FAQ
This is the total amount of benefit an insurance policy will provide the insured in a year’s timeframe. Therefore, it is also the most that the insurance carrier will reimburse a dental office.
Assignment of Benefits (AOB) is simply where the insurance reimbursement (check) is directed (written to). This could be the patient or the office. In most cases the office and/or patient has the option to designate AOB for either patient or provider. If you are in-network, every insurance carrier will allow AOB to go to the office. However, some companies (Ex: Delta) have policies that don’t allow AOB to go to the office when out of network.
Many states have laws to prevent insurance companies from restricting AOB. As of 2021, half the states in the country have some law regarding AOB.
Many states have laws to prevent insurance companies from restricting AOB. As of 2021, half the states in the country have some law regarding AOB.
Deductible is the amount of money a patient will need to pay first each policy year before an insurance company will start reimbursing for services. Traditionally 100% covered services like diagnostics and cleanings do not require the deductible to be paid first, but Basic and Major services such as fillings and crowns will.
While a deductible is a once-a-year amount of money, a copay is a per-code amount of money the patient is responsible to cover. Copay amounts are determined by the insurance policy of the patient; traditionally this is 20% for Basic services and 50% for Major services.
MAC (Maximum Allowable Charge) is when insurance companies have lower benefits for lower premium plans. Instead of paying off a percentage of UCR, MAC plans will pay off a percentage of a lower fee schedule or just pay a flat low fee per procedure. The dentist will still collect the total of the fee schedule they are contracted for. MAC plan patients end up paying more out of pocket due to the lower reimbursement.
Reimbursement is the money that an insurance company provides for services rendered, either to the patient or the office. This can be in the form of a check, EFT, or credit card.
A write off is the adjustment made in a ledger between normal office fee and a discounted fee. These adjustments can be anything from network discounts, coupons, specials/promotions, etc. It is important to note that with insurance these write-offs should only be entered after ALL claims have been processed for a specific procedure. Meaning if a patient has two policies, don’t post any write-offs until after the secondary claim processes. There should only be ONE write-off entry per date of service, not multiples.
Most policies cover two “cleanings” per year, which include either prophy or perio maintenance. Which means insurance will cover 2 of either, or one of each, but no more than 2 total.
The D4355 FMD code states you cannot do a comprehensive exam on the same date. You can instead file a D0140 – Limited Exam and get reimbursement. Then file the D0150 at the follow-up re-eval visit. For more information, check out Exams on Same Date of Service as Treatment Course.
D7510 - Incision and Drainage - is a stand-alone procedure when there is a need to make an incision and drain an area of the mouth due to infection. With all extraction codes, it is assumed that flushing and cleaning up the area is part of the extraction procedure, not a separate action. Meaning that the D7510 would be an inclusive part of the extraction by definition. In order to bill D7510, it must be on a different day as the extraction.
Most dentists will never encounter a need for the implant retained restoration codes. These are only used when the crown is directly cemented onto the implant because the implant/abutment is a single piece of metal (like a mini-implant).
Screw retained implant crown is an abutment and crown that are fused/cemented in the lab. They originated as two pieces and therefore still utilize two codes.
Screw retained implant crown is an abutment and crown that are fused/cemented in the lab. They originated as two pieces and therefore still utilize two codes.
Insurance companies change codes on claims in order to provide reimbursement. Some lower premium claims see composite and other such services as extra, and therefore push the cost off to the patient. This process is called a Downgrade.
The key about downgrades is they only affect what insurance reimburses. The patient is still responsible for the amount of the service that was provided. If you did a composite, you would collect in total for the composite. Downgrades mean patients paid less for premiums and will pay a higher percentage when they get treatment.
The key about downgrades is they only affect what insurance reimburses. The patient is still responsible for the amount of the service that was provided. If you did a composite, you would collect in total for the composite. Downgrades mean patients paid less for premiums and will pay a higher percentage when they get treatment.
There is a lot of debate surrounding this question. The ADA’s stance is that insurers should treat the coding as the preparation or impression date (Trans.1989:547). The insurance companies don’t even agree among themselves; Opinions vary widely as to whether a company will pay at initiation or completion of the service.
Dental offices typically find it much easier to bill for the procedure either when first started (impression) or when the majority of the work is done (preparation). And of course, patients should be held responsible for costs from the beginning.
There are pros and cons to whether you file a claim on prep or seat date. So unfortunately, there is no single right answer to this question; no hard and fast rules about whether one approach is more correct than the other, both are possible and done commonly. What can be important is knowing how each carrier sees the coding (prep or seat) because this can affect both how you communicate with them and how you should estimate for the patient, especially at the end of a policy year when treatment might span the gap. Best approach is to ask the carrier during the verification process and update your internal office “blue book” to ensure you’ve correctly captured that carrier’s policies before the claim has been processed.
Dental offices typically find it much easier to bill for the procedure either when first started (impression) or when the majority of the work is done (preparation). And of course, patients should be held responsible for costs from the beginning.
There are pros and cons to whether you file a claim on prep or seat date. So unfortunately, there is no single right answer to this question; no hard and fast rules about whether one approach is more correct than the other, both are possible and done commonly. What can be important is knowing how each carrier sees the coding (prep or seat) because this can affect both how you communicate with them and how you should estimate for the patient, especially at the end of a policy year when treatment might span the gap. Best approach is to ask the carrier during the verification process and update your internal office “blue book” to ensure you’ve correctly captured that carrier’s policies before the claim has been processed.
As of 2021, 40 states have laws protecting dentists against fee capping for non-covered services. The complexity comes in that each state defines a covered service differently. In most cases, when a patient maxes out the service is still considered covered even if the insurance company will no longer send reimbursement. To check your state’s specific rules, please visit this page.
NO. This is a common myth in the industry. Only one company even tries to claim this is a valid requirement. Check out the free public CE course here on Myths in Dental Insurance.
The gender section on claim forms MUST match what the patient/subscriber put on their application. A common challenge here is many patients have coverage through their employer, so it is important the patient makes sure the gender they designate is the same on all company records as well as dental office records and claim forms.
Basic information necessary is tooth number, x-ray, and reason for treatment. However, the better the information provided the more likely to get reimbursement and a quicker response. Photos and mid-op information help tremendously. For case specific examples please see the CE course.
Basic information necessary is the complete perio chart, x-rays, and quadrants treated. More common requested information is specific teeth treated, amount of time the procedure took, and supporting clinical notes. Photos can help tremendously as well as many times x-rays don’t show the entire picture.
For case specific examples and ways to get almost every claim paid please see the CE course
For case specific examples and ways to get almost every claim paid please see the CE course
You should always submit your full office fee on a claim form. This comes from both ADA recommendations as well as almost every in-network agreement stipulates that you will submit full fee. It is also smarter from a practice management view. If your fee submitted is lower (due to data error) than the insurance contracts agreed upon network fee schedule, insurance will pay the lower of the two values and the office loses money.
This depends on the specific company. Some companies will pay both services like normal. Commonly though insurance companies will reduce the benefit of the second service by the amount reimbursed for the first. The timeframe of this when done is often the frequency limitation of the filling. Whether to credit the patient for the cost of the filling is typically up to the office; the insurance company is only saying they will pay for the final treatment as if it were the only treatment provided.
Our recommendation is to provide the patient with the estimate that means the largest out of pocket expense. This way if you are wrong, it means a credit to the patient. Refunds after the fact are simple, collections are not.
Every insurance company has three basic sets of fees: Negotiated fee schedule for in-network dentists, UCR for out of network dentists, and MAC for low premium plans.
When you are out of network, the policy will most likely pay off the lower of UCR or your full fee. However, lowering paying policies pay off a set fee schedule called MAC. (See terminology for MAC). Most companies will send checks to the office if requested; however, a couple of insurance companies will send OON checks to the patient, unless forbidden by state law.
You will also want to make sure to ask specifically what percentage they pay on for OON, which can be different from the percentage they pay in-network.
When you are out of network, the policy will most likely pay off the lower of UCR or your full fee. However, lowering paying policies pay off a set fee schedule called MAC. (See terminology for MAC). Most companies will send checks to the office if requested; however, a couple of insurance companies will send OON checks to the patient, unless forbidden by state law.
You will also want to make sure to ask specifically what percentage they pay on for OON, which can be different from the percentage they pay in-network.
Abutments can be prefab or custom, coding depends on what you are using: D6056 and D6057.
The retainers for the bridge depend on whether they are on top of an abutment or not and type of material.
Abutment supported retainer crowns: D6068 - D6074
Implant supported retainer crowns (do not use the D6056/D6057 as the abutment/implant is a single fused piece): D6075 - D6123
The pontics will be the same code as natural tooth bridges, based on material used: D6205 - D6252
The retainers for the bridge depend on whether they are on top of an abutment or not and type of material.
Abutment supported retainer crowns: D6068 - D6074
Implant supported retainer crowns (do not use the D6056/D6057 as the abutment/implant is a single fused piece): D6075 - D6123
The pontics will be the same code as natural tooth bridges, based on material used: D6205 - D6252
Initial dates can be estimated. Now, the biggest point is insurance frequencies, which can be anywhere from 5-10 years. If the crown is over 10 years old, or over the frequency of the policy, that is all that matters. I often write: 10+ years.
This has been a coding challenge for years. Insurance companies have viewed membranes as only for perio surgery since they are in the D4000 series of codes. Yes, they would cover it, but not for surgical D6000 or D7000 procedures. This has always been a contention point for dental teams. With the new 2023 coding updates, we now have codes for membranes in both the D6000 series and D7000 series to help prevent these miscommunications from happening.
One of the most common coding misunderstandings has been surrounding the D9110 Palliative Care code. This is not an exam code, although many have tried to use it as such due to exam frequency problems. D9110 is a minor treatment to relieve pain before definitive treatment can be done later. This means you will still want to code your exam (likely D0140) and any x-rays you take along with the D9110. Most policies cover only two exams per year, making it to where the patient may need to cover the cost for the exam.
Yes! We find incorrect EOBs on a daily basis. The automated computer systems work well often, but they are not infallible. Learning what you should be expecting to see can save yourself a lot of hassle and potential mistakes. If you have a specific EOB that is puzzling you, please submit it through the "Ask a Question" form and DIG would love to get you an expert response!
We often will end up with patients that had SRP in the past, but insurance does not have a history of it. Whether the patient is new to your office or existing, the answer is the same. D4910 requires a history of SRP. If filing with insurance for the first time, you will need to include the date of the original SRP (estimated if necessary) and a brief narrative on why the patient still needs PM.
Pulp caps are a commonly disallowed procedure by insurance companies. When OON, expect no reimbursement. When in-network, you will need to treat these as optional upgrades to get paid. See the Upgrade CE course here to learn the system and waivers for being able to charge for these and other services.
Often CBCT is not a covered procedure in many policies. Unfortunately, there is no way around this from the insurance company side as they are hard exclusions. These would need to be patient directed billing costs.
Procedures have specific claim documentation requirements that are hard coded, meaning no getting away from. X-rays for crowns is one common requirement. Best practices is to handle every case the same way and always get the x-ray. Yes, insurance can avoid paying on a claim if you do not have the required documentation. The positive on this is you can and should bill for that x-ray.
The best way to handle secondary insurance is to estimate zero coverage and assign benefits to the patient. In most states, the patient is responsible for the lower network fee between both insurance policies. The office is allowed to collect up to full fee as a combination of reimbursement from both insurances policies.
If you would like a detailed breakdown and different scenario examples, please look at this textbook resource.
If you would like a detailed breakdown and different scenario examples, please look at this textbook resource.
In general, EOB software language only provides a short list of responses, which are not very descriptive. So, in most cases, the EOB answer is not precise, just the closest answer the system has available. Therefore, you should read this response as communicating: “there is not enough information to justify reimbursement, please submit more documentation to support coverage”.
If you would like a more detailed answer, please check out the CE courses: Dental Insurance Myths and Achieving Reimbursement for Crowns, BUs, and Other Restorative Services
If you would like a more detailed answer, please check out the CE courses: Dental Insurance Myths and Achieving Reimbursement for Crowns, BUs, and Other Restorative Services
Yes, to review a claim as a dentist and render an opinion, the dentist must have a current license in the state the treatment was rendered. You can and should request this information be shared in the case of a denial.
Depends on the reason. If the patient was unemployed or their policy was terminated on the date of service, yes, they can. There is often a maximum length of time in which an insurance carrier can request past payments be returned, depending on the contract and your state laws. Ex: In Texas, for claims past 180 days insurance cannot demand refunds except in instances of fraud.
Pre-Authorizations are guarantees of payment within the medical community. Pre-Determinations are generally NOT in dentistry. Some states have passed laws to make them guarantees, and at TDIG (?) we expect to see more of these laws enacted to protect patients from unexpected bills due to insurance. In the meantime, some resources to try:
To achieve 2 and 3, it is important as an office NOT to take responsibility for this error by ever thinking you should just write off the balance. Always remember the insurance company is there to help the PATIENT with costs, NOT to be a potential source of loss for the office.
- Involve the state department of insurance
- Have the PATIENT complain to the insurance company directly
- Have the PATIENT ALSO complain to their employer’s HR department
To achieve 2 and 3, it is important as an office NOT to take responsibility for this error by ever thinking you should just write off the balance. Always remember the insurance company is there to help the PATIENT with costs, NOT to be a potential source of loss for the office.
Most insurance companies see the common root canal codes as the completion of the procedure. The start of the procedure is a pulpectomy, which is also a code which is commonly disallowed because it is part of the overall procedure (if completed). Yes, insurance is entitled to that refund if the service was not completed.
However, the PATIENT is responsible for the cost of the pulpectomy or start of the procedure. A great practice management tip here would be to advise the patient if they do not return for completion, they will owe $X more because insurance only helps THEM with payment if the service is finished.
However, the PATIENT is responsible for the cost of the pulpectomy or start of the procedure. A great practice management tip here would be to advise the patient if they do not return for completion, they will owe $X more because insurance only helps THEM with payment if the service is finished.
It can be. To achieve higher fees requires both understanding affiliations and having strong negotiation skills. Some dental offices are not good at either. While it is possible to negotiate yourself, if you hire a company that understands both affiliations and negotiations, they can often generate a much better result than you can achieve on your own.
Typically, No. Delta has been phasing out Premiere for years. It is only in a few areas of the country where Delta does not have enough dentists that it might offer this option.
This depends on the company, but most will allow renegotiations every 18-24 months.
Some low-end policies pay off a lower fee schedule. These are called MAC plans (maximum allowable charge). The patient is responsible for the balance of your in-network fee, so these should be thought of as downgrades.
The average maximum in 1960s was $1000. In 2021, it is around $1250, which with inflation is a massive decrease. This happens mostly because insurance company data only shows that 4-6% of patients ever utilize their maximum. The data does not reflect the need for increase on a national scale.
For a deeper discussion of why this number is so low and what YOU as a dentist or office can do about it, check out this free membership CE course: Understanding The Insurance Game.
For a deeper discussion of why this number is so low and what YOU as a dentist or office can do about it, check out this free membership CE course: Understanding The Insurance Game.
When you sign a network contract, part of that contract states that you agree that the insurance company can network lease you (basically like subletting an apartment), which means you may now be in-network with two (or multiple) companies under the same fee schedule. There are potential pros and cons of this situation.
A positive result from network leasing is you can gain exposure to more patients with no extra effort on your part. Often signing up with insurance companies is a pain, with massive paperwork. Network leasing requires no effort on your part.
If you understand how network leasing works, you can also strategically sign up with some companies to get in network with other companies you want and gain access to higher fee schedules for BOTH companies.
The negative result usually comes from the lack of knowledge of which networks you are in and the ensuing confusion and frustration.
A positive result from network leasing is you can gain exposure to more patients with no extra effort on your part. Often signing up with insurance companies is a pain, with massive paperwork. Network leasing requires no effort on your part.
If you understand how network leasing works, you can also strategically sign up with some companies to get in network with other companies you want and gain access to higher fee schedules for BOTH companies.
The negative result usually comes from the lack of knowledge of which networks you are in and the ensuing confusion and frustration.
What you should do as an office is first inform each insurance company of any changes. Many insurance companies just need the credentialing information about the new/temp dentist.
Locums Tenens is the term for a short-term replacement provider, and the term recognized in most areas of the healthcare industry.
Decades ago this was not an issue at all, insurance plans did not tend to care much about temporary dentists, it was a massive amount of useless paperwork back then. In today’s world, the regulations the insurance companies must follow requires them to maintain a lot more information, including current and temp dentists.
Each plan has a different set of rules they maintain, which can be highly frustrating for the office. The best answer is to call provider relations for each company and follow their guidelines. Many companies will allow you to bring on a temp or replacement dentist for 3-12 months before needing full credentialing to account for short notice changes in the office.
Locums Tenens is the term for a short-term replacement provider, and the term recognized in most areas of the healthcare industry.
Decades ago this was not an issue at all, insurance plans did not tend to care much about temporary dentists, it was a massive amount of useless paperwork back then. In today’s world, the regulations the insurance companies must follow requires them to maintain a lot more information, including current and temp dentists.
Each plan has a different set of rules they maintain, which can be highly frustrating for the office. The best answer is to call provider relations for each company and follow their guidelines. Many companies will allow you to bring on a temp or replacement dentist for 3-12 months before needing full credentialing to account for short notice changes in the office.
In many cases the best way to get the most information about policies is to have a phone call with the company to answer specific questions. However, in many ways this is not feasible to do daily for small or single provider offices. The next common answer is to use the insurance provider’s online portal for eligibility and breakdown information. Since this is an emerging option, some companies have better online information than others.
Outsourcing this process has become more popular, especially since Covid. An outside company that handles only insurance can sometimes be more efficient and effective at obtaining this information.
Finally, some companies are trying to bridge the gap here and provide more automated ways to handle getting more information without needing to pick up the phone. A couple of these companies are looking very promising for both cost effectiveness and data accuracy. We at TDIG are keeping a close eye on these options and will keep members updated through newsletters.
Outsourcing this process has become more popular, especially since Covid. An outside company that handles only insurance can sometimes be more efficient and effective at obtaining this information.
Finally, some companies are trying to bridge the gap here and provide more automated ways to handle getting more information without needing to pick up the phone. A couple of these companies are looking very promising for both cost effectiveness and data accuracy. We at TDIG are keeping a close eye on these options and will keep members updated through newsletters.
This can be highly frustrating, because yes there is a trend to ask or require more information today for a claim vs years ago. As technology improves, so does the expectation to use it. In today’s world, the usage of intra-oral photos has become of key importance to relaying information to the insurance company for payment. Good news is the cost of these cameras has gone from thousands of dollars each to hundreds, making it far easier and more affordable to capture photos.
Delta Dental is a group of over 30 different independent entities that share some common rules and name, but not communication. First thing to check is make sure you are sending the claim to the CORRECT Delta Dental office / address.
Secondary insurance is highly complex because there are 4 different ways insurance companies handle coordination of benefits. A common challenge with offices however is misinterpreting the EOBs and then writing off too much. Please utilize the secondary insurance calculator online to prevent errors, which you can find in the resources/tools section here.
