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Dental Administration 101. INSTRUCTOR Robbie Heath | 919 271 8863. What is Dental Insurance Coverage for individuals that provides assistance with paying for the cost of dental treatment Medical designed to cover costs associated with diagnosing and treating medical illness

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Dental administration 101

Dental Administration 101


Robbie Heath | 919 271 8863

Dental administration 101

  • What is Dental Insurance

  • Coverage for individuals that provides assistance with paying for the cost of dental treatment

  • Medical designed to cover costs associated with diagnosing and treating medical illness

  • Dental designed to provide coverage for preventative dental services-Patients assume larger portion

Dental administration 101

  • Group Dental Plans

  • Dental benefits sponsored by an employer

  • Insured- Employer pays a portion of monthly premiums to an insurance company on behalf of the employee. Insurance company pays providers

  • Self-funded- Employer collects premiums and invests the funds. Dental claims are processed and paid by the employer to the provider

Dental administration 101

  • Preferred Provider Organization- PPO

  • Patients have a choice in choosing providers but benefit most by using an “in-network provider”

  • In Network

  • Insurance carriers and dental providers agree upon a contract that sets pre-negotiated contracted rates for reimbursement by providers. Rates are determined by the insurance carrier and are based on UCR (usual, customary, and reasonable fees)

  • Out of Network

  • Refers to a patient covered by a PPO plan who chooses to receive care from a dental provider that does not have an agreed upon contract with the insurance carrier

Dental administration 101

  • Managed Care Plans- DMHO, HMO

  • Insured patients must see participating assigned providers only

  • Less expensive to employers

  • If patients go outside of network they are financially responsible for all charges

  • Managed care plans do not pay non-participating providers

  • Providers may only refer to specialist also participating in the managed care program

Dental administration 101

  • Direct Reimbursement Plans

  • Self-funded plans

  • Reimbursement to the plan member by the employer/plan

  • Plan member pays total bill to the provider at the time of service

  • No insurance carrier involvement

Dental administration 101

Who is Involved?

  • Carrier- The insurance company (ex. Metlife, Cigna, Guradian)

  • Group- Employer or organization that provides the dental plan to the employee

  • Group number- Unique number assigned by an insurance carrier to identify the employer or group sponsoring the insurance coverage for an employee

  • Subscriber- The employee or member who holds the insurance plan

  • Dependent- Family member or spouse of a subscriber who is eligible for benefits sponsored by the subscriber

  • Provider- Dentist or dental office that provides dental treatment

Dental administration 101

  • Individual Plans

  • Work as group plans except there is no employer.

  • Patient purchases and pays premium for their own insurance coverage

  • Copays and deductibles still apply

  • Tax Funded Plans

  • Medicare- Provides medical coverage as part of social security benefits; does not provide dental coverage

  • Medicaid- State and federal funded medical and dental insurance coverage. Fees are paid directly to the provider through state or federal funded plans

    • Pays approximately 50% of the bill to providers

    • Participating providers must write off the remainder bill for patients under the age of 18

    • Adult patients are only billed $3.00 per visit

    • Strict rules regarding allowable procedures

Dental administration 101

  • Discount Plans

  • Not an insurance plan

  • Provided through insurance carriers

  • Participants pay a small yearly fee to be allowed to receive the discounted contracted fee from participating providers

  • No insurance claim to file

  • Participants directly pay discounted fees to provider at the time of service

  • Uninsured Patients

  • Subject to full price of dental procedures

  • Does not benefit from contracted rates

  • May need or benefit from payment plan

  • Care Credit vs In-house financing

Dental administration 101

  • Understanding Patient’s Benefits

  • Breakdown of Benefits refers to the outline and criteria of benefits a plan offers

  • Breakdown of Benefits form is specific to the needs of an office and is used to notate plan benefits

  • This form covers certain needed information

  • Subscriber Information

  • Patient Information

  • Insurance Company Information

Dental administration 101

  • What is an Effective date & Why is it Important?

  • Eligibility-Is the patient eligible for services on the date of service

  • Waiting periods-An amount of time a patient must wait before eligible for services

    • Preventative Services usually are not subject to a wait period

    • Basic restorative services are usually subject to a 6 month wait

    • Major services may include oral surgery, prosthodontics, periodontics, and endodontics and usually are subject to a one year wait

Dental administration 101

  • Prior placement or service dates

    • Replacement Period- The amount of specified time a patient must wait before the insurance will pay towards replacing certain procedures such as dentures, partials, bridges, and crowns. Usually 5-10 years

    • Missing Tooth Clause- Protects insurance carriers from tooth replacement costs for teeth missing prior to the plans effective date

Dental administration 101

  • Benefit time period

    • Calendar year- January 1 to December 31

    • Benefit year- Start date of plan running for one year

  • Deductibles

  • A set dollar amount a patient will have to personally satisfy prior to the insurance carrier contributing to the dental bill

    • Usually $25.00, $50.00, or $100.00

    • Usually applies to services other than preventative and diagnostic

Dental administration 101

  • Yearly Maximum

  • An annual dollar amount an insurance plan will pay toward the cost of dental care within a specific benefit period

    • Usually 1,000, 12,00, or 1,500 per year

    • All payments for any reason paid by insurance is subtracted from this amount

  • Coinsurance

  • A percentage or portion of the cost per procedure that is paid by the plan member

    • Outside of the deductible

    • Usually in a percentage amount

Dental administration 101

Three Levels of Coinsurance

Preventative & Diagnostic

Exams, Prophies, X-rays, Sealants, Flouride

Basic Restorative


Perio, Endo, and Oral Surgery Vary by Plan

Major Services

Crowns, Dentures, Partials, Implants, Bridges

Dental administration 101

  • Services Particular to the Individual Provider or Group

    • Sealants & Flouride treatment coverage and age limitations

    • Debridements

    • Buildups

    • Implants

    • Nightguards

    • Nitrous Oxide (N2O)

Dental administration 101

  • Other Important Benefit Information

  • Frequency Limitations

  • Describes how often a particular service is covered by a dental insurance plan.

    • Exams

    • Prophy

    • FMX/Panorex

    • Bitewings

    • PerioMainanence

    • Scaling and Root Planing

    • Fillings

    • 6 months vs 2 per calendar year

Dental administration 101

  • History

  • Due to frequency limitations, providers must know the dates of most recent services

    • Date of last FMX/Pan

    • Date of last prophy

    • Date of last Exam

    • Date of last bitewings

Dental administration 101

  • Billing of Dental Crowns

  • Prep Date- insurance carrier requires that the crown be billed on the day that the tooth is prepped

  • Seat Date- insurance carrier requires that the crown be billed on the date the crown is permanently delivered. Date of prep and seat must be notated when billing

  • Common area for insurance fraud

  • When billed on seat date- core buildup is billed on prep date

Dental administration 101

  • How Are Insurance Carriers Billed

  • Dental providers communicate with insurance carriers through dental claim forms

    • ADA Dental Claim Form

    • Mail

    • Electronic

    • Insurance carriers have 30 calendar days to respond to dental claims

    • Non-compliant insurance carriers can be reported to the NC Insurance Commissioner

Dental administration 101

  • Assignment of benefits

  • Patient is assigning his or her insurance benefits to the dental office as payment of the treatment received

    • Payment goes directly to the provider

    • Assignment of benefits must be authorized on the dental claim form

  • Predeterminations

  • Itemized list of dental services that a patient requires, rather than has been completed, and is submitted by dental claim form

    • Not a request for authorization to begin treatment

    • A written document stating exact amount of reimbursement an insurance carrier will pay towards needed treatment

    • Not a requirement

Dental administration 101

  • Secondary Insurance

  • Patient is covered by his/her own sponsored employer insurance

  • Patient, in addition, is covered by spouses employer sponsored insurance plan as a dependent

  • Coordination of Benefits applies

    • Responsibility of dental office administrator

    • Patients employer sponsored insurance plan is always the primary

    • Birthday rule- applies to dependents of parents who both have employer sponsored insurance plans: the insurance plan of the parent whose birthday occurs first in a calendar year is the primary plan for all dependents