Basic Dental Insurance Coding and Billing

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

If the subscriber changes jobs, is laid off, or retires, his / her coverage is usually terminated within 30 days of the change in employment. COBRA The rules for eligibility under other gov’t programs, such as Medicare and CHAMPUS, vary greatly.

The dental office should ALWAYS contact the insurance carrier to verify benefits BEFORE services are rendered. There is no dental coverage under Medicare !

Coverage can change month to month for some individuals, so it is important to verify benefits before each visit. Know how to read the insurance card ! They are all different ! Sometimes medical card includes dental; sometimes patient has separate cards.

EMPLOYER – buys the coverage as a benefit for the employees, and negotiates the limitations and benefits of the plan. CARRIER – is responsible for covering only the level of treatment that is included in the plan purchased.

Information explaining the coverage under a specific plan is found in the benefits booklet that is supplied to the subscriber (employee). Ask the patient to bring their benefits book to the first dental visit so coverage can be reviewed.  !

LEAT – Least Expensive Alternative Treatment This is a limitation in a dental plan that allows benefits only for the least expensive treatment.

For Example : The patient needs a replacement for a missing tooth. The treatment choices are a fixed bridge for $6000.00 or a removable partial denture for $1200.00. Under the LEAT rule, the carrier will pay benefits only for the partial denture. The patient may have the bridge done but the carrier will only pay the $1200.00. The patient must make up the difference.

Dual Coverage Dual coverage is when a patient has dental insurance coverage under more than one plan. When this is the case, it is necessary to take steps to be sure that the correct benefits are paid.

When there is dual coverage you must determine which carrier is primary and which is secondary. There are specific questions on a claim form that ask for this information.

Coordination of Benefits Husband & Wife both have dental insurance coverage for each other If wife is patient, her insurance is primary and her husband’s insurance is secondary. If husband is patient, his insurance is primary and his wife’s insurance is secondary.

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

Birthday Rule cont’ Mother’s Birthday April 23, 1968 Father’s Birthday February 9, 1968 Who’s insurance is primary ?

Terminology Usual, Customary, and Reasonable (UCR) Schedule of Benefits Fixed Fees Coinsurance / Copayment Deductible

Deductible Individual Deductible – each covered family member must meet this amount in covered services before the insurance will start paying. Family Deductible – total amount of covered services to be paid by family before the insurance will start paying.

Dependent: A child or spouse of the subscriber. Eligibility: The process of determining whether the patient is eligible for benefits. Exclusions: Services not covered by the dental policy.

Maximum: The maximum dollar amount a benefits plan will pay toward the cost of dental care over a specific period of time (usually one calendar year) Predetermination of Benefits: Also known as a pretreatment estimate, is an admin procedure that may require the dentist to submit a treatment plan to the insurance company before treatment begins.

Dental Coding Developed by the American Dental Association CDT-1 1991

CDT Categories I. Diagnostic D0100 – D0999 II. Preventive III. Restorative D2000 – D2999 IV. Endodontics D3000 – D3999

V. Periodontics D4000 – D4999 Prosthodontics, Removable D5000 – D5899 Maxillofacial Prosthetics D5900 – D5999 Implant Services D6000 – D6199

IX. Prosthodontics, fixed D6200 – D6999 X. Oral Surgery D7000 – D7999 Orthodontics D8000 – D8999 Adjunctive General Services D9000 – D9999

CDT Explanations Each code consists of five digits The first digit is always a D which indicates that this is a dental procedure The 2nd digit is a number that indicates the category of dental service (I – XII) The remaining numbers indicate specific services within each group _ _ 999 indicates an “unspecified code”

Example: Code D2150 D indicates that this is a dental procedure 2 indicates that this is a restorative procedure 1 indicates that this is an amalgam restoration 5 & 0 provide details about the type of restoration