Week 4 Dental Insurance Predeterminations & ODA Fee Guide PDF

Dental Insurance Predeterminations & ODA Fee Guide Week 4  What information is 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 p...

Dental Insurance Predeterminations & ODA Fee Guide Week 4  What information is 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) The electronic submission of insurance claims. A dental office equipped to do so uses a computer program to transmit claim information electronically either over the telephone lines or over the Internet. When a claim is sent electronically, the insurance carrier acknowledges receipt of the claim and responds, giving the status of the claim. When the claim has been accepted and acknowledged, the patient can expect to receive payment sooner, usually within a few days. Advantages of EDI They speed up claim processing, allow prompt error correction, provide immediate claims calculations, and reduce paperwork.  Provincial Fee Guides ◦Ontario Dental Association (ODA) – *Refer to DCConnect for 2024 ODA Fee Guide ◦Suggested Fee Guide for General Practitioners (general dentists) Provincial Fee Guide Codes ◦ Category of services : Procedure Code #: ◦ Diagnostic 01000-09999 ◦ Preventive 10000-19999 ◦ Restorative 20000-29999 ◦ Endodontic 30000-39999 ◦ Periodontic 40000-49999 ◦ Removable Prosthodontics 50000-59999 ◦ Fixed Prosthodontics 60000-69999 ◦ Oral Surgery 70000-79999 ◦ Orthodontic 80000-89999 ◦ Adjunctive General Services 90000-99999 Type of Service Description Diagnostic Radiographs (bitewings, periapicals), diagnostic study models, panoramic xrays, Preventive Recare appts, prophylaxis, pit and fissure sealants Restorative Fillings, crowns Endodontic Root canal therapy, associated treatment Periodontics Scaling, root planing, surgical procedures Prosthodontics – Removable Full and partial dentures, relines Prosthodontics – Fixed Bridges, pontics Oral Surgery Extractions, complicated/uncomplicated surgery Orthodontics Ortho bands, braces, fixed/removable appliances Adjunctive General Anesthetic, general & conscious sedation, lab services 02102 Example: Diagnosis ◦Code # 01103, New Client Examination and Diagnosis: Complete permanent dentition ◦Code # 01202, Limited Recall Examination ◦ permanent dentition ◦Code # 02141, Single Bitewing ◦Code # 02601, Single Panoramic Specialist’s Suggested Fee Guide ◦ There are 9 classes of Specialists, each with individual Suggested Fee Guide- Orthodontist, Periodontist, Oral Surgeon, etc. ◦ Contains Procedure codes and Fees that are unique to a specialty. Community Service Dental Plans/Programs Province of Ontario Benefits: ◦Healthy Smiles Ontario ◦Ontario Works (O.W) ◦Ontario Disabilities Support Program (O.D.S.P) ◦Ontario Seniors Dental Benefit plan ◦Ontario Health Insurance Plan (OHIP) 02102  What is a Predetermination? ⚫ An estimate sent to the insurance carrier for pre-authorization of dental treatment ⚫ Not a guarantee of payment ⚫ You need to file a pre-d for any single treatment worth $300.00 or more ⚫ Form similar to an insurance claim form ⚫ Free service that the dentist provides to the client ⚫ It is generally used for crowns, bridges, dentures, implants, wisdom teeth extractions, periodontal surgery  For extensive dental work To ensure a procedure is covered Why do I need a pre-d? To see if you will exceed your maximum To help the client and the dentist make more informed decisions about your dental care How long does it take? ◦ The average response is 4 -6 weeks from the insurance carrier ◦ To expedite the process, you can send the x-ray or intraoral photo along with any relevant information instead of waiting for the insurance carrier to request it ◦ EDI if fast, but sometimes cannot send x-rays or photo’s for most companies ◦ Always send duplicate x-rays.  How does it work? 1. The dentist office sends a proposed treatment plan – the predetermination with copy of relevant x-rays, and a letter of explanation to the insurance carrier 2. The insurance carrier checks for coverage ✔ Limitations or exclusions ✔ Maximums ✔ Alternate benefits clause ✔ Co-payments 3. The carrier sends reply letter to the client X-rays Always send duplicates or digital copies Send intraoral camera pictures if you have one in your office, this is just like the dental consultant looking in the patients’ mouth Crowns and Bridges ◦ X-rays and intraoral photo’s ◦ Letter of explanation or expertise ◦ Why does the tooth require a crown, due to an extensive filling or root canal treatment ◦ When was the tooth extracted for bridge placement Dentures They will want to know the number of the missing teeth When were the teeth extracted in both arches? Does the client presently wear prosthetic appliances? How old are the present appliances? Insurance quiz ◦ To be completed online on DCConnect with respondus ◦ Must be completed by Thursday February 8, 2024 11:59 pm ◦ One attempt – once started must complete