Insurance Primer

The following are basic benefit features that apply to most plans:

• Coinsurance—The majority of plans provide 100% coverage for routine diagnostic and preventive services. Member responsibility for restorative and surgical procedures is typically 20% for Type 2 (basic) services and 50% for Type 3 (major) services.
• Deductible—Typically $25-$50 must be paid by the member before benefits are provided. The deductible generally does not apply to Type 1 services such as cleanings, exams, and X-rays. 
• Annual Maximum—Most plans include a plan maximum, which can vary in price. The most common plan maximum is $1500/year. Benefits may be based on a calendar year, running from January 1 to December 31, or on a plan year that coincides with the purchaser’s fiscal year. 
• Rollover Maximums—Most plans include a rollover maximum option. This allows members to retain a portion of unused monies for the following benefit year. In most cases, additional requirements must be met to be eligible for this benefit. For example, a requirement that the member receive at least one exam in the prior year.
• Enhanced Benefits—Many plans offer enhanced coverage based on a member’s specific health conditions or dental risk scores. These enhancements are based on scientific evidence and often allow for additional cleanings or adult fluoride treatments that fall outside the standard plan limitations.
• Limitations and Exclusions—Dental benefits are designed to provide help with dental expenses and not to cover everything a patient may need. There are generally frequencies or time limitations for treatment that apply. Almost every plan provides a policy and procedure document that details its benefit limitations and exclusions. It is prudent to review these documents for any plan you deal with on a regular basis. Below are a few examples of plan limitations  or exclusions:
  • One cleaning every six months
  • Full mouth X-rays every five years 
  • Fillings every two years 
  • Crowns every five years 
  • No coverage for services performed solely for cosmetic reasons 
  • Waiting periods for more extensive services, like bridges or dentures
  • Missing tooth exclusions – when these apply, the plan will not pay for the replacement of a tooth that was missing prior to coverage  

Verify Benefits

All of the major plans provide member-specific benefit and eligibility details on their websites. To protect member information, dental offices must register to access this information. It is well worth the effort to be able to access information about your patients’ specific benefits, including:

• Claim history
• Remaining maximums
• Deductible status
• Time limitations

The process begins with eligibility. It is wise to check eligibility for each new patient and for any existing patient who has a plan change. It is recommended that you use a carrier web portal instead of customer service to check eligibility, especially for carriers with whom you have a significant number of patients enrolled. Compare online eligibility information to patient registration information or, at least, to the information displayed on the member ID card.

Carrier’s self-service tools and web portals are designed to answer the vast majority of your routine benefit and eligibility questions. Online tools streamline the verification process, allowing you to provide your patients with a printed summary of their benefits. They also help you avoid spending unnecessary time on hold waiting for the next available customer service agent to answer your question or entangle you in an endless automated voice response loop. 

You should also set up your billing record to match the patient’s enrollment in their dental plan. For example, if a patient is listed as William with his dental carrier, but is listed as “Bill” within your dental records, you should use the name William when submitting claims. The same holds true for dates of birth. Correct information should always be confirmed with the patient. If the insurance company has an incorrect date of birth, ask your patient to get it corrected by their plan sponsor. The goal is to avoid errors and rework for all involved.

Some insurance companies utilize algorithms with matching logic to address discrepancies in name and date of birth. That approach can result in errors that can lead to confusion for you and your patient. It is best to have matching information right from the start.  

Upon Initial Validation of Patient, Check For:

• Accurate member ID 
• Active coverage for treatment dates—Check for benefit effective or termination dates
• Matching spelling of the patient’s name – Avoid nicknames 
• Matching date of birth—If the date of birth provided by the patient differs from the one on file with the insurance company, the patient is responsible for correcting the information through their employer or by contacting the insurance company’s customer service. 
• Active student verification if the dependent is over age 19
• Type of plan and whether your office is participating in the plan’s provider network. This is particularly important for plans with varying coinsurance and/or deductibles, depending on whether treatment is in-network or out-of-network.

Successful Dental Benefit Management
Patients want and expect their dental practice to understand and support their dental insurance process. It is essential that the staff at your practice take the necessary actions to ensure the best possible outcomes in claim management. Removing financial barriers for your patients helps support treatment acceptance and optimal dental health. 

Managing Eligibility
Plan sponsors (employers, unions, or associations) manage their eligible populations. Many submit eligibility electronically using approved HIPAA transactions. In the case of electronic eligibility updates, even if the insurance company corrects information in their systems, those changes are overwritten with the next eligibility file update. That is why the member needs to get the incorrect data updated at the source.

An area where things are more tightly managed than they were in the past is the verification of student eligibility. In simpler times, dental offices would include the name of the school the patient attended on the claim, and if their coverage allowed for students, they were considered eligible. As plan sponsors work to control their claim costs, only verified student claims are processed. The verification process requires that subscribers validate the student status of their dependents annually. Delays in complying with this process, which is handled differently based on plan sponsor, are another reason for claim delays and ultimately denials.

Eligibility for group coverage is ultimately determined by the plan sponsor, based on their eligibility rules for benefits. In many cases, the plan sponsor is paying all or a portion of the premium for their members’ benefits.  In the case of a self-funded business, plan sponsors also assume the full cost of claims. As a result, savvy plan sponsors closely monitor their eligibility listings. By law, plan sponsors have up to 72 days to terminate an employee’s coverage. 

Yes, dentists should always report their full fee for the procedure code on the claim form, regardless of the benefit amount, according to the American Dental Association (ADA) Center for Coding, Dental Benefits, and Quality. The full fee represents the costs of providing the service and the value of the dentist’s professional judgment in providing the service. As dentists determine their fees for services rendered, the full fee can be any amount, starting from zero dollars (i.e., $0.00). A $0.00 report on a claim form is a valid entry.

A contractual relationship with any payer does not change the dentist’s full fee. For example, dentists in a payer’s network agree to offer a discount and sometimes agree to additional processing policies that stipulate a “least alternative benefit” or “bundling,” which specifies how a service might be billed against. A common policy includes combining separate DO and MO restorations on a single tooth and paying for a single MOD. This is simply the payer’s benefit policy and should not influence your treatment plan. When this occurs, the payer’s explanation of benefits (EOB) must clearly detail how the dental benefit plan’s provisions affected the payment amount. The explanation must not suggest to a patient that the treatment was somehow incorrect or unnecessary. Patient education prior to treatment is crucial to the success of a practice.

It is also vital that the dentist does not report a full fee that is artificially inflated over what they usually expect to collect when no benefit is involved. If the fee collected for a given procedure is never more than $90, then the dentist should not report a full fee of $100. The ADA Code of Ethics states that “The fee for a patient without dental benefits shall be considered a dentist’s full fee. This is the fee that should be represented to all benefit carriers regardless of any negotiated fee discount.”

Over time, fees reported to the plan on claim forms are used to monitor trends and serve as the basis for the payer setting allowable amounts for the area. These analyses will not accurately reflect the true market trends if dentists in that area aren’t submitting their full fees. Coordination of benefits is also dependent upon the fee reported on the claim form.

A dental plan administers a “benefit” to the patient and is not intended to cover all charges. If you bill the full fee, the patient will receive the maximum benefit from their plan. CDT Code and claim submission assistance is available from the ADA Third Party Payer Concierge.

By law, plan sponsors have up to 72 days to terminate an employee’s coverage. Termination of benefits can be further impacted by the availability of optional COBRA coverage and/or, in the case of a job change, the transfer of coverage to a new employer’s plan. Most carrier websites provide coverage dates, but these dates can change due to retroactive updates to information. Your best source is your patient. It is important to be aware of any benefit changes that occur. Ultimately, understanding changes to their eligibility is the patient’s responsibility. However, a knowledgeable practice administrator who can help navigate the process is a great way to provide excellent customer service.