1. DENTAL INSURANCE Chapter 14

2. 2 DENTAL INSURANCE Learning Outcomes 14-1Locate and describe the parts of the mouth and the teeth. 14-2Recognize key words, conditions, and treatments related to dentistry. 14-3Describe six types of benefits offered by dental insurance plans. 14-4Discuss the claim form and coding methods commonly used to submit dental insurance claims.

3. Chapter 143 Key Terms ADA Dental Claim Form Canines Current Dental Terminology (CDT) Dentin Dentist’s Pretreatment Estimate Dentist’s Statement of Actual Services Enamel Gingivae (sing., gingiva) Incisors Mandible Maxilla Maxillofacial surgery Molars Occlusion

4. Chapter 144 Key Terms Oral cavity Oral surgery Palate Premolars Prophylaxes (sing., prophylaxis) Prostheses (sing., prosthesis) Pulp Uvula

5. Chapter 145 Dental Terms Mouth Oral cavity consisting of: Gingivae Teeth Tongue Tonsils Bone structure: Mandible or lower jaw Maxilla or upper jaw Palate

6. Chapter 146 Dental Terms (cont’d) Teeth Crown, neck, and root Enamel Dentin Pulp 32 permanent teeth 4 incisors 2 canines 4 premolars 6 molars Equal number in mandible and maxilla for a total of 32

7. Chapter 147 Dental Insurance Purchased by individual Provided by employer Most policies reimburse policyholders for dental expenses Dental managed care plans available Dentists may be participating (PAR) or non- participating (nonPAR) Coverage varies by procedure and carrier

8. Chapter 148 Dental Benefits Preventive Benefits Prophylaxes, or cleanings, at regular intervals Diagnostic Benefits Diagnostic procedures such as x-rays Basic Benefits Restorative work Endodontics Periodontics

9. Chapter 149 Dental Benefits (cont’d) Prosthodontic Benefits Bridges and dentures (prostheses) Orthodontic Benefits Braces and straightening Oral and Maxillofacial Surgery Benefits Surgery and anesthesia

10. Chapter 1410 Medical Insurance and Dental Benefits Medicare does not cover dental care Medically necessary oral surgery is covered Medicaid covers some dental procedures Fees set by individual states Blue Cross and Blue Shield policies Most policies include dental coverage

11. Chapter 1411 Similar to Workers’ Compensation First Report of Injury File within 5 days of visit Describes Condition of patient’s teeth/gums prior to injury Nature and extent of injury Repair/replacement of teeth required and cost Contains Employer and supervisor’s name and address Date and time of accident Patient's description of injury Dental Injury Claims

12. Chapter 1412 Dental Coding Maintained by American Dental Association (ADA) Current Dental Terminology, 4th edition (CDT) Only procedure codes are used; no dx codes Surgical procedures submitted on a medical claim form CROWNS –– SINGLE RESTORATION ONLY D2710Crown – resin (laboratory) D2720Crown – resin with high noble metal D2721Crown – resin with predominantly base metal D2722Crown – resin with noble metal D2740Crown – porcelain/ceramic substrate D2750Crown – porcelain fused to high noble meta

13. Chapter 1413 Dental Coding (cont’d) 5 digits beginning with D 12 categories Diagnostic Preventive Restorative Endodontics Periodontics Prosthodontics, Removable Maxillofacial prosthetics Implant services Prosthodontics, Fixed Oral surgery Orthodontics Adjunctive services

14. Chapter 1414 Dental Claim Forms Dentist’s Pretreatment Estimate Determine coverage and amount of reimbursement Submitted prior to treatment Dentist’s Statement of Actual Services Submitted after treatment

15. Chapter 1415 Dental Claim Forms (cont’d) ADA Dental Claim Form Patient coverage information Details about the examination and treatment plan Information on billing and billing dentist

16. Chapter 1416 Critical Thinking What services may be covered by a dental insurance policy? Depending on the individual policy, coverage may include preventive; diagnostic; basic; prosthodontics; orthodontics; and oral and maxillofacial surgery.