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Dental bill format for Supervision

hello and welcome to our screencast on need-to-know dental insurance terms and vocabulary for coders sponsored by a DPC academy of dental practice careers my name is Becky Kerber and I am the owner and lead instructor here at academy of dental practice careers today we will be discussing some of the terms and vocabulary words that you will be using and hearing when billing dental insurance let's get started the first term is allowable charges that is the maximum amount paid for each procedure our next term is alternate benefit another word for this would be downgrade this is a provision in a dental plan contract that allows the third party payer or the insurance company to determine the benefit based on an alternative procedure and that is generally less expensive than the actual procedure that was provided or proposed the next term is ancillary ancillary is something that exists mainly to support the main operation procedure or business and that is answered in box 37 through 47 of your universal claim form assignment of benefits that is the authorization given by the subscriber to a patient or a patient to a dental benefit plan that is directing the insurance company to make payment directly to the provider of services and normally we use box 37 on the universal claim form and we put signature on file we can also use SOF the acronym for signature on file for that in that box balance billing balance billing is billing the patient for the difference between the amount paid by the dental benefits plan and the fee charged by the debt to and make sure to check all the specifications of the dental benefit contract that the doctor signed birthdate rule and this pertains to dual insurance on dependence so this is a method used to determine which parent is considered the primary subscriber of dental coverage this rule simply states that the parent whose birthdate comes first in the year is the primary subscriber so for example if parent number one has a birth date of February 8 1964 and parrot number two has a birth date of October 15 1962 pet number one is actually the primary subscriber the insurance company will go off of the month and day not the year and that is how they consider which which subscriber is primary and which is secondary clearinghouse when submitting claims electronically they are transmitted by our dental office to what is called a clearinghouse and that Clearinghouse will then format and submit our claims in real-time to hundreds of different insurance companies for payment make sure to check with your practice management software company and see which clearing houses are actually compatible with your software Cobra consolidated Omnibus Budget Reconciliation Act Cobra is legislation that mandates guaranteed medical and dental coverage for a period of 18 months after the loss of group benefits coverage individuals are given the option of purchasing their own coverage at a group rate under special cobra contracts so after an employee is either dismissed or laid off they have 18 to purchase the same group coverage that they had while they were employed coordination of benefits or Co B this is when insurance carriers coordinate benefits of two or more benefit policies and keep in mind the total benefits paid should not be more than 100 percent of the original service deductible this is the service fee that the patient is responsible to pay for before the insurance will consider payment of additional services this deductible may be payable either annually during a lifetime or as a family and once again when you're checking the breakdown of benefits make sure to see what the deductible is and what period of time of whether its annual lifetime or family dependents dependents are persons who are covered under another person's dental benefits policy plan and that can include the children and the spouses but it is not limited to them the terms of the dependent coverage are also stated in the benefits contract when checking the breakdown of benefits with subscribers make sure to ask if there is dependent coverage and as an external marketing tool you can use the names and the as as a marketing tool when talking to the patients and get the dependents in for their checkups down coding or downgrade another word is alternate benefit and this is a method of changing a reported benefits code by the insurance company to reflect a lower cost for a procedure exclusions the option in a dental benefits program to exclude dental services and procedures and it's outlined in the patient contract and benefit book again make sure when checking the breakdown of benefits that you check for any exclusions we also have explanation of benefits or EOB and this is the voucher that is attached to insurance checks that explain how much was paid adjusted or denied on an insurance claim fee-for-service that is the traditional method of billing by dentists in private practice whereby the dentist charges for each dental service performed fee schedule this is a list of charges for dental services and procedures established by the dentist or a dental benefits provider and mutually agreed upon I highly recommend that the practice makes sure to update there you see our usual customary and reasonable once a year but also any dental benefit programs that the dentist is contracted with make sure you update those fee schedules every 12 to 24 months FSA or flexible spending account this is an account that is employee reimbursement account primarily funded with employee designed salary reductions funds are reimbursed to the employee for health care medical or dental and dependent care and/or legal expenses and they are considered non-taxable so an employee will have their employer take out a certain amount of money per paycheck and that money is before taxes that in return is put in a fund that that employee has the option of drawing off of for certain medical dental and legal expenses frequency make sure to check this when you check the breakdown of benefits and this is the number of times per year or benefit term that an insurance will pay on specific services specifically or for example x-rays crayons Pro fees and other procedures also make sure of the wording with the frequency make sure that you make the distinction between two times per year or one every six consecutive months there is a difference in that wording limitations that is restricting conditions regarding payment contained within a group dental contract such as age materials use period of eligibility or waiting periods and the waiting periods are usually on major and they're usually twelve months maximum allowance the total amount of dental specific benefits or dollars that will be paid toward dental services and procedures maximums are determined by the provisions of individual group contracts and make sure to check when checking that breakdown of benefits make sure to check if it's a plan year or a calendar year that makes a difference NPI or national provider identifier and that is a number assigned to the doctor specifically to identify the doctor and the practice and this is not the tax ID number non-participating dentist this is a dental professional who is not under contract with a dental benefits plan and they provide dental services and procedures to enrollees another word for this is a dentist that is out of network open enrollment this is a period of time during a year when a member of a dental benefits program has the option of selecting the type of coverage and the provider of dental services I highly recommend that around Labor Day of every year you send out the treatment needed letter and that treatment that needed letter simply states that the patient was in at the beginning of the year or sometime during the year and they had a treatment plan of X number of dollars and as they know they have X number of dollars for their insurance benefits per year and if they don't use those benefits per year they lose it so it does not roll over and this letter simply states make an appointment so that you can take advantage of your insurance maximums for the year now on top of that after the letters go out it is important to me follow-up phone calls those phone calls are 12 times more likely to get results than just the letter itself and it is because it is simply because of open enrollment because the enrollees or the subscribers have open enrollment at their work during this period of time they have different options and they also may have different questions and because we're making that phone call they are more likely to ask those questions and more likely to ask for the information regarding their plans and what insurance the doctor takes so with that we can actually set up an appointment or keep the patient within the practice for the next year because we've been able to inform them of their dental insurance benefits participating dentist that is a dentist who has contracted with a dental benefits organization to provide dental care to specific enrollees pair ID this is the identification number that is used by the Insurance Clearing House to identify the insurance carrier this number is essential when transmitting electronic claims a subscriber that is the holder of the dental benefits insurance policy so normally this is the person whose name is on the card and any additional coverage is extended to the spouse and the children there are other terms to describe the subscriber and those terms are enrollee insured certificate holder and my favorite is the owner of the policy table of allowances this is a list of the services and procedures that will be paid by the dental benefits plan with a dollar amount assigned to each procedure the table of allowances are also referred to as schedules of allowance and indemnity schedules and make sure again to have a notebook at the front desk with the fee schedules or table of allowances that are connected to the insurance companies that the doctor is contracted with and make sure to have those available at the front desk and also have those updated in your computer system waiver of deductible many times the yearly deductible is waived on certain preventive and diagnostic procedures and this is in order to influence the patients to seek less expensive dental procedures and get it and get those procedures done on a yearly basis usual customary and reasonable or UCR usual fee that is the fee the dentist uses most often for a given dental service customary fee that is the fee determined by the insurance company third-party payer for from actual submitted fees for specific dental services reasonable that is a determination by the third party that a particular service for a given procedure has been modified to take into consideration unusual complications or the demographics of the practice waiting periods and that is a certain period of time established by the insurance company before a certain procedure or procedures will be covered and that usually applies to the major category and that would be crown and bridge and it is usually a twelve month waiting period thank you and thank you for tuning into our dental insurance terminology and coders screen if you