Dental Insurance & ODA Fee Guide

Dental Insurance Predeterminations & ODA Fee Guide

• This document covers dental insurance predetermination and the ODA fee guide.
• The week is week 4.

Information Required in a Client's Insurance File

• Policy/Group: The patient's insurance policy number.
• Division/Section No.: The division or section related to the policy number, if applicable.
• Insured: The insured's name.
• Birth date: The insured's birth date.
• Certificate No./Subscriber ID: The insured's identification number.
• Patient: The patient's name.
• Birth date: The patient's birth date.
• Relationship to Insured: The patient's relationship to the insured.

Electronic Data Interchange (EDI)

• EDI is the electronic submission of insurance claims.
• A dental office uses a computer program to electronically transmit claim information either over telephone lines or the internet.
• When a claim is sent electronically, the insurance carrier acknowledges receipt, and responds, giving the claim status.
• When the claim is accepted and acknowledged, patients receive payment sooner, typically within a few days.

Advantages of EDI

• EDI speeds up claim processing.
• EDI allows prompt error correction, provides immediate claims calculations, and reduces paperwork.

Provincial Fee Guides

• The Ontario Dental Association (ODA) fee guide for 2024 is available on DCConnect.
• Suggested fee guides are for general practitioners.

Provincial Fee Guide Codes

• Codes range from diagnostic (07000-09999), preventative (70000-79999), restorative (20000-29999), and more.
• This list provides a breakdown of procedure codes by service category (diagnostic, preventive, restorative, etc.).

Type of Service and Descriptions

• This table details various dental services (diagnostic, preventive, restorative, etc) along with their descriptions.

Example Diagnosis Codes

• Specific codes are provided for new client examinations, limited recall examinations, single bitewings, and single panoramic x-rays

Specialist's Suggested Fee Guides

• Nine specialist classes (e.g., orthodontists, periodontists, oral surgeons) each have unique fee guides.
  • The fee guides contain procedure codes and fees.

Community Service Dental Plans/Programs

• The document lists various community benefits (Healthy Smiles Ontario, Ontario Works, Ontario Disabilities Support Program, etc.) for service plans.

MCCSS Schedule of Dental Services and Fees (January 2019)

• This presents a schedule of dental services and associated fees.

Radiographs (Including Radiographic Examination and Diagnosis and Interpretation)

• Various radiograph types, including intraoral, periapical, occlusal, and bitewing, and their corresponding fees.
  • Maximums are indicated for various radiographs for different time periods for patients and dentists

What is a Predetermination?

• A predetermination is an estimate sent to the insurance carrier for pre-authorization.
• It's not a guarantee of payment.
• A pre-d is required when the cost of treatment exceeds a certain amount ($300).

Why do I need a pre-d?

• Clients need a pre-d to ensure a procedure is covered and to see if they will exceed maximums. It enables clients and dentists to more carefully decide on dental care.

How long does it take?

• The average response time for a predetermination is 4-6 weeks.
• To expedite processing, send relevant information like X-rays or intraoral photos along with any information requested by the insurance carrier.
  • EDI may be faster, but not always possible

How does a predetermination work?

• The dentist sends information like a treatment plan, X-rays, and explanations.
• The insurance company checks coverage, exclusions, maximums, and alternative benefits.
• The insurance company responds to the client by providing a reply letter.

X-rays

• Always send duplicates or digital copies of X-rays to the carrier.
• If available, use intraoral camera pictures.

Crowns and Bridges

• X-rays and intraoral photos are required.
• An explanation is needed, detailing why a crown is required, e.g. due to extensive fillings or root canal treatment.
  • Include why the tooth was recently extracted, if that is the case for a bridge

Dentures

• The dentist should know the number of missing teeth.
• Information about when the teeth were extracted is useful, as well as if the client currently uses any prosthetics and the age of those appliances .

Quiz

• A quiz is included.

This document explains dental insurance predetermination and the ODA fee guide. It lists the information required in a client's insurance file, such as policy number, insured's name and electronic data interchange (EDI). The week is week 4.