATMENT FORMS #10 Insurance Verification Form #11 Insurance Benefits/Payment Agreement
Flexible Spending Accounts and Direct Reimbursement Plans #12 Relevant Sections of the IRS Code Regarding Orthodontics and Flexible Spending Accounts #13 Sample Sales Letter for Direct Reimbursement #14 Instructions for Setting Up a Direct Reimbursement Plan in Your Office
#15 REQUEST FOR REIMBURSEMENT OF DENTAL EXPENSES EMPLOYEE DIRECT REIMBURSEMENT PLAN
#16 FSA Election #17 Computing FSA Deductions #18 Claim for FSA Reimbursement
Complaint Forms #19 SAMPLE FORM TO FILE COMPLAINT WITH STATE INSURANCE COMMISSIONER
#20 SAMPLE FORM TO FILE COMPLAINT TO AAO
REPORT ON INSURANCE REFUSALS/REQUEST FOR ADDITIONAL INFORMATION
#21 Form
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PRIVACY POLICYPRIVACY POLICYPRIVACY POLICYPRIVACY POLICY
MODEL PolicyMODEL PolicyMODEL PolicyMODEL Policy
I. INTRODUCTION
Recently, the United States Department of Health and Human Services (HHS) issued comprehensive regulations relating to the privacy of patient records. It is the intent of this office to comply with each of these new rules, and this policy is designed to provide a framework to accomplish this goal. These rules apply to this office because, among other things, we transmit patient records electronically. However, the rules apply to all “protected patient information,” whether in electronic or paper form, or whether disclosed orally. For purposes of this Privacy Policy, “protected patient information” includes any individually identifiable information, such as names, dates, phone/fax number, email addresses, and demographic data. II. PRIVACY OFFICIAL
EMPLOYEE’S NAME shall be this office’s “privacy official.” As such, he/she shall be responsible for implementing this Privacy Policy, as well as developing any future amendments or revisions to this Policy. III. CONTACT PERSON
EMPLOYEE’S NAME shall be designated as this office’s “contact person.” He/she shall
therefore be responsible for receiving any complaints or inquiries about patient privacy matters, and responding to such complaints or inquires.
The Contact Person shall document all complaints or inquiries received.
If any patient or other person desires to make a complaint relating to patient privacy, the
Contact Person shall instruct him or her to submit the complaint in writing. The Contact Person shall then investigate the complaint or inquiry, determine a resolution in conjunction with DOCTOR’S NAME, and respond to the complainant or inquirer as to the results of the investigation and resolution.
If the inquiry is a complaint, the person shall be advised of his/her right to file a complaint with HHS and notified that the complaint must be filed within 180 days of the date of the alleged violation.
IV. PRIVACY TRAINING
This office will routinely undertake privacy training for all staff. The training will occur on an annual basis for all existing staff, unless otherwise changed to a more frequent basis. In addition, all new staff shall participate in privacy training immediately upon their commencement of employment with this office. The Privacy Official will maintain a record of this training.
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V. USE AND DISCLOSURE OF PROTECTED PATIENT INFORMATION
A. GENERALLY
No protected patient information shall be used or disclosed in any manner other than in conformity with this Policy. Staff should always be mindful of the need to maintain confidentiality of patients’ records and protected health information. Thus, for example, in certain instances it may be appropriate to lower voices or request waiting patients stand a few feet away from patients with whom you are discussing treatment aspects, scheduling appointments, etc.
Access to protected patient information shall only be given to the following staff members: INSERT TITLES OF STAFF MEMBERS B. NOTICE AS TO USE AND DISCLOSURE OF PATIENT INFORMATION
The form Notice attached to this Policy shall be given to all patients at their first appointment. A copy of the Notice must be maintained in each patient’s file.
The Notice may be amended upon approval of DOCTOR’S NAME. If the Notice is
amended, it must be amended promptly and distributed to all patients who have been given the earlier version(s). No material change to the Notice will be implemented prior to the effective date shown on the revised Notice.
C. CONSENT TO USE AND DISCLOSE PATIENT INFORMATION
The Consent form attached to this Policy shall be presented to all patients with the notice at their first appointment and prior to the disclosure of any of the patient’s protected health information. It must be signed and dated by the patient. A copy of the signed and dated Consent shall be kept in the patient’s file.
This form is required to use or disclose any protected patient information in connection
with treatment, payment, or “health care operations.” (Health care operations include performance reviews, training, certification, accreditation, and licensing.)
If any patient refuses to sign the Consent Form, DOCTOR’S NAME may refuse to treat
the patient, unless the patient presents an emergency situation. (In that case, the Consent Form will be obtained as soon thereafter as is practicable.)
If DOCTOR’S NAME has an “indirect relationship” with the patient (i.e., where DOCTOR’S
NAME is providing treatment as to an isolated matter at the request of another health care provider), it is not necessary that a Consent Form be obtained from the patient. However, if reasonably possible, it is our policy that a Consent Form be obtained in all instances.
• A patient may revoke the Consent in writing at any time.
• The Notice and Consent may not be combined on the same form.
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D. AUTHORIZATION TO USE AND DISCLOSE PATIENT INFORMATION
If DOCTOR’S NAME ever determines that protected patient information will be used or disclosed for any purpose other than in connection with treatment, payment, or health care operations (defined above), then the patient must sign the Authorization Form attached to this Policy. For example, this form would be appropriate where the patient’s information will be used to determine whether to hire the patient, making a disclosure of the information to a financial institution, marketing, etc.
Special rules apply (and additional items must be included in the form) where
DOCTOR’S NAME intends to use the protected health information for his own purposes, additional items are requested by DOCTOR’S NAME in connection with disclosure by other third parties, or where the use or disclosure relates to research that includes the patient’s treatment.
Unlike the Consent Form, a patient will not be refused treatment on the basis of
his/her refusal to sign the Authorization Form. A patient may revoke the Authorization in writing at any time. In general, the Authorization Form should be reviewed by legal counsel prior to signature by the patient.
E. “MINIMUM NECESSARY” USE AND DISCLOSURE OF PATIENT INFORMATION FOR
NON-TREATMENT PURPOSES
Wide latitude is given as to the use or disclosure of patient information for purposes of treatment. Thus, any information that DOCTOR’S NAME deems appropriate will be used or disclosed.
However, if the use or disclosure of protected patient information occurs for any other reason (i.e., for payment, reimbursement, or health care operations, etc.), the information used, disclosed, or requested must be limited to the minimum degree to accomplish the purpose for which the use, disclosure, or request is made. (Note that this restriction does not apply to uses or disclosures of the information to the patient to whom the information relates.)
F. DISCLOSURES TO SERVICE PROVIDERS
Any disclosure to service providers by this office (i.e., labs, collection agencies, attorneys, accountants, etc.) may only occur after certain safeguards are in place. Namely, there must be a written agreement substantially in the form attached to this Policy prior to the release of any protected patient information. Because there are special rules in the privacy regulations relating to vendors and unique state laws, the attached form should be reviewed by legal counsel prior to signature.
VI. SPECIFIC PATIENT REQUESTS
A. FOR RESTRICTIONS ON USE AND DISCLOSURE
Patients may request restrictions on the use and disclosure of their protected health information. However, we are not obligated to honor these requests. But if we elect to honor the request, we must adhere to it. Any denial must be in writing.
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B. FOR COMMUNICATION OF THEIR INFORMATION
Patients have the right to request confidential communication of their protected health information. For example, they may request that the information be communicated by alternative means (i.e., sending correspondence to their office rather than to their home). If such a request is made, we will abide by that request as long as it is reasonable. C. FOR INSPECTION AND COPIES OF THEIR RECORDS
Consistent with applicable ethics rules of the American Association of Orthodontists and the new privacy rules, we will provide patient records to them or their designee at any time. However, special permission from DOCTOR’S NAME must be obtained prior to releasing the information if the information is compiled in anticipation of, or for use in, litigation or administrative (i.e., dental board) proceedings. (The new privacy rules do not require that the information be provided to the patient in those instances.) Any denial must be in writing. D. TO ADMEND OR MODIFY THEIR HEALTH INFORMATION
From time to time, patients may request that their protected health information be modified. Generally, we will honor their requests. However, such requests will not be honored if the information on file is accurate and complete. Any denial must be in writing. In addition, any denial of this type of request must advise the patient of his/her right to file a complaint with the HHS Secretary.
E. FOR AN ACCOUNTING OF DISCLOSURES
If requested and unless an exception exists, we will provide patients with a written accounting of all disclosures of their protected health information that we have made for the period requested, but not to exceed six yearssix yearssix yearssix years from the date of the request.
Unless decided otherwise by DOCTOR’S NAME, we will not provide disclosures relating to the following:
1. Treatment of the patient; 2. Payment by or on behalf of the patient; 3. Health Care Operations (i.e., information disclosed in connection with
performance reviews, training, certification, accreditation or licensing); 4. Disclosures made to the patient; 5. Disclosures made to other treatment providers (i.e., their general dentist,
periodontist, oral surgeon, etc.); or, 6. Any disclosures that occurred prior to April 14, 2003.
VII. VIOLATION OF PRIVACY POLICY
Any violation of this Privacy Policy shall be grounds for discipline, including termination. Compliance with this Policy is required in addition to all other office personnel policies, if any.
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(We recommend you use Dr. office/name as a header on this page)
PRIVACY NOTICE
This notice is required by the new patient privacy regulations issued by the United States This notice is required by the new patient privacy regulations issued by the United States This notice is required by the new patient privacy regulations issued by the United States This notice is required by the new patient privacy regulations issued by the United States Department of Health and Human Services (HHS), and describes how your medical information may Department of Health and Human Services (HHS), and describes how your medical information may Department of Health and Human Services (HHS), and describes how your medical information may Department of Health and Human Services (HHS), and describes how your medical information may be used or dbe used or dbe used or dbe used or disclosed, and how you may gain access to your medical information.isclosed, and how you may gain access to your medical information.isclosed, and how you may gain access to your medical information.isclosed, and how you may gain access to your medical information.
Your protected medical information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses and demographic data) may be used or disclosed by us in one or more of the following respects:
• To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you;
• To Third Party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account;
• To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
• Internally, to all staff members who have any role in your treatment; and/or
• To other patients and third parties who may overhear conversations about your treatment, scheduling, etc.
Under the new privacy rules, you have the right to:
• Request restrictions on the use and disclosure of your protected health information;
• Request confidential communication of your protected health information;
• Inspect and obtain copies of your protected health information through asking us;
• Amend or modify your protected health information;
• Receive an accounting of certain disclosures made by us of your protected health information; and,
• You may file a complaint with the HHS Secretary as to any violation by us of your privacy rights, which must be filed within 180 days of the violation.
We have the following duties under the privacy rules:
• To only utilize your protected health information as set forth in the attached Consent Form and/or Authorization Form;
• To obtain your written consent to use your protected patient information for treatment, payment or health care operations, and to refuse treatment if you refuse to sign the Consent Form;
• To obtain your written authorization to use your protected patient information for any purpose other than treatment, payment or health care operation;
• To use reasonable efforts to limit the amount of protected health information that is used, disclosed or requested to the minimum degree necessary where such information is used, disclosed or requested for purposes other than treatment; and,
• To obtain satisfactory assurances from our business associates who render services to our office that your protected health information will be safeguarded by them.
Please note that we are not obligated to:
• Honor any request by you to restrict the use or disclosure of your protected health information;
• Amend your protected health information if, for example, it is accurate and complete; or,
• Provide an atmosphere that is totally free of the possibility that your protected health information may be overheard by other patients and third parties.
If you have any questions about the information in this Notice, please let us know. Thank you.
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PRIVACY CONSENT
This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign and date this form. Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure). You have the right to review our office’s privacy notice prior to signing this Consent Form, a copy of which was given to you with this Consent Form. You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request. We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice. You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been take in reliance on this Consent. Thank you for your cooperation. Please let us know if you have any questions. _____________________________ Patient’s Signature _____________________________ Print Name _____________________________ Date
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PRIVACY AUTHORIZATION
This Authorization is required by the privacy regulations recently promulgated by the United States Department of Health and Human Services. Your protected health information, including individually identifiable information, such as name, dates, phone/fax numbers, email addresses, demographic data, photographs, x-rays, study models and IDENTIFY SPECIFIC DATA will be used or disclosed for the purpose of (check all that apply): Lectures/presentations; Publications; Research; Practice Marketing; and/or Other (specify):__________________________________________________________ This information will be disclosed by the following people:____________________________ ______________________________________________________________________________. This information will be disclosed to the following people/entities:______________________ ______________________________________________________________________________. This Authorization will expire on INSERT DATE. You have the right to revoke this Authorization at any time in writing. However, your revocation will not be effective to the extent that this Authorization has been relied on. The information used or disclosed per this Authorization may be subject to re-disclosure by the recipient(s), and thus, no longer protected by the privacy rules. _______________________________ Patient Signature _______________________________ Print Name _______________________________ Date
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PRIVACY AGREEMENT
This Privacy Agreement is entered into by DOCTOR’S NAME (the “Orthodontist”), and BUSINESS ASSOCIATE NAME (the “Business Associate”) effective as of the date of signature by the last party, and per the privacy rules promulgated by the United States Department of Health and Human Services (HHS). In connection with the Business Associate’s service to the Orthodontist, certain protected health information (as defined by the HHS rules, and including individually identifiable information such as names, dates, phone/fax numbers, email addresses and demographic data) will be disclosed by Orthodontist to the Business Associate. All such information may only be used in connection with the treatment of the patient, payment of or for the patient, and the health care operations (i.e., performance reviews, training, certification, accreditation and licensing) of the Orthodontist if the patient to whom the information relates has executed a written consent to such use. Such information may be used for any other purpose only after the patient to whom the information applies has executed an authorization. Any information requested, used or disclosed for any purpose other than in connection with treatment may only be requested, used or disclosed to the limited degree necessary to accomplish the purposes for which such request, use or disclosure is made. Business Associate agrees to be bound by this provision, and further agrees to maintain the confidentiality of all protected health information it receives from Orthodontist through, for example, not disclosing any such information to any other person or entity at any time during or after the relationship with Orthodontist ends. Business Associate agrees that it has the necessary policies, procedures and safeguards in place to permit its compliance with this Agreement. This Agreement and the underlying relationship between Orthodontist and Business Associate may be terminated by Orthodontist if Orthodontist determines that Business Associate has violated any material term hereof. In the event of a conflict between this Agreement and any other Agreement between Orthodontist and Business Associate, this Agreement shall control. Except as modified herein, any such other Agreement is hereby ratified and affirmed. In witness whereof, the parties have signed this Agreement on the dates set forth by their signatures. ______________________________________ ____________________________________ Orthodontist Business Associate ______________________________________ ____________________________________ Date Date
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Patient Education / Sample Letters and FormsPatient Education / Sample Letters and FormsPatient Education / Sample Letters and FormsPatient Education / Sample Letters and Forms
Patient education will help to avoid problems. Establishing your office policy at the very
beginning of the relationship with a patient sets the ground rules for a productive and satisfying experience for the patient.
When problems arise, it is very important that you prevent the occasional claim related complication from adversely affecting your doctor-patient relationship. Discuss the situation with the patient/insured as soon as possible. The AAO Third Party Hotline is a valuable AAO service to its members and staff and can offer you assistance in dealing with claims related problems. Take advantage of this opportunity if needed. The number is (314) 993(314) 993(314) 993(314) 993----1700.1700.1700.1700.
The following sample policies, patient education information, and sample letters and forms have been helpful in avoiding or clarifying and solving problems should they occur. We are thankful of various SAO members who have shared this information with us.
STEP-BY-STEP PROCESSING OF DENTAL INSURANCE FOR MANAGED CARE PLANS PATIENT EDUCATION (3 pages) A Sample Office Policy B Sample Policy for Office not Accepting Orthodontic Insurance (but encouraging FSA) C Sample Policy for Office not Accepting Orthodontic Insurance (but encouraging DR) D Sample Explanation of Orthodontic Insurance Benefit with Sample Information Form SAMPLE LETTERS AND FORMS # 1 Letter from Patient to Insurance Company:
Refusal of Request for Tax Identification Number # 2 Letter from Patient to Insurance Company: Refusal of Request for Continuation of Treatment Form i.e. Dates of Service # 3 Letter from Patient to Insurance Company: Refusal of Request for Orthodontic Records # 4 Letter from Doctor to Patient: Doctor’s Refusal to Accept Assignment of Benefits # 5 Letter from Doctor to Patient: Acceptance of Assignment of Benefits as Non-provider for Insurance # 6 Helpful Information to Patient: Denial of Claims # 7 Letter from Patient to Insurance Company: Denial of Claim # 8 Letter from Doctor to Patient: Doctor Non-participation in Preferred Provider Plans # 9 Office Policy Regarding Monthly/Quarterly Continuation of Treatment Forms #10 Insurance Verification Form #11 Insurance Benefits/Payment Agreement #12 Relevant Sections of the IRS Code Regarding Orthodontics and FSAs #13 Sample Sales Letter for Direct Reimbursement #14 Instructions for Setting Up a Direct Reimbursement Plan in Your Office #15 Request for Reimbursement of Dental Expenses from Employee Direct Reimbursement Plan #16 FSA Election #17 Computing FSA Deductions #18 Claim for FSA Reimbursement
#19 Sample Form To File Complaint With State Insurance Commissioner #20 Sample Form To File Complaint To AAO
#21 Report On Insurance Refusals/Requests For Additional Information
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STEP-BY-STEP FILING OF DENTAL INSURANCE FOR MANAGED CARE PLANS
GOAL: Provide the means for affordable orthodontic treatment and payment guidelines. PURPOSE: Provide a systemic means of filing orthodontic dental insurance while maintaining accountability for timely payment by the insurance company. STEP 1: INITIAL TELEPHONE CALL After determining the service the caller wants and setting an appointment. Check to see if the patient (parent) has dental insurance through a HMO. If so, explain that the patient may need a referral from the primary care provider or preauthorization from the HMO. Stress that the patient needs to bring the prescription or the referral to the initial appointment (HMO only). STEP 2: INITIAL OFFICE VISIT Photocopy the front and back of the insurance card. Make sure you have the following information:
• NAME OF DENTAL INSURANCE COMPANY
• TELEPHONE OF DENTAL INSURANCE COMPANY
• MAILING ADDRESS FOR CLAIMS ADMINISTRATION OF DENTAL INSURANCE COMPANY (IF FILING PAPER CLAIMS)
• SOCIAL SECURITY # OF PERSON RECEIVING BENEFITS
• GROUP # OF DENTAL PLAN
• PLAN # New Patient coordinator informs the patient of his/her benefits and explains office policy
• Does office accept assignment of benefits or will office file insurance claims with check being paid directly to patient?
• If insurance company does not pay within xx days, patient will be asked to pay and seek reimbursement from dental insurance company
• Records fee due when taken
• Initial treatment fee due when braces are placed
• Insurance claims filed on day services are rendered While the patient is waiting to be seen, New Patient Coordinator or Insurance Coordinator calls the insurance company to request the following information re: the patient's orthodontic benefits:
• Verify benefits
• Check eligibility
• Check benefit amount(s)
• Plan maximum: o Is it lifetime or annual? o How is it paid: 50% or 80% etc.
• Age limit
• Waiting period
• Deductibles
• Amount of benefit already used DOUBLE CHECK MAILING ADDRESS FOR CLAIMS AND TRY TO GET FAX# WHICH COULD EXPEDITE PROCESSING IF CLAIMS ARE “LOST”. If office is unable to reach the insurance company while the patient (parent) is in the office, reassure the patient (parent) that office will call after it is learned what orthodontic benefits the insurance plan offers and explain the benefits over the telephone.
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STEP 3: FILING OF INSURANCE AND MASTER FILE
• Patients with insurance benefits will have individual files (initiated by New Patient Coordinator and maintained by Insurance Coordinator).
• Files will be maintained in filing cabinet and placed in alphabetical order.
• A copy of every form that is mailed to the insurance company will be placed in file in sequential order by date.
• All correspondence pertaining to that individual patient, including Explanation of Benefits (EOBs), notices of changes/cancellation, etc. will be attached, and acted on as needed.
To file an insurance form:
• Fill out patient’s original copy or ADA generic claim or orthodontic software claims form. HINT: Make initial fee high and the monthly payments so that they charge out on a monthly basis equal to or less than the treatment time. The higher down payment means more reimbursement initially. All insurance companies have a ratio as to how they reimburse on the initial placement. They do not state that, so if the initial placement fee is high, you should get the highest possible reimbursement upfront. For example: For a fee of $3500, make the initial fee $1500; and 20 monthly payments of $100.
• The original form is mailed with the dates of service and appropriate codes and signatures.
• Insurance form should be completed and mailed on date appliances are placed.
• Copies of original insurance form should be placed in the patient’s chart as well as in the master file.
STEP 4: MAINTAINING INSURANCE TICKLER FILE For some insurance companies, you only file once and the rest is automatic. For other insurance companies, a separate “tickler file” should be kept and maintained. This will have all individual insurance forms pre-printed and placed in the appropriate place for future filing of all insurance forms. The correct place for future claims will depend on the already predetermined payment schedule for insurance companies, e.g. monthly vs. quarterly. For example: If the patient is a 24-month treatment, you will have 24 monthly installments or 8 quarterly installments printed. If the patient is a 12-month treatment, you will have 12 monthly installments or 4 quarterly installments printed.
• For each patient, you print a master or original claim form, and then make copies of the original claim to equal the number of monthly (quarterly) payments according to the schedule.
• Print out monthly (quarterly) claims equal to the number of months (quarters) of treatment.
• Attach the copy of the original claim to the monthly (quarterly) installment claim forms. The monthly (quarterly) claim goes on top and in the “REMARKS FOR UNUSUAL SERVICES” , write in red SEE ATTACHED COPY.
• Make sure each month and charge for that month (quarter) is written in.
• Place each monthly (quarterly) installment claim in the appropriate month to be filed.
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TICKLER FILE
The tickler file will be a minimum of 24 one-month folder files. For example, January through December current year and January through December next year.
Each month, a new date is added for 24 months in advance to replace the current month. If you are sending out all of January 2007 claims, you now want to move the file folder to the back of the file box for January 2007 claims. This now brings February 2007 claims to be the next filed.
On the day that the patient is seen, the insurance form should be mailed.
When benefits are received, the initial EOB should be checked with the insurance benefit in the computer or in your records to make sure it matches. The EOB should be placed into the insurance file, with the most current placed on the top. MONTHLY MONITORING
1. All forms are sent to the insurance companies from the tickler file for that month. 2. Once a month, the insurance file report is printed on the 1st of the month (if using
orthodontic software) in order to follow up on initial claims sent. Sending a form (by mail or electronically) does not guarantee that you will get paid. Insurance companies are in the business to make money and will stall on paying the benefits for as long as possible. YOU MUST FOLLOWUP ON ALL CLAIMS SUBMITTED. The monthly monitoring will list all outstanding insurance claims so that you can monitor payment.
3. If an insurance company has not paid on a claim already sent, it must first be called to check on the status of the claim. If the company claims it did not receive the original claim, first ask if they have a fax so that a copy can be faxed to them. If not, then go through procedure again to file an initial claim. DOCUMENT THE NAMES OF THE INDIVIDUALS WITH WHOM YOU SPOKE, THE DATE, AND THE TIME OF THE CALL.
4. Once a patient’s insurance benefits have been maximized, REMOVE FROM THE MASTER FILE AND PLACE IN PATIENT FILE FOR FUTURE REFERENCE IF NEEDED.
WHAT TO DO IF BENEFITS ARE CANCELLED
If you receive notification from the insurance company that the benefits have been cancelled or are not available:
• The patient must be contacted and made aware of this information to make sure there is not an error on the part of the insurance company.
• Once insurance cancellation is verified and no further benefits are available, the financial coordinator notifies the patient (parent) so he/she can pay the insurance balance in a lump sum payment OR change the financial contract and adjust the monthly fees over the original remaining payment months.
• The new contract needs to be signed by the patient by the time of the next appointment. The patient cannot be seen without a new financial contract.
• Remove all remaining forms from the tickler file.
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PATIENT AND DENTAL BENEFITS INFORMATION PATIENT AND DENTAL BENEFITS INFORMATION PATIENT AND DENTAL BENEFITS INFORMATION PATIENT AND DENTAL BENEFITS INFORMATION
DATE________DATE________DATE________DATE________________ PATIENT’S NAME____________________________________DATE OF BIRTH_____/_____/______PATIENT’S NAME____________________________________DATE OF BIRTH_____/_____/______PATIENT’S NAME____________________________________DATE OF BIRTH_____/_____/______PATIENT’S NAME____________________________________DATE OF BIRTH_____/_____/______ Mo / day / year RESPONSIBLE PARTY________________________________SOCIAL SECURITY #____RESPONSIBLE PARTY________________________________SOCIAL SECURITY #____RESPONSIBLE PARTY________________________________SOCIAL SECURITY #____RESPONSIBLE PARTY________________________________SOCIAL SECURITY #____----________________----____________________ ADDRESS___________________________________________________ADDRESS___________________________________________________ADDRESS___________________________________________________ADDRESS_______________________________________________________________________________________________________________________________________________ PHONE (HOME)_____________________(WORK)_________________(CELL)___________________PHONE (HOME)_____________________(WORK)_________________(CELL)___________________PHONE (HOME)_____________________(WORK)_________________(CELL)___________________PHONE (HOME)_____________________(WORK)_________________(CELL)___________________
TYPE OF BENEFIT: INDEMITY ________ OR
PPO ________
DHMSO ________
PLHSO ________
SELF-FUNDED
DIRECT REIMBURSEMENT ________ DR
DIRECT ASSIGNMENT ________ DA
FLEX PLAN ________ FSA
MEDICAL SAVINGS ACCOUNT ________ MSA
HEALTH REIMBURSEMENT ARRANGEMENT________ HRA
MAXIMUM BENEFIT___________________________ REMAINING BENEFIT AVAILABLE________________ EMPLOYERS NAME___________________________________________________________________ DENTAL BENEFIT PROVIDER NAME____________________________POLICY #__________________ ADDRESS _____________________________PATIENT ID #_______________ PHONE________________________________FAX_______________________ CONTACT PERSON_________________________________________________ EFFECTIVE DATE___________________ EXPIRATION DATE_________________ I hereby authorize release of any information relating to claim. ______________________________________________________________________________ Date_______________________________________________________________ Date_______________________________________________________________ Date_______________________________________________________________ Date_________________ Signature
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INFORMATION ON THIRD PARTIESINFORMATION ON THIRD PARTIESINFORMATION ON THIRD PARTIESINFORMATION ON THIRD PARTIES (One sheet per Insurance Company)
NAME OF INSURANCE CO._________________________________________________ ADDRESS_________________________________ ADDRESS______________________ ________________________________ FOR CLAIMS____________________ ________________________________ (if different)____________________ Telephone #____________________________ Fax#__________________________ DateDateDateDate Ext Ext Ext Ext Patient’s Name/ Insured’s Name____ Patient’s Name/ Insured’s Name____ Patient’s Name/ Insured’s Name____ Patient’s Name/ Insured’s Name____ ____ Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ ____Talked to___________________________ ____ Re: _________________________________ PATIENT’S/EMPLOYERS USING THIS INSURANCE:PATIENT’S/EMPLOYERS USING THIS INSURANCE:PATIENT’S/EMPLOYERS USING THIS INSURANCE:PATIENT’S/EMPLOYERS USING THIS INSURANCE: ____________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / _______________ ____________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / _______________ __________________________________________________ / _____________________ ____________________ / _________________________ / _____________________ ____________________ / _________________________ / _____________________ ____________________ / _________________________ / _____________________ ____________________ / _______________ ____________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / ___________________________________ / _____________________ ____________________ / _______________ COMMENTS/HELPFUL HINTS REGARDING THIS INSURANCE CO.COMMENTS/HELPFUL HINTS REGARDING THIS INSURANCE CO.COMMENTS/HELPFUL HINTS REGARDING THIS INSURANCE CO.COMMENTS/HELPFUL HINTS REGARDING THIS INSURANCE CO.
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A. SAMPLE OFFICE POLICY FOR OUR PATIENTS WHO HAVE ORTHODONTIC “INSURANCE”
Orthodontic treatment is handled in a different manner than conventional dental benefit plans. This office is happy to cooperate with families who are covered by dental insurance. We only ask that you read your policy to be sure that you are fully aware of any limitations of the benefits provided. Normally orthodontic treatment has a life-time maximum benefit from $500-1500 or a percentage of that total fee. The fees we charge for services rendered to those who are insured are our usual and customary fees charged to all patients for similar services. Your policy may base its allowances on a fixed schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies pay claims promptly, and others delay payments many months. Since we have no say in the selection of your insurance company, we ask that you look upon your insurance company as a device that reimburses you for dental expenses. It is your company, and it is your responsibility to see that you are reimbursed promptly. As a courtesy service to you, we will complete all forms pertaining to your claim and send them promptly to your company. With increasing numbers of orthodontic benefit plans, we find it impossible to have a complete and accurate knowledge about all of these programs or our individual patient’s status with respect to their own program. Therefore, our office follows the policies on insurance as described below:
1. If you are eligible for orthodontic benefits under your plan, we will complete the American
Dental Association standardized Claim Form for you to be mailed to your company so that you may be reimbursed for your payments made to our office.
2. Within the estimated treatment time our patients can provide: cancelled checks, cash receipts, and the above form along with the insured’s signature to provide adequate proof of continuing treatment to the insurance company.
3. Direct payments from the insurance company will NOT be accepted by our office. All benefit payments from the insurance must be made DIRECTLY to the insured.
4. Preauthorization by the insurance company should be strictly limited to: (a) defining the patient’s eligibility, (b) establishing the extent of coverage, and (c) recognition of the orthodontist’s determination of the extent of service to be rendered. Proper establishment of these factors does not require the submission of diagnostic records.
Records can be made available for review in our office by a professionally qualified insurance representative if a more detailed understanding of the case is necessary.
Traditionally, the finest orthodontic service has been based on a mutual understanding between the doctor and the patient; and we wish to maintain this professional relationship in our office. We will be glad to answer any questions you may have regarding your orthodontic coverage.
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B. Sample Policy for Office not Accepting on Orthodontic InsuranceB. Sample Policy for Office not Accepting on Orthodontic InsuranceB. Sample Policy for Office not Accepting on Orthodontic InsuranceB. Sample Policy for Office not Accepting on Orthodontic Insurance
(but encouraging FSA)(but encouraging FSA)(but encouraging FSA)(but encouraging FSA)
Dental insurance is a contract between your employer and a particular insurance company. All patients are financially responsible for the entire fee and insurance companies are responsible for reimbursing the employee. Insurance reimbursement schedules vary and may not coincide with our convenient office monthly budget plan; however, each contract will pay out over the course of treatment (an amount never more than 50% of the total fee). In fact, the insurance company’s maximum amount may be far less than 50% of the fee, because typically, it is a per-person-life-time benefit of $1,000 or $1500 while comprehensive orthodontic treatment fees often exceed $5,000. Our office does not belong to any managed care plans where the patient’s right to choose his/her dentist has been eliminated and a fee has been pre-negotiated for a specific service. Patients who wish their choices and treatment options restricted will find “managed care” orthodontics available. We have decided not to reduce or diminish our service to fit Third Party requirements and controls. We encourage our patients to make use of flexible spending accounts (FSAs) or medical savings accounts as additional options or alternatives for paying out-of-pocket. These are tax-deductible plans equal to your tax bracket plus 7.65% withheld for Social Security etc. A 28-40% savings on an orthodontic fee in the $4,000 range is a significant discount at Uncle Sam’s expense and a considerable savings for required dental expenses. Section 125 of the IRS Codes allows the use of pre-tax dollars for qualified health care expenses; however, your employer must make the decision to activate such a plan. Flex Plans or “Cafeteria Plans” can be used with insurance to cover the co-payment or services not covered by the insurance contract. In summary, dental insurance is a highly variable benefit and can be renewed, revised, or completely changed to a new company annually. We want our patients to know as much about the subject of dental benefits and its variations as possible. There are sound and proven reasons why the dental profession always encourages self-funded dental benefit plans that are dollar-based rather than procedure-based and plans that allow freedom to choose any dentist. The dental profession believes it is in the patient’s best interest as well as his/her responsibility to decide with his/her dentist the best service for long-term dental health rather than have that decision made by the insurance company’s review “expert” who may not be a licensed dentist or who could not be expected to appreciate the demands of a discriminating/knowledgeable purchaser of the best and finest dentistry. Orthodontics is a service profession extensively personalized and dedicated to creating a long term worthy investment in oral health with the added enhancement of facial attractiveness so critical to well being. Of all the things you wear, your smile is the most important. DOCTOR’S NAME OFFICE CONTACT INFORMATION
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C. Sample Policy for OffC. Sample Policy for OffC. Sample Policy for OffC. Sample Policy for Office not Accepting Orthodontic Insurance ice not Accepting Orthodontic Insurance ice not Accepting Orthodontic Insurance ice not Accepting Orthodontic Insurance (but encouraging DR)
Date Name Address City, State, Zip Dear (Patient): Our office is committed to communicating with you at every step of your orthodontic care. Good communication is an important key to providing excellent orthodontic care. That’s why we felt it is important to inform you that the dental benefits program your employer provides for you is a preferred (or “network”) plan. In these types of plans, the participating doctors have agreed to discount their normal fees. Thus, the doctor is listed as a “preferred provider” in these network plans. Our office is not a participating provider with the dental network associated with your employer’s program. However, this does not mean you cannot receive treatment from our office. You have the You have the You have the You have the right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not participate in the network.participate in the network.participate in the network.participate in the network. It is probable that you may incur greater out-of-pocket costs by receiving care out of the network. Please check with your dental benefits plan or your employer’s human resources professional for details on any actual cost differences. By the way, do you know that there are other dental plans on the market, which will allow you to visit the dentist or orthodontist of your choice without a reduced benefit? One such plan is called “direct reimbursement”. With direct reimbursement you can visit the dentist or dental specialist of your choice and have a dental program that covers any and all types of dental treatment. If you would like additional information on this type of plan, please contact. Thank you for taking the above into consideration before you make the decision on who will provide your orthodontic treatment. If I may be of further assistance, please call me at any time. Sincerely, DOCTOR’S NAME OFFICE CONTACT INFORMATION
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D. WHAT YOU SHOULD KNOW ABOUT YOUR ORTHODONTIC INSURANCE BENEFITD. WHAT YOU SHOULD KNOW ABOUT YOUR ORTHODONTIC INSURANCE BENEFITD. WHAT YOU SHOULD KNOW ABOUT YOUR ORTHODONTIC INSURANCE BENEFITD. WHAT YOU SHOULD KNOW ABOUT YOUR ORTHODONTIC INSURANCE BENEFIT
As you begin orthodontic treatment, an understanding of how your orthodontic insurance works will be helpful in receiving the maximum benefit for which you are eligible. Orthodontic benefits are separate from dental benefits and usually have a different percentage of benefit and lifetime maximum. Even though you are covered by dental insurance, you may not have orthodontic coverage. A plan booklet is generally available to you from your employer who describes the details of your policy and should outline any orthodontic coverage that might be available to you and your family. Familiarizing yourself with the details of your coverage may avoid misunderstandings later. Please do not hesitate to call the insurance carrier to inquire about coverage and benefit payment schedules. EligibilityEligibilityEligibilityEligibility
The requirements for eligibility vary. Some policies require a waiting period for new employees, while others may require a specific number of hours to be worked per pay period to remain eligible. If eligibility is lost during orthodontic care, the balance of any outstanding benefit is also lost. Orthodontic coverage in some cases is available only to dependent children under the age of 19. If you are unsure of eligibility requirements, you should refer to the plan booklet or contact the insurance administrator at your place of business. How BeneHow BeneHow BeneHow Benefits Are Calculated?fits Are Calculated?fits Are Calculated?fits Are Calculated?
There is no universal formula for calculating the amount to be paid for orthodontic services. It is common for orthodontic benefits to be paid at 50% of the treatment fee to a lifetime maximum amount. Your policy may have a yearly deductible. What If I Have Multiple Coverage?What If I Have Multiple Coverage?What If I Have Multiple Coverage?What If I Have Multiple Coverage?
If the patient is covered by more than one orthodontic insurance policy, the carriers will determine which plan is considered the primary policy. Often this determination is made by birthdates of the insured parties. This method of determination is not a universal formula, but is individual to each carrier. The secondary insurance carrier will not declare or pay benefits until the primary carrier has determined the charge which it will cover. The secondary carrier usually requires the primary carrier to send written confirmation of benefits covered. Receipt of BenefitsReceipt of BenefitsReceipt of BenefitsReceipt of Benefits
The benefits from your insurance will be presented to you on a schedule determined by your carrier relative to your individual insurance policy. The insured party will receive the benefit and is responsible for supplying whatever verification/continuation of treatment information that is necessary. It is very important to inquire from your insurance carrier if this verification is required and what type of information should be submitted to them on either a monthly or quarterly basis for payment reimbursement. The timeliness of your actions will reflect the response time for receiving your benefits and the insurance carrier may not provide you with reminders. How We Can HelpHow We Can HelpHow We Can HelpHow We Can Help
Please provide my office with the appropriate form from the carrier with your portion of the form completed and signed. We will complete the form and attempt to maximize the benefit for the patient.
RecommendationsRecommendationsRecommendationsRecommendations We recommend that you document all of your written communications and telephone conversations with your carrier and the name of the party you spoke with for future information if needed.
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SAMPLE LETTERSSAMPLE LETTERSSAMPLE LETTERSSAMPLE LETTERS
# 1 Letter to Insurance Company# 1 Letter to Insurance Company# 1 Letter to Insurance Company# 1 Letter to Insurance Company Refusal of Request for TaxRefusal of Request for TaxRefusal of Request for TaxRefusal of Request for Tax Identification Number (from AAO) Identification Number (from AAO) Identification Number (from AAO) Identification Number (from AAO)
DATE NAME INSURANCE COMPANY ADDRESS CITY, STATE, ZIP RE: Request for Provider Federal Identification Number Dear NAME: I am writing in response to the Additional Information Request from your company to DOCTOR’S NAME in reference to a dental claim on PATIENT’S NAME, dependent child of INSURED NAME DENTAL PLAN I.D. #XXXXXX. Based on your request of DATE OF REQUEST, the claim has not been processed because your information lacks DOCTOR’S NAME’ Tax I.D. number. However, because DOCTOR’S NAME is not accepting assignment, we do not believe it is necessary to provide this information. As you probably know, the purpose of a tax I.D. number, as dictated by the federal government, is to report earned income to the IRS. The American Association of Orthodontists (AAO) agrees that the tax I.D. number is a necessary requirement when doctors accept direct assignment of benefits. However, for doctors who do no accept assignment, we recommend that they do not provide their Tax I.D. number because of errors involving the possibility of double income reporting. In addition, since the requirement to report income is the responsibility of the doctor when they do not accept assignment, the AAO and our membership feel there is no legal reason for insurance companies to have this confidential information. Therefore, only if the doctor accepts assignment does it become necessary for the doctor to submit their Tax I.D. number, so that the insurance company can report income and provide a 1099. We have verified this matter with numerous tax officers at the IRS, as well as the IRS Research Department. In an effort to not penalize the insured due to conflicting interpretations of IRS regulations, we would appreciate it if you could expedite the processing of this claim so that the insured receives reimbursement as quickly as possible. Thank you, in advance, for your cooperation in this matter. Please contact me at TELEPHONE NUMBER to confirm that you have resolved this matter. Sincerely, EMPLOYEE’S NAME TITLE
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#2 Letter to Insurance Company: Refusal of Request for Continuation of Treatment Form i.e. dates of service (from AAO)
DATE NAME INSURANCE COMPANY ADDRESS CITY, STATE, ZIP Dear NAME: It has recently come to my attention that your company only pays for dental claims filed in connection with specific dates of service. Given the nature and time span of orthodontic treatment, this policy is quite troublesome. As a convenience to their patients, orthodontists generally allow payment of orthodontic fees to be made in easy monthly installments. Thus, a patient/insured may incur an expense during a month that he / she has not visited the doctor. This means that the insured will not get their full benefits that are due them. Most insurance companies have agreed to accept copies of office receipts or cancelled checks as proof of continued orthodontic treatment. It is kindly asked that you consider amending your procedures in this manner. Should you have any questions, please contact me at TELEPHONE NUMBER. Sincerely, EMPLOYEE’S NAME TITLE
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#3 Letter to Insurance Company:
Refusal of Request for Orthodontic Records (from AAO) DATE NAME INSURANCE COMPANY ADDRESS CITY, STATE, ZIP RE: Insured: INSURED NAME Group: POLICY Patient: PATIENT NAME Control Number: NUMBER Dear NAME: I am writing this letter on behalf of DOCTOR’S NAME regarding your request for submission of dental records in order to process the above referenced claim. Since the vast majority of claims administrators do not regularly make such requests, these additional expenses are not reflected in the fee for service. Therefore, it is important to consider the following concerns when reviewing your administrative policies:
(1) Orthodontists are required BY LAWBY LAWBY LAWBY LAW to maintain all original patient records. (2) In order to comply with a request for patient x-rays and records, orthodontists must incur
additional expenses for costs such as staff time, duplication, and postage. If you must receive such records, it is reasonable for doctors to request claim administrators to pay a prepaid fee for the duplicate records. As an alternative to requesting the patient’s records, you may consider contacting the orthodontist’s office if you have any questions regarding the claim. It is in the best interest of all parties involved to resolve this claim as soon as possible. If you have any questions, please do not hesitate to contact me at TELEPHONE NUMBER. Sincerely, EMPLOYEE’S NAME Dental Benefits Specialist C: Dr.’s office
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#4 Letter from Doctor to Patient:
Doctor’s Refusal to Accept Assignment of Benefits
DATE INSURED’S NAME ADDRESS Dear INSURED’S NAME: As a courtesy, we file insurance claims on behalf of our patients for orthodontic services performed in our office. You will receive reimbursement from your insurance company under the terms of your plan. It is important to remember that these benefits belong to you and it is up to you to ensure that you are receiving appropriate reimbursements. You will be responsible for paying our office for any services provided that are not covered by your insurance company and for any fees that are above the amount payable by your benefits program. Unlike most medical insurance, employees purchase dental insurance for their employees to supplement the cost of care; therefore, most dental benefits do not cover the complete cost of care. In cases where conflicts arise over reimbursement, denial of claims or proposed treatment, or other administrative problems, for a service that appears to be covered by your dental benefits plan, we recommend that you involve your employer (or plan purchaser) in order to find an appropriate solution. Sincerely, DOCTOR’S NAME
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#5 Letter from Doctor to Patient: Acceptance of Assignment of Benefits as Non-provider for Insurance
Companies
DATE INSURED’S NAME ADDRESS Dear INSURED’S NAME: As a courtesy, we file insurance claims on behalf of our patients for orthodontic services provided in our office. Although we may not have a contract as a provider for your insurance company, you may elect to assign the benefits payable to you to our office and apply these payments toward the cost of treatment. If we are filing claims on your behalf, please be sure to sign the authorization of benefits form on the ADA claim form. This allows us to receive reimbursement directly from the insurance carrier on your behalf. We do reserve the right to accept the assignment of benefits based upon the particular contract that has been entered into between you and your employer. Most orthodontic benefits provided by your employer may only cover a portion of the cost of treatment. You will be responsible for the balance of the amount not covered by your insurance company. Under certain circumstances, we may not be willing to accept an assignment of benefits which would preclude us from receiving our full fee. Be sure to consult your benefits manager or plan administration for a complete understanding of your insurance coverage. Sincerely, DOCTOR’S NAME
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#6 Helpful Information to Patient Denial of Claims (from AAO)
If you receive a denial of a claim for orthodontic benefits from a dental insurance company or other TPA, where the employer has included orthodontic coverage, you as a patient or parent of a patient, with the help of your provider, should:
• Retain a copy.
• Request a copy of your plan documents and summary plan description. These documents should detail the claims procedure, how claims are denied and the rights of the participant to appeal denials.
• Communicate to the insurance company or TPA your objection to the reason for denial in writing, referencing the particular reason, in accordance with the plan documents, that the claim is being denied.
• If the reason for denial does not fit the claims procedure and how claims are denied in your plan documents and summary plan description, quote those areas in the following sample response letter (Exhibit 7).
• The above information should be sent to your employer, the TPA, and, if applicable, the insurance company.
Additional Helpful Ideas for Patient Whose Claim Has Been Denied
• Exhaust all reasonable avenues for resolution with the insurer. This means using all levels of appeal.
• Make sure all supporting documentation is included with the claim.
• File a complaint with your Employee Benefits Manager or human resources person.
• If a claim cannot be resolved through the appeals process and if the plan is State regulated, contact the State Insurance Commissioner and file a complaint, which clearly outlines your case. (See Chapter 8)
• Ask your plan administrator what you are responsible for paying when you use your dental benefits (i.e. deductibles, co-payments).
• Read your plan carefully so that you are aware of the extent of your dental coverage.
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#7 Letter from Patient to Insurance Company: Denial of Claim (from AAO)
DATE TPA ADDRESS RE: PATIENT’S SOCIAL SECURITY #, FULL NAME, and CLAIM NUMBER Dear TPA: I received notice that the above referenced orthodontic claim was denied for the following reason: INCLUDE THE EXACT WORDING ON THE DENIED CLAIM After reviewing my plan document and summary plan description, I request that you reevaluate the claim because the orthodontic claim does fit the benefit criteria stated in Section: INSERT SECTION NUMBER OF PLAN DOCUMENT OR SUMMARY PLAN DESCRIPTION. For Example: In Section V. 2b (“Orthodontic benefits are paid after a $50.00 deductible, at 50% of the fee up to a maximum of $1,000 for dependents up to the age of 19”). Sincerely, INSURED’S NAME
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#8 Letter from Doctor to Patient: Doctor Non-participation in Preferred Provider Plans
DATE NAME ADDRESS CITY, STATE, ZIP Dear PATIENT’S NAME: Our office is committed to communicating with you at every step of your orthodontic care. Good communication is an important key to providing excellent orthodontic care. That’s why we felt it is important to inform you that the dental benefits program your employer provides for you is a preferred (or “network”) plan. In these types of plans, the participating doctors have agreed to discount their normal fees. Thus, the doctor is listed as a “preferred provider” in these network plans. Our office is not a participating provider with the dental network associated with your employer’s program. However, this does not mean you cannot receive treatment from our office. You have the You have the You have the You have the right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not right to receive treatment from our office and benefits from your employer even though we do not participarticiparticiparticipate in the network. pate in the network. pate in the network. pate in the network. It is probable that you may incur greater out-of-pocket costs by receiving care out of the network. Please check with your dental benefits plan or your employer’s human resources professional for details on any actual cost differences. By the way, do you know that there are other dental plans on the market, which will allow you to visit the dentist or orthodontist of your choice without a reduced benefit? One such plan is called “direct reimbursement”. With direct reimbursement you can visit the dentist or dental specialist of your choice and have a dental program that covered any and all types of dental treatment. If you would like additional information on this type of plan, please contact the American Association of Orthodontists at (800) 424-2841, the ADA or your State Dental Association. Thank you for taking the above into consideration before you make the decision on who will provide your orthodontic treatment. If I may be of further assistance, please call me at any time. Sincerely, DOCTOR’S NAME OFFICE CONTACT INFORMATION
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#9 OFFICE POLICY REGARDING MONTHLY/QUARTERLY CONTINUATION OF TREATMENT FORMS
I do not sign these forms because IT IS A DISSERVICE TO YOU, THE INSURED. I charge you a total fee and break it into convenient monthly payments, which have no relation to office visits. Most insurance companies would reimburse you depending on your monthly office visits and not your financial agreement with this office. The problem arises when your office visits aren’t exactly once a month: Monthly Monthly Monthly Monthly Visits PaymentsVisits PaymentsVisits PaymentsVisits Payments January 1 $100.00$100.00$100.00$100.00 February 0 $100.00 $100.00 $100.00 $100.00 March 2 $100.00$100.00$100.00$100.00 Total $300.00$300.00$300.00$300.00
Benefits From ContinuationBenefits From ContinuationBenefits From ContinuationBenefits From Continuation Of Treatment Forms Of Treatment Forms Of Treatment Forms Of Treatment Forms $ 50.00 $ 50.00 $ 50.00 $ 50.00 (50 % of 100.00) $ 0.00 $ 0.00 $ 0.00 $ 0.00 (No Visits) $ 50.00$ 50.00$ 50.00$ 50.00 $ 100.00 $ 100.00 $ 100.00 $ 100.00
Benefits From Benefits From Benefits From Benefits From Canceled ChecksCanceled ChecksCanceled ChecksCanceled Checks $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00 $150.00 $150.00 $150.00 $150.00
I would not be able to sign the form for February and you may not receive benefits for that month even though you had made a monthly payout to the office. By attaching copies of your canceled checks, or office receipt, to the monthly/quarterly form, you will receive all the benefits due you.
AMERICAN ASSOCIATION OF ORTHODONTISTSAMERICAN ASSOCIATION OF ORTHODONTISTSAMERICAN ASSOCIATION OF ORTHODONTISTSAMERICAN ASSOCIATION OF ORTHODONTISTS 460 NORTH LINDBERGH BOULEVARD
ST. LOUIS, MISSOURI 63141 (314) 993-1700
© AMERICAN ASSOCIATION OF ORTHODONTISTS
We do We do We do We do notnotnotnot accept accept accept accept assignment. assignment. assignment. assignment. Please send all Please send all Please send all Please send all payments directly payments directly payments directly payments directly to the employee. to the employee. to the employee. to the employee.
Member
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#10 Insurance Verification Form
Insurance Verification form Medical / Dental Primary or Secondary Date______________________ Insured_______________________________________Employer_____________________________ SS #______________________________________Group #__________________________________ DOB_______________ Relationship to insured____________________________________________ Patient’s name_________________________________________DOB__________________________ Age______________Full time student status verify_________________________________________ Insurance Company Mailing Address for claims_____________________________________________________________ City______________________________________State____________ Zip_________________ Payor ID__________________________________Fax #________________________________ Can claim preauthorization and actual services be faxed?____________Yes_______________No Is Dr. a provider?__________Yes_________No Benefits paid to provider?_________Yes_________No Coverage: ________self________spouse_________family_________child___________other Any waiting period?____________________________________________________________ Max allowance_________________per person/family___________________year When does calendar year start?_________________________________________ Deductible______________________met____________________applied to________________ Benefit used to date_________________________ Fee schedule_________________________________or_________% UCR_________________ Age limits__________________________ Prev____________________ Sealants___________Flouride__________ Basic___________________ Frequency_________ how often_________ Major___________________ Crowns___________ built up 2950_______ Endo____________________ 5 yr replmct_______ Missing teeth co_____ OS_____________________ Are prostho pd at prep or seat date________ Nitros covered________________________ Limitations Exam 6months_________ 2 per year________other_____________________ Xrays FMX/Pano________3 years__________ other_____________________ BWX (2) (4) per 6 mo____________ year__________other__________ Prophy 6 months_______2 per year__________other________________________ Perio pro (D4910)_________________#years_______________________ Is patients claim form needed?______________________ Preauthorization needed? __________________________ Spoke to__________________________________conversation recorded____________________
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#11 Insurance Benefits/Payment Agreement
(Hospital Name) for Jaw Surgery INSURANCE BENEFITS/PAYMENT AGREEMENT
Patient:_________________________________________ Date:________________________ Guarantor:______________________________________________________________________ As a service to you, we have verified your insurance benefits verbally with ___________________________________________Insurance Company. The benefits we verified are only verbally acknowledged by your carrier, NOT their guarantee of payment. Payment on your claim is subject to your insurance company’s review upon receipt of your claim. Your insurance company estimates they will cover the surgery at ____% of their fee schedule (which they do not verify by phone) beyond a deductible amount of $_____________. This deductible amount has/has not been met according to our verification. I further understand the following estimate of expenses: 1. Value of services rendered: $_________________ 2. Down payment: $_________________ 3. Estimated balance: $_________________ I understand I am responsible for that amount the insurance company does not cover. If the insurance company denies my claim or does not respond within 45 days, the balance above is due in full. If the insurance benefit exceeds the estimated balance, a refund will be sent to you. Dated the________day of____________________. 20_______. ____________________________________________________ Patient, Parent or Guarantor _____________________________________________________ Witness
______________________________________________________ Witness
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#12 Relevant Sections of the IRS Code Regarding Orthodontics and Flexible Spending Accounts
Who Can Be Reimbursed:
• Expense must be for medical care for employee, employee’s spouse or dependents. IRS Code Section 152(a)
• This includes dependents whom the employee claims on his or her tax return as well as dependents for whom the employee doesn’t claim the exemption because that dependent receives gross income over the exemption amount. IRS Code Section 152 (a),(d)
• If the employee is divorced or separated, a child who is not the employee’s dependent under federal income tax law will be nonetheless treated as the employee’s child for purposes of the statutory provisions governing Health Flexible Spending Accounts. IRS Code Section 105(e)
Time Period for Reimbursable Expenses:
• The only expenses that can be reimbursed by a Health Flexible Spending Account are expenses incurred during the coverage period as defined in the employer’s plan document. IRS Code Section 125(b)(3)
Expenses Must be Supported by Adequate Paperwork:
• A Health Flexible Spending Account must require participants to provide a written statement from an independent Third Party stating that the medical expense has been incurred and the amount of such expense and a Health Flexible Spending Account participant must provide a written statement that the medical expense has not been reimbursed or is not reimbursable under any other health plan coverage. IRS Code Section 125
Is Orthodontic Care Reimbursable Under a Health Flexible Spending Account?
• Yes, IRS Code Section 213 (b)(1) is entitled “Medical, dental, etc. expenses” and the term “medical care” is defined to include “amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body….”
• Reimbursement of orthodontic fees paid entirely up-front might be considered aggressive by the IRS and not usually allowed. IRS Code Section 125
• Reimbursement under a Health Flexible Spending Account is related to both treatment and payment for the treatment. For example, the payment of 1/3 of a total price of treatment may not be reimbursable at the time of payment, but may be after an equivalent (i.e., 1/3) amount of the treatment is completed.
Example Regarding Orthodontic Expenses: In September 1997, Bobby’s parents contract with his orthodontist to have orthodontic treatment. During the first visit (October), the child will be x-rayed and fitted for braces. During the second visit (November), the braces will be installed. During the 15 subsequent monthly visits, the braces will be adjusted. Eventually (18 months after the first visit, if all goes as planned,) the braces will be removed, and perhaps a retainer will be fitted for use thereafter. For these services, Bobby’s parents pay $3,000 on the date of the first visit. In the above example, it is clear that the entire $3000 cannot be reimbursed as a calendar 1997-plan year expense, because in 1997, Bobby was not provided with all the care that gave rise to the expense. How much of the $3000 can be reimbursed as a calendar 1997 plan year expense? The orthodontist can apportion the $3000 to the office visits the child makes over the contract’s 18-month period. If the orthodontist estimates that one third of the total time that he or she will spend with the child (and one third of the expense for supplies) will occur during the first two visits (both in 1997), and that the remaining time and expenses will be spread evenly over the remaining months, then it seems reasonable that $1000 of the $3000 could be reimbursed as a 1997 expense, $1500 as a 1998 expense, and $500 as a 1999 expense. The orthodontist’s letter apportioning the expenses should be attached to the reimbursement request form submitted each month by the employee to his or her employer or Flexible Spending Account Third Party
administrator. Source: Employee Benefits Institute of America
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#13 Sample Sales Letter for Direct Reimbursement
DATE BENEFITS MANAGER’S NAME COMPANY ADDRESS Dear BENEFITS MANAGER’S NAME: Like many decision-makers, you may be at a crossroads when it comes to dental coverage for your employees. On one side is the old, worn, beaten down path of the insured plan; and on the other is what many decision makers have found to be the much smoother, simpler, more cost-effective path of choice—Direct Reimbursement. The advantages of Direct Reimbursement:
• Savings up to 25% compared to a traditional insured dental program.
• Allows for freedom of choice in selecting your dentist.
• Pays for any and all dental treatment not covered under Medical.
• Is cost-effective because it is self-funded and encourages plan participants to be concerned with the price of dental care.
• Allows for efficient claim payment.
• Creates a win/win/win relationship between employer, employee, and dentist.
• The employer-fund dollars remain with the employer and can earn interest until claims are actually paid.
• The employee identifies with the employer as the benefits provider rather than an insurance company. Morale improves.
If you would like a free cost estimate and plan design consultation, please call my office or the American Association of Orthodontists directly at (800) 424-2841 ext. 215. Sincerely, DOCTOR’S NAME CONTACT INFORMATION
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#14 Instructions for Setting Up a Direct Reimbursement Plan in Your Office
Direct reimbursement is an insurance plan which is simple and effective. Many small businesses can administer it themselves or they can hire a Third Party Administrator. As the name implies, employers agree to directly reimburse employees for their dental expenses. The employee can choose his/her own provider. The employee must submit a receipt for reimbursement. In Dr. McCamish’s plan, the policy is printed in the Employee Manual. Employees of the Corporation are eligible (after one year of employment) for direct reimbursement of dental expenses as follows:
• Persons covered: employee and immediate family. An immediate family member is defined as spouse or non-married children who are under the age of 21 and still living at the residence or who are full-time students and not married.
• Percent reimbursed: 50%.
• Maximum: $500 per calendar year for employee and family combined. The plan operates as follows: when an employee goes to the dentist, he/she obtains a
Request for Reimbursement of Dental Expenses Form from the Corporation. After the service is rendered, the employee asks the dentist to complete his/her section of the claim form and attach a copy of the receipt showing that the bill was paid by the employee. The employee then brings the Reimbursement Form and paid receipt to the Corporation for reimbursement for 50% of what the service cost (i.e., if the bill was $100, the employee would be reimbursed $50). Employees may continue to use the Direct Reimbursement plan until they have received a maximum reimbursement of $500 for the calendar year (January through December.) In Dr. McCamish’s office, the plan is secondary to any other dental coverage. Receipts and direct reimbursement claim forms must be submitted for reimbursement within 60 days of the date on which the payment was made.
With a five-year history, the cost per employee ranges from $93.99 to $159.61. The number of employees ranged from 16-19 and the number of persons covered under the plan ranged from 49-57. The cost per covered individual ranged from $32.47 to $50.87 over the five-year span. It takes about a hour a month to administer the plan.
SAMPLE INSTRUCTIONS FOR DIRECT REIMBURSEMENTSAMPLE INSTRUCTIONS FOR DIRECT REIMBURSEMENTSAMPLE INSTRUCTIONS FOR DIRECT REIMBURSEMENTSAMPLE INSTRUCTIONS FOR DIRECT REIMBURSEMENT
Step-by-step instructions to Employees 1. Obtain a Request for Reimbursement of Dental Expenses Form. 2. Upon completion of services, pay dental provider and ask that his/her office staff complete the Provider section of the request for Reimbursement Form. 3. Turn in completed request for Reimbursement Form and a receipt from the dental provider to the employer’s representative. Step-by-step instructions to Employer Representative 1. Provide Reimbursement Forms to employees as requested. 2. Receive completed Reimbursement Form. 3. Verify that all information on completed form conforms with the Employee Manual. 4. Write check to employee while keeping in mind the percentage reimbursed and the calendar year limit. 5. Complete individual and group yearly summary reports.
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#15 REQUEST FOR REIMBURSEMENT OF DENTAL EXPENSES EMPLOYEE DIRECT REIMBURSEMENT PLAN
� To Be Completed By EmployeeTo Be Completed By EmployeeTo Be Completed By EmployeeTo Be Completed By Employee:
Employee Name:_____________________________ Patient Name:_____________________________ Relationship of Patient to Employee: Self Spouse Dependent Portion of Fee for Current Services NOT covered by another dental plan: $ __________ Method of Payment: Check Cash Credit Card I certify that: 1. The charges files are NOT eligible for reimbursement under any other coverage. 2. The provider has been paid in full or in accordance with a payment plan worked out with him/her. 3. Dependent claims are for dependents who are eligible under this plan. Signature:_____________________________ Date:_____________________________
� To Be Completed By Provider of Dental ServicesTo Be Completed By Provider of Dental ServicesTo Be Completed By Provider of Dental ServicesTo Be Completed By Provider of Dental Services: Patient’s Name:_____________________________ Date of Service:_______________ Fee:__________ Dental Procedure Performed: ____________________________________________________________ Name and Address of Provider: Please check one:
� Claim information HAS NOT and WILL NOT be furnished to an insurance carrier.
� Claim information HAS been furnished to an insurance carrier. I certify that the services and supplies specified above were provided to the named patient and that payment was made on the date shown for the fee shown. I further certify that payment was made in full or in accordance with the payment plan I have worked out with the patient. Signature:_____________________________ Date:_____________________________ NOTE TO PROVIDER: Please attach a receipt to this form. Office Use Only: Amount of Reimbursement $______ Date: __Office Use Only: Amount of Reimbursement $______ Date: __Office Use Only: Amount of Reimbursement $______ Date: __Office Use Only: Amount of Reimbursement $______ Date: ______ Check#__________ Check#__________ Check#__________ Check#______ Total Amount for Year $______Total Amount for Year $______Total Amount for Year $______Total Amount for Year $______
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#16 FSA Election
Flexible spending AccountFlexible spending AccountFlexible spending AccountFlexible spending Account----Election & Payroll DeductionElection & Payroll DeductionElection & Payroll DeductionElection & Payroll Deduction FSA Plan Year: January 1FSA Plan Year: January 1FSA Plan Year: January 1FSA Plan Year: January 1----December 31, 2001December 31, 2001December 31, 2001December 31, 2001
Please complete the following information and then indicate below the benefit options that you will be electing. Payroll deductions are based on semi=monthly. Flexible Spending Accounts (Medical Reimbursement & Dependent Daycare) will be for 24 pay periods, through December 31, 2001 Name:Name:Name:Name: ____________________________________ Social Social Social Social Security:Security:Security:Security:__________________ Address:Address:Address:Address: ____________________________________ Birth Date:Birth Date:Birth Date:Birth Date: ___________________ City: _______________ State: ______________City: _______________ State: ______________City: _______________ State: ______________City: _______________ State: ______________ Zip Code:Zip Code:Zip Code:Zip Code: ______________________ Primary Beneficiary: ______________________________ Relationship: ____________________ Contingent Beneficiary: ___________________________ Relationship: ____________________
FLEXIBLE SPENDING ACCOUNTSFLEXIBLE SPENDING ACCOUNTSFLEXIBLE SPENDING ACCOUNTSFLEXIBLE SPENDING ACCOUNTS
Medical Reimbursement $_______________ Annual Election
Dependent Care Reimbursement $_______________ Annual Election
I understand the FSA plan offered to me and have elected to participate ___________________________________ Signature
I understand the FSA plan offered to me and have elected not to participate
________________________________ Signature Date: _________________________
Spouse: ____________________ SS#: ____________________ Birth Date: _________________Spouse: ____________________ SS#: ____________________ Birth Date: _________________Spouse: ____________________ SS#: ____________________ Birth Date: _________________Spouse: ____________________ SS#: ____________________ Birth Date: _________________ Children: SS# Children: SS# Children: SS# Children: SS# Birth Date: Birth Date: Birth Date: Birth Date: _________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ _________________________ _________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ _________________________ _________________________ ____________________________________________ ____________________________________________ ____________________________________________ _______________________ _____________________________ _____________________________ _____________________________ _________________________ _________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ _________________________ _________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ _________________________
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#17 Computing FSA Deductions
The following worksheet will help you calculate your applicable expenses The following worksheet will help you calculate your applicable expenses The following worksheet will help you calculate your applicable expenses The following worksheet will help you calculate your applicable expenses and how much that would be in an FSA deduction each payday.and how much that would be in an FSA deduction each payday.and how much that would be in an FSA deduction each payday.and how much that would be in an FSA deduction each payday.
Medical/DMedical/DMedical/DMedical/Dental/Vision Reimbursement Accountental/Vision Reimbursement Accountental/Vision Reimbursement Accountental/Vision Reimbursement Account Medical Expenses, such as:Medical Expenses, such as:Medical Expenses, such as:Medical Expenses, such as: Deductible and coDeductible and coDeductible and coDeductible and co----payspayspayspays $ __________$ __________$ __________$ __________ Routine physical examsRoutine physical examsRoutine physical examsRoutine physical exams $ __________$ __________$ __________$ __________ PrescriptionsPrescriptionsPrescriptionsPrescriptions $ __________$ __________$ __________$ __________ Chiropractic careChiropractic careChiropractic careChiropractic care $ __________$ __________$ __________$ __________ Dental Expenses, such as:Dental Expenses, such as:Dental Expenses, such as:Dental Expenses, such as: Deductibles andDeductibles andDeductibles andDeductibles and co co co co----insurancesinsurancesinsurancesinsurances $ __________$ __________$ __________$ __________ Routine checkRoutine checkRoutine checkRoutine check----upsupsupsups $ __________$ __________$ __________$ __________ OrthodonticOrthodonticOrthodonticOrthodontic $ __________$ __________$ __________$ __________ Vision Care Expenses, such as:Vision Care Expenses, such as:Vision Care Expenses, such as:Vision Care Expenses, such as: ExamsExamsExamsExams $ __________$ __________$ __________$ __________ EyeglassesEyeglassesEyeglassesEyeglasses $ __________$ __________$ __________$ __________ Contact lenses, solution, cleanersContact lenses, solution, cleanersContact lenses, solution, cleanersContact lenses, solution, cleaners $ __________$ __________$ __________$ __________ Total Estimated MedTotal Estimated MedTotal Estimated MedTotal Estimated Medical/Dental/Vision Expensesical/Dental/Vision Expensesical/Dental/Vision Expensesical/Dental/Vision Expenses $ __________ + __________ = $________$ __________ + __________ = $________$ __________ + __________ = $________$ __________ + __________ = $________ Annual Amount # of Pay Periods* Per Pay Period
Dependent Care Reimbursement AccountDependent Care Reimbursement AccountDependent Care Reimbursement AccountDependent Care Reimbursement Account Payment to a dependent care facilityPayment to a dependent care facilityPayment to a dependent care facilityPayment to a dependent care facility $ __________$ __________$ __________$ __________ or individual per yor individual per yor individual per yor individual per yearearearear Payment to other care providersPayment to other care providersPayment to other care providersPayment to other care providers $ __________$ __________$ __________$ __________ Total Estimated Dependent Care ExpensesTotal Estimated Dependent Care ExpensesTotal Estimated Dependent Care ExpensesTotal Estimated Dependent Care Expenses $ __________ + __________ = $________$ __________ + __________ = $________$ __________ + __________ = $________$ __________ + __________ = $________ Annual Amount # of Pay Periods* Per Pay Period
Total Pay Period ReductionTotal Pay Period ReductionTotal Pay Period ReductionTotal Pay Period Reduction $ _______$ _______$ _______$ _______ (Add total estimated medical/dental/vision and total estimated dependent care.)
Total Per Pay Period *Weekly, 52 paydays Bi-weekly, 26 paydays Semi-monthly, 24 paydays Monthly, 12 paydays
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#18 Claim for FSA Reimbursement
Employer ______________________________
Name ____________________ SS # ____________________ Employee # ___________________
Dependent Care Expense ClaimsDependent Care Expense ClaimsDependent Care Expense ClaimsDependent Care Expense Claims Period CoveredPeriod CoveredPeriod CoveredPeriod Covered Name of Name of Name of Name of
Dependent(s)Dependent(s)Dependent(s)Dependent(s) FromFromFromFrom ToToToTo
Name, Address and TaxpayerName, Address and TaxpayerName, Address and TaxpayerName, Address and Taxpayer Identification # of Provider of ServiceIdentification # of Provider of ServiceIdentification # of Provider of ServiceIdentification # of Provider of Service
Amount Amount Amount Amount IncurredIncurredIncurredIncurred
*TOTAL DEPENDENT CARE EXPENSE *TOTAL DEPENDENT CARE EXPENSE *TOTAL DEPENDENT CARE EXPENSE *TOTAL DEPENDENT CARE EXPENSE CLAIMCLAIMCLAIMCLAIM
*NOTE: The total amount claimed under the Plan for any coverage period must not exceed the lesser of your earned income for the plan year or the earned income of your spouse. (If your spouse is either a full-time student or is incapable of taking care of himself or herself, then he or she is deemed to have monthly earnings of $200 (if there is one (1) child or dependent, and $400 if there are two (2) or more). No payment may be made under the plan if the service provider is your dependent for federal income tax purposes, or if your child or stepchild and is under age 19.
Unreimbursed Medical Expense ClaimsUnreimbursed Medical Expense ClaimsUnreimbursed Medical Expense ClaimsUnreimbursed Medical Expense Claims Date expense Date expense Date expense Date expense
IncurredIncurredIncurredIncurred Name of Service Name of Service Name of Service Name of Service
ProviderProviderProviderProvider Expense Expense Expense Expense
DescriptionDescriptionDescriptionDescription Person for Whom Person for Whom Person for Whom Person for Whom Expense IncurredExpense IncurredExpense IncurredExpense Incurred
Net AmountNet AmountNet AmountNet Amount
TOTAL MEDICAL CARE EXPENSE CLAIMTOTAL MEDICAL CARE EXPENSE CLAIMTOTAL MEDICAL CARE EXPENSE CLAIMTOTAL MEDICAL CARE EXPENSE CLAIM
READ CAREFULLY:READ CAREFULLY:READ CAREFULLY:READ CAREFULLY: The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Company’s Cafeteria Plan with respect to such expenses and that the medical expenses have not been reimbursed or are not reimbursable under any other health plan coverage. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan which relate to such expense.
__________________________________ ______________________________ Employee’s Signature Date
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COMPLAINT FORMS
#19 SAMPLE FORM TO FILE COMPLAINT WITH STATE INSURANCE COMMISSIONER
Name: _________________________________________________
Address: _________________________________________ ____________________________________________
Home Telephone:__________________________ Work Telephone: ___________________________ Your Age Group: ( ) Under 25 ( ) 25 – 49 ( ) 50 – 64 ( ) 65 and up Name of Insurance company:__________________________________________________________ Type of Insurance Involved: Auto_______ Life_______ Health_______ Property_______ Other___________ Name of Insured shown on policy: ______________________________________________________ Policy Number:________________________________ Claim Number:_________________________ Agent’s Name:____________________________________ Agent’s Telephone:__________________ Adjuster’s Name:__________________________________Adjuster’s Telephone:________________ Date of Loss:____________/________/________ Have you already contacted your company or agent concerning your complaint? Yes ( ) No ( ) If yes, when and whom? ______________________________________________________________________ Are you presently represented by an attorney? Yes ( ) No ( ) Have you filed in any court? Yes ( ) No ( ) Explain your complaint fully in the order of events. Use the back of this form or additional sheets if necessary.... ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Attach copies of any letter you have written or received, copies of receipts, bills, contracts, or any other documentation concerning your complaint. If your complaint is about an insurance advertisement, attach a copy of the advertisement. . . . PLEASE DO NOT SEND ORIGINALS.PLEASE DO NOT SEND ORIGINALS.PLEASE DO NOT SEND ORIGINALS.PLEASE DO NOT SEND ORIGINALS. Have you previously filed a complaint with the Department concerning this problem? Yes ( ) No ( )
Signature:______________________________________Date:_____________________________ Please return completed form and any documentation to:
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#20 SAMPLE FORM TO FILE COMPLAINT TO AAO
AAO Member Complaint FormAAO Member Complaint FormAAO Member Complaint FormAAO Member Complaint Form (Third-Party Payers)
1. Member Name:
2. Complete Mailing Address:
3. Date(s):
4. Third-Party Payer Name:
5. Are you a contracted provider with this plan? Yes_______ No_______
6. Nature of problem or complaint; Mark all that are applicable:
_________Payment denial/Pre-Treatment authorization denial
_________No direct pay to non-participating provider
_________Benefit denial
_________Delay in payment(s)
_________Change in code to less complex or less expensive procedure
_________Combined procedure(s) resulting in lower benefits
_________Problems with/lack of coordination of benefits
_________Requests for additional treatment information/records
_________Loss of patient claims or additional treatment information
_________Other (Please explain)
Provide a thorough explanation of the problem:
Who may we contact for further information?_____________________________
***Please provide a copy of the appropriate Patient Information Release Authorization Form***
NOTE: This file may be saved to your computer, and completed. Send the forms as an attachment via email to: [email protected] OR Print the document and fax to (314) 993-6843, Attn: Ann Sebaugh
SAO OFFICE INSURANCE GUIDESAO OFFICE INSURANCE GUIDESAO OFFICE INSURANCE GUIDESAO OFFICE INSURANCE GUIDE
#21#21#21#21 REPORT ON INSURREPORT ON INSURREPORT ON INSURREPORT ON INSURANCE REFUSALS/REQUESTS FOR ADDITIONAL INFORMATIONANCE REFUSALS/REQUESTS FOR ADDITIONAL INFORMATIONANCE REFUSALS/REQUESTS FOR ADDITIONAL INFORMATIONANCE REFUSALS/REQUESTS FOR ADDITIONAL INFORMATION
Doctor Name________________________
PATIENTPATIENTPATIENTPATIENT DATE DATE DATE DATE CLAIM CLAIM CLAIM CLAIM SENTSENTSENTSENT
(E) or (M)(E) or (M)(E) or (M)(E) or (M)1111
INSURANCE INSURANCE INSURANCE INSURANCE COMPANYCOMPANYCOMPANYCOMPANY
DATE OF DATE OF DATE OF DATE OF CONTACT CONTACT CONTACT CONTACT BY BY BY BY COMPANYCOMPANYCOMPANYCOMPANY
ADDITIONAL ADDITIONAL ADDITIONAL ADDITIONAL INFORMATION INFORMATION INFORMATION INFORMATION REQUESTEDREQUESTEDREQUESTEDREQUESTED
REASON REASON REASON REASON FOR FOR FOR FOR DENIALDENIALDENIALDENIAL
TELEPHONE TELEPHONE TELEPHONE TELEPHONE CALLS BY MY CALLS BY MY CALLS BY MY CALLS BY MY STAFFSTAFFSTAFFSTAFF2222
COMMENTCOMMENTCOMMENTCOMMENTSSSS
1 1 1 1 Please indicate if the claim was sent (E)lectronically or (M)ailed 2222 Please indicate the number of times and length of call to the insurance company to discuss claim