Homework 2
What does In Network mean?
An authorised dentist who has signed a participating agreement with the insurance company and agrees to accept the
insurance company’s determined allowable charge (fee schedule) as payment in full for covered services
What does Out of Network mean?
A dentist who has not signed a participating agreement with the insurance company
What is a missing tooth clause?
Relates to whether a limitation applies for prosthetic services. Ifa tooth is missing before effective date, insurance
company may or may not allow for patient to be eligible for prosthetics. If they allow that means they will pay for the
service hence “No” Missing Tooth Clause and vice versa
What is a waiting period?
An initial period of the health during which no benefit is payable for certain procedures or services.
What is frequency limitation?
The number of claims that a patient are allow to make over a given period of time.
What is Primary Insurance?
It is health insurance that pays first on a claim for medical and hospital care.
What is secondary insurance?
It is a coverage you can buy separately from a medical plan.
What is a subscriber?
The subscriber is the person subscribing to or carrying the insurance plan for the patient case.
What is a coordination of benefits?
Is the process insurance companies use to determine how to cover your medical expenses when you’re covered by
more than one health insurance plan. It clarifies who pays what by determining which plan is the primary payer and
which is secondary.
What is a Payor ID?
The Payer ID or EDI is a unique ID assigned to each insurance company. It allows provider and payer systems to talk
to one another to verify eligibility, benefits and submit claims.
What is a Deductible?
Amount member must pay for covered services before the plan begins to pay for such services. If the deductible is
$2,000, then you would be responsible for paying the first $2,000 in health care you receive each year, after which the
insurance company would start paying its share
What is a yearly max?
Total dollar amount (per member) in a benefit year and or lifetime payable by dental insurance company. Separate
maximums may be there for other services like orthodontics or implants if stated in the benefit plan or contract.
Why do you get a referral number to a call?
Refers to the permission or authorization of the insurance plan that they may require in order to see a recommended
specialist, doctor, hospital, or type of treatment.
What is a bulk check?
A bulk insurance payment is a single payment from an insurance company for multiple patient accounts
What is an EFT? (Electronic Funds Transfer?
A bulk insurance payment is a single payment from an insurance company for multiple patient accounts
What does timely filling mean?
Timely filing is when you file a claim within a payer-determined time limit.
Provide 5 reasons why an Insurance company might deny a claim
1. The claim has errors
2. You used a provider who isn’t in your health plan’s network
3. Your care needed approval ahead of time.
4. You get care that isn’t covered.
What are the 3 ways you can verify a patient’s dental benefits?
1. Insurance company websites- dental office provides the website credentials
2. Phone calls- talking to Customer Representatives
3. Fax back from insurance company
What happens when the Run down of benefits/verification of benefits is incorrect?
Ineffective eligibility and benefits verification leads to increasing claim rejection. Delayed payments leading to delayed
access to patient care, resulting in low patient satisfaction. Increased claim rejections due missing patient data.
Why is it important to completely fill out the Verification Form for the patient?
For patients, insurance verification helps to avoid unexpected bills and understand financial obligations ahead of time.
For healthcare providers, it ensures they will receive payment for the services rendered and reduces the chances of
denied claims, which can be costly and time-consuming to resolve.
If I work for Burger King and I have Delta Dental Group #99943 and my friend also works for Burger King and
has Delta Dental Group #99940- do we have the same benefits? Why or why not
All the time there is necessary to check the coverage
