Traditional dental plans are also known as indemnity plans. Insurance companies reimburse indemnity claims based on the UCR (usual, customary, and reasonable fee) for the services rendered by the dental professionals. Additionally, these plans allow patients to opt for their desired dental professionals. When paired with preferred provider organization (PPO) plans, these plans are referred to as traditional and preferred dental plans.
PPO or traditional and preferred dental plans are regular indemnity dental plans with in-network dental professionals. The in-network dental professionals sign contracts with insurance companies to render their services at a predetermined charge and accept the amount as full payment. Similar to traditional dental plans, patients can seek dental care from either in-network or out-of-network dentists; however, dental coverage is higher for visiting in-network dental professionals.
Submitting a dental claim is one of the most crucial processes in revenue cycle management, which if not done correctly, can lead to a high claim denial ratio. Therefore, understanding the billing guidelines is highly important for dental professionals when submitting claims for traditional and preferred dental plans.
- Accurate Information: The submitted claim should have complete and accurate information of the following:
- Patient’s demographics, current insurance card, SNN, DOB, etc.
- Diagnosis of the patient.
- Additional details such as area of oral cavity, tooth system, tooth number or letter, tooth surface, missing teeth information. Etc.
- Details and correct codes of the rendered services.
- Date of service and number of required appointments.
- Supporting documents of the rendered services.
- Details of any special circumstance (if occurred)
- Charge entry
- Pre-Authorization: Insurance companies may require pre-authorization of some specified treatments, which if not taken can lead to claim denial. The authorization should be taken after the diagnosis and prior to treatment. Dental professionals can seek authorization either electronically (numeric entry on the CMS-1500 or ADA 2012 claim form) or via mailing the document to the payer.
- Pre-certification: Ensuring if the patient is eligible to have surgery or hospitalization as per their insurance policy by the payer is termed pre-certification.
- Pre-determination: Determining the maximum amount that is covered by the patient’s dental insurance policy for services like primary surgery, consulting services, postoperative care, etc. is termed as pre determination.
Note: Many private insurance companies require either pre-certification or pre-determination if the treatment requires any in-patient or out-patient surgery, elective procedures, or hospitalization. If these criteria are not met, payers are liable to not reimburse the dental claim.
- Co-payment: Dental professionals are required to collect the co-payment for the rendered services as mentioned in the dental insurance policy of the patient. Dental professionals are not allowed to waive the co-payment amount and can attract legal action on the basis of violating the contract policy of the insurance company.
General Guidelines for Claim Submission:
- 2002 American Dental Association (ADA) claim form should be used to file CDT codes.
- Both the ADA claim form and an HCFA-1500 claim should not be filed for the same treatment. If done so, the second claim is rejected as a duplicate claim.
- If both CDT & CPT codes are used in dental claims, insurance companies process the claim using CDT codes.
- Dental professionals are required to file the actual charge for the rendered services. Allowable charges can be provided for informational purposes but are not used by insurance companies to process dental claims.
- OSHA charges must be included within the procedures performed and should not be charged separately.
Guidelines for Non-Surgical Claims:
- CDT codes should be used to file non-surgical claims. Non-surgical claims containing CPT code instead of CDT code are returned or denied.
- If prophylaxis and fluoride services are provided on the same date and filed as one procedure, the dental claim is denied. Dental professionals should ensure to file both the procedures separately to get full reimbursement of the dental claim.
- The name(s) of the drug(s) used should be mentioned with code D 9630.
Guidelines for Oral Surgery Claims:
- CDT or CPT code can be filed for oral surgery claims while other services such as office visits, X-rays, etc. are required to be filed with CDT codes only.
- Extraction services must be filed with CDT codes only. Additionally, tooth numbers should be mentioned in the description field if the HCFA-1500 claim form is used to file the claim.
- Diagnosis code 520.6 should be used to file a claim for each and every service i.e surgical & non-surgical provided for the impacted teeth.
- If the claim is filed for services like dental office visits, X-rays with diagnosis code 524.3 but without primary code, a brief description of the services that will be rendered should be mentioned in the form. In case of a failure to do so, the claim will be denied.
- If CPT code 41899 is used for any surgical services such as extraction, in the dental claim, it will be returned without reimbursement.
New Hampshire Dental Credentialing