How to Decide Between Prep Date and Seat Date for Claims Submission

This question has circulated around offices for decades: Do we submit crowns and other multi-visit procedures upon starting or at completion?

The answer is not a simple yes or no. As with most things in life, it’s not that easy, and anyone giving you a straight answer is missing part of the story. So, let’s review the facts and the complete situation so you can decide what to do within your own office:

1) Claim Standards Set by the ADA

Point #53 on the ADA claim form makes it clear: “Procedures … are in progress … or have been completed.”
The claim form states you can bill either in progress or upon completion, which means that from a claims-standards point of view, either option is correct and legal.

2) Insurance Companies Pay on Which Date?

Of course, this is the real issue. Everything in dentistry comes down to how insurance companies respond to claims. When you call and ask each insurance company whether they pay on prep date or seat date, you will get both answers. The split is almost down the middle, with half the companies choosing the prep date and half choosing the seat date.

3) Reimbursement vs. Legality

Trying to bill some claims on prep date and some claims on seat date would be a logistical nightmare for an office, with a huge potential to lose or forget to file claims. This is neither recommended nor required. Keep in mind that when an insurance company says they pay on a certain date, that is their reimbursement preference, which has nothing to do with your legal requirement for submission. The office should therefore choose one method and stick with it to avoid errors and mistakes.

4) End of Year

Whether you file on prep or seat date usually does not matter. The one time it does matter is when you have treatment that spans different policy years. If you prep in one policy year and seat in another, problems can arise—no matter whether the insurance pays on prep or seat date. Insurance companies can demand refunds either direction (been there, done that both ways), so the goal should be for every office to prep and seat in the same policy year whenever possible.

5) Is Prep or Seat Date Better?

Neither is universally better; both have pros and cons. The goal for the office should be to review both options and select the one that matches your workflow best.

• Prep date: Simpler billing, less chance of missing a claim, faster payment, and most work and expenses occur at the prep visit. You also tend to get an insurance response before the patient returns for seat. The downside is that some companies may require you to send additional information later.
• Seat date: Everything is completed when you send it, so insurance companies typically don’t have issues or ask for more information. However, you get paid slower, there is more chance of missing a filing, and you will not know the reimbursement before completing the case.

Note: Cigna is a “special” example, as they typically won’t pay for the buildup until after the crown is approved, so it does not matter whether you file on prep or seat date.

6) When to Bill the Patient?

Regardless of what you do with insurance, the strong recommendation is to bill the patient 100% of their expected co-insurance before you start the work.

A common mistake many dental offices make is splitting payment for multi-visit procedures based on the appointment (e.g., 50% at prep and 50% at seat). Without going into an entire article about why, you will have far fewer clinical, billing, scheduling, and follow-up issues if the patient has paid before you begin work on almost any procedure.

7) How to Handle End-of-Year Timing

Maintain good communication with your lab. Our labs send us a schedule every year indicating that if a case is started on X date, it will be back in our office by Y date. This gives us a final date each year where we can start a crown and still be sure we can seat it before the end of the year (or policy year). This allows us to avoid scheduling work that cannot be completed within the same policy year.

In the rare situation where a patient has an urgent issue, you can prep for a temporary crown but not take the impression. The impression is what defines the start of a definitive crown case, so delaying it lets you push the official start into the policy year in which you can complete the case and avoid insurance problems.

As a final note: If you must break this rule and start and finish in different policy years, it is highly recommended to have the patient pay in full (in or out of network) and let insurance reimburse the patient. Insurance companies can only demand a refund from the entity they paid, and they are far less likely—or able—to demand a refund from the patient.

Summary

Filing claims on either prep date or seat date is legitimate. Which one to choose depends on selecting the set of pros and cons that works best for your office. The main concern arises when treatment spans two policy years, and offices should take steps to prevent these issues. Information is key, and often an ounce of prevention is worth far more than any amount of cure.