Dental Insurance Review

What is the role of the dental receptionist in dental insurance?

To assist the patients in understanding their insurance benefits

What is a dental insurance program?

A contract between the patient’s employer and the insurance carrier.

What is a co-payment?

The outstanding fees that a patient pays that dental insurance does not cover. (i.e. Insurance covers 80%, patient pays 20%)

What is shared risk?

The factors included in the insurance plan to enable the patient to share some financial responsibility and make informed decisions about proceeding with treatment.

Who is the subscriber?

The person who is insured.

What is the eligibility requirement?

In which the insured party must work with their employer for a set amount of time in order to avoid taking advantage of the dental benefits and then leaving the job.

What is an assignment dental office?

Where the office directly bills the insurance company and the patient pays the co-pay only.

What is a non-assignment dental office?

Where the office has the patient pay upfront and the patient is reimbursed afterwards.

What is a deductible?

An annual fee that the patient pays based on the calendar year, fiscal year, or rolling year.

What is plan A?

Basic/routine services.

What is covered under plan A?

Hygiene, fillings, root canals, fillings, simple extractions

For an ESTIMATE, does plan A do EDI, or a standard dental claim form and x-ray?

EDI, no x-rays or standard dental claim forms.

What does EDI stand for?

Electronic Data Interchange

What is plan b?

Major restorative services, anything that requires surgery or the dental lab.

What is covered under plan b?

Crowns, bridges, dentures, implants, veneers

What is plan c?

Orthodontic services.

What is covered under plan c?

braces

For an ESTIMATE, what does insurance require for plan b?

Standard dental claim form, office verification, x-rays.

For an ESTIMATE, what does plan C require?

Date of extraction, standard dental claim form, a panoramic x-ray, office verification

What is the missing tooth clause?

If you got your tooth knocked out before your insurance started, it is not covered.

What is EOB?

Explanation of benefits

Can you send x-rays through email?

YES

What is the birthday rule?

The spouse whose birthday goes first on the calendar covers their dependent/child. (i.e. January 1st goes before February 1st)

What is EDI?

The electronic submission of insurance claims

Who is the dependent?

Someone other than the policy holder who is covered under the insurance plan. Can be a child or spouse.

What is the group ID?

A unique code that identifies the coverage.

What is the member ID?

A unique number that lets the insurance company track and process claims.

What is an annual limit?

A limit set by the insurance company for the benefit year. Can be for any plans. Combined limits are usually for plan a and b.

What is a lifetime maximum?

The maximum amount a plan will pay over the course of a lifetime. Usually for orthodontic treatment (i.e. you only need braces once)

What is a calendar year?

A financial year set from January to December.

What is the association that determines procedure codes and prices?

The BCDA

What is a primary plan?

The policy holder’s plan

What is a secondary plan?

When a patient has coverage under two different dental plans. Can be from a second job or a spouse.

What is EFT?

Electronic Funds Transfer

What is COB?

Coordination of benefits between two plans

What is the maximum percent two plans can cover?

100%

How long does it take for EDI to process?

Just a few days

How long does it take for non Plan A procedures to process?

Depends on where the insurance company is located - can take a month or more.

Can you send a secondary plan EDI for COMPLETED treatment?

NO - must be a SDCF

For SINGLE insurance, how do you send claims for COMPLETED treatment?

EDI for all

For ESTIMATES for SINGLE insurance, how do you send the claims?

EDI for primary plan, SDCF for secondary plan

For COMPLETED treatment, how many times should a patient sign a SDCF?

Three times

For an ESTIMATE, should a patient sign a SDCF?

No, office verification only

What should you make sure a patient profile has before doing insurance?

Full name, birthday, gender, marital status

What plans are government funded?

First Nations Health Authority Dental Plan, Canadian Dental Care Plan, British Columbia Dental Plan, Veteran Affairs Canada

What government plan is optional?

Canadian Dental Care Plan

What are the two government plans where the dentist MUST provide service?

First Nations Health Authority Dental Plan and Veteran Affairs Canada

Do estimates expire?

YES - expiry date is printed on the statement or can be found online

Do insurance plans cover everything?

NO - plans have limits and restrictions

What are the three types of x-rays?

Periapical, bitewing, and panoramic