Billing Information

Changes in Insurance

Even the simplest change can prevent your insurance claim from being processed correctly. You may still have the same insurance company but did the Group Number or Plan Number change? Did the Subscriber Number change?

To prevent this situation, please be prepared to verify the Group Number and Subscriber Number.

Reasons Your Claim Can Be Denied By Your Insurance Carrier

Subscriber needs to correct with insurance company:

• Your name or the patient's name is misspelled
• The patient's birth date is wrong
• Your Subscriber Number or Group Number is wrong
• The Student Status has not been updated with your insurance company
• You did not see a provider within your network
• Insurance has terminated

We can help with these situations:

• You have not reached your benefit maximum for the year
• Your insurance company only allows cleanings every 6 months or 2 times per year
• Not a covered benefit
• You have a waiting period for Major Restoration procedures
• There is a missing tooth clause

Please ask if you have a concern.

How We File Claims

On the same day you receive services your charges are entered and a claim is generated.

We file over 80% of our claims electronically to insurance companies. Electronic claims are generated within 2 days of your visit. We file paper claims when your insurance carrier may not be able to receive claims electronically or your services may require additional information to be sent.

If you are having major restorative procedures your insurance company generally requires:

• An X-ray of the tooth or teeth being restored
• A Narrative for the reason for the restoration
• If you are having Periodontal work, Perio charting needs to be completed

If you have not been a long term patient and we do not have a history of past dental work you may need to provide us with information such as:

• When did you have previous restoration on the tooth or teeth?
• How long has a tooth or teeth been missing?

Did You Have an Accident?

If you or a family member is being seen as the result of an accident we will need your medical insurance. Your medical insurance is primary in these situations and needs to be filed prior to your dental insurance. Filing claims in this order will prevent most delays in the claim being paid.

What is an accident?

• A car accident where you have injured or think you have injured a tooth
• A fall or trauma to the mouth that has injured a tooth

What is not an accident according to your Insurance Company?

Your insurance company generally does not define biting on something hard and chipping or breaking your tooth as an accident.

What should you do if you or a family member has had an accident?

• Contact your dentist within 24-48 hours of the accident
• Contact your medical & dental insurance companies within 24-48 hours of the accident
• Most insurance companies require you to be seen within 24-48 hours of the accident
• Give your medical insurance to the staff at the clinic at the time of your appointment

Do insurance companies have any limitation with coverage?

Yes they can. It is best to contact your medical insurance immediately to get directions from them as to what needs to be done for benefits to be received.

What happens if procedures cannot be performed to restore the tooth within a short period of time (less than 6 months)?

Contact your insurance company to see if there are any limitations. In most cases, if an exam was performed within 24-48 hours with documentation as to why restorative care cannot be completed at this time, this is sufficient.

Please contact your medical and dental insurance if you have any questions.

Coordinating benefits with your Medical and Dental Insurance

We will file all claims for the accident to your medical insurance first. If the medical insurance denies or only pays a portion we will coordinate benefits with your dental insurance. Please inform the staff of any follow up care that needs to be filed under the accident claim.

Preauthorizing Your Services

Preauthorizing is when we send a claim with additional information in advance of the services being performed. This is done so that the patient will know in advance if the services to be performed will have dental benefits. Having this information allows the patient to plan for services that are not an emergency to be done in the next plan year when benefits are available.

How accurate is a Preauthorization?

Your insurance company does not guarantee they will pay this amount and it is ONLY an ESTIMATE of benefits.

Having services prior to the preauthorized work performed may use your remaining benefits or reduce the amount available.

For example:

• You will be having a crown done that costs $1000.
• You have a maximum benefit of 1,000 for the year
• You have used $400 in benefits already this year and have $600 remaining
• Your estimate of benefits for the crown is $475 ($50 deductible & 50% coverage)
• The estimate is that the insurance will pay $475 and you will pay $525 for the crown
• Before you have the crown done you will come in and have 4 fillings that uses $300 of your benefits
• You have the crown done and the insurance pays $300. Why?

Maximum Benefit	$1,000
Used Benefits	$400
Filling Benefits	$300
Available Benefits	$300
Total Benefits Used	$1,000

You exceeded your benefits so $175 of the estimate will now be part of the patient responsible balance. The insurance will pay $300 and you will pay $700.

PLEASE ASK YOUR DENTAL PROVIDER TO PREAUTHORIZE ANY FUTURE MAJOR RESTORATIVE SERVICES IF YOU HAVE A CONCERN FOR YOUR PATIENT RESPONSIBLE BALANCE

What is Major Restorative Care?

• Crown
• Root Canal
• Denture (Partial or Full)
• Bridge
• Periodontal Care

Can I have other services Preauthorized?

Yes, we recommend that multiple fillings, extractions or sealants be Preauthorized if you have a concern regarding benefits. Please ask us to preauthorize these services as this is not done without the request of the patient or parent.

For Billing and Insurance Services, call (608) 661-6410.