Download Insurance - Byrne Consulting

Insurance:
A Window of Opportunity
107th Annual Session
American Association of Orthodontists
Seattle, Washington
May 20, 2007
Byrne Consulting
306 Sparta Court
Bel Air, MD 21014
Phone 800-580-6580
Fax 410-638-6655
[email protected]
Insurance:
A Window of Opportunity
American Association of Orthodontists
107th Annual Session
Presented by Tina Byrne
59%
The number of patients who had
orthodontic benefits under their
dental insurance.
-2004 AAO Member Census
1
Increase Patient Numbers
Increase Case Acceptance
Customer Service Factor
Administrative Time
Benefit Changes
Patient’s Expectations
Delinquency
Loss of Relationships
2
Dental Plans
Traditional
• Freedom of Choice
• Straight Forward Benefit
• Fee for Service
Dental Plans
Participating Provider Organization
• Network
• Benefit Incentives for In-Network
– Patient continues to have a choice
• Fee Schedules
– Set by area
– Benefit calculated against PPO fees
• Usual, Customary, Reasonable
– Calculated by the dental plan
Dental Plans
Dental Health Maintenance Organization
•
•
•
•
Capitation
Closed Door – MUST be participating
No Benefit out of network
Referral required from PCD
3
Other Benefits
Flex Spending / Cafeteria Plans
•
•
•
•
Pre-Taxed savings
Use it or Lose it
“Healthcare” reimbursement
Out of pocket return
– Possible coordination with insurance benefit
Discount Plans
Level of Service
Level I
• Fee for Service / Superbill / Walk-out Claim
Level II
• Fee for Service / Claim Submission /
Assignment of Benefit
Level III
• Participation
Serve or Swerve?
Practice Goals
• New Patients
• Case Acceptance / Starts
Practice Profit
• Operating Cost
Unique Practice Situation
•
•
•
•
Local Employers
Competition
Referral Base
Growth
4
Insurance . . . DO
Maintain a Service Factor
• Verification / Direction
• Education / Communication
• Timely & Accurate Submission
Insurance . . . DON’T
Own Responsibility
• Chase Benefits
• Question Benefits
Place Practice at Risk
• Fraud
– Fees Charged
– Dates of Treatment
Successful Insurance Practices
Position the practice
• System
• Well-versed team
Adhere to policies
Manage claims like clockwork
Benefits don’t contribute to delinquents
5
Position the Practice
Educated Team
• Fluent with Process
– Plans & Participation
– Clauses & Guidelines
» Coordination of Benefits
» Waiting Periods
» Age Limits
Our office is dedicated to providing a positive orthodontic experience for every patient. That’s why
we’re happy to guide you every step of the way through orthodontic insurance. This gives all of us
something to smile about!
Dental insurance can be very complex. There are many different types of insurance plans, all with
various types of coverage. We are pleased to work with you and your insurance carrier to obtain the
maximum orthodontic benefit for your treatment. As many insurance companies will only release plan
information to the insured member or subscriber, please complete the following information and bring
this form with you to your initial examination appointment.
Personal Information:
Patient:
Today’s Date:
Subscriber or Insured Member Information
Full Name:
Employer:
Birth Date:
ID or SS#:
Plan or Group Number:
Insurance Company Name:
The following information must be obtained by contacting your insurance company or plan
administrator. This will allow our office to estimate your insurance benefit, and submit claims for
orthodontic treatment.
Plan Information:
Claims Mailing Address:
Amount of Benefit: $
Percentage of Fee Paid:
On-going Submission Required:
Payments ‰ Monthly
Made:
‰ Semi-Annual
%
Yes
No
‰ Quarterly
‰ Annually
6
Coordination of Benefits
Required to report both benefits
Submit secondary claim with EOB from
primary
Birthday rule applies
• Court orders may supersede
Coordination of Benefits
Non-duplication clause
• Secondary pays only the difference
between primary and what it would have
paid if primary
Participating fees prevail with dual
coverage
Waiting Periods
Period is from the Effective Date of Plan
No coverage for pre-existing treatment
• Probable pro-rated benefit for patient in
treatment
7
Position the Practice
Educated Team
• Fluent with Process
– Plans & Participation
– Clauses & Guidelines
– Terminology
www.byrne-consulting.com
Formularies
Estimating Benefits
• Percentage Over Dollar Amount
$2500 benefit paid at 50%
Treatment Fee of $4000
Estimated Benefit = $2000
Formularies
Estimating Benefits
• PPO Participation ¬ Fee Schedule
$2500 benefit paid at 50%
Treatment Fee of $4000
Allowed Fee of $3600
Estimated Benefit = $1800
8
Position the Practice
Resourceful and Organized
• Maintain updated database
– Insurance Companies
– Employers
– Fee Schedules
9
Insurance Policy
Accept Primary Only
• Can’t be certain of coordination of
benefits
• Easier to give than to take away
• Plan benefits constantly change
Insurance Policy
Miscellaneous Charge
Reimbursement to Patient
• Can’t be certain of benefit
• Inevitably contribute to delinquents
• Not usually a patient seen frequently
10
Insurance Policy
Credit new benefits AFTER submission
and payment
• Can’t be certain of pro-rated benefits
• Wasted time changing contracts
• Your pending change identifies an
unknown to the patient – more likely
acceptance of benefit
Insurance Policy
Minimum amount for patient portion of
monthly fees
• Reduces “at risk” patients from falling
through the cracks
• Easier to add payments to a plan than
recalculate amounts of payments
• Patients let payments “slide” if amount is
lower
Everything has been said before, but since nobody
listens we have to keep going back and beginning
all over again.
- André Gide
11
Communication
“Will you accept my insurance?”
“Mrs. Byrne, we take care of submitting all
the necessary paperwork or claims, and we
allow the benefit to be mailed directly to you.
If you choose, you are welcome to apply it to
your account balance.”
Communication
“Do you participate with my insurance?”
“Mrs. Byrne, we do work with your insurance
company, we are an out-of-network provider
with your particular plan.”
Communication
12
Communication
Communication
Communication
13
Communication
Communication
Communication
14
Claims Management
Initial Claim
• Patient / Subscriber Information
– Dual coverage ¬ primary coverage
•
•
•
•
•
Practice Information
CDT Code
Banding Date
Treatment Time
Initial, Monthly, Total Fee
Claims Management
Standardize Information
15
Timely Submission
Initial Claims – Same Day
Misc. Charges – Same Day
Ongoing Claims – 1st of Each Month
Organize Follow-Up
TO BE SUBMITTED
SUBMITTED
PENDING PAYMENT
HOLDING FOR
SUBMISSION
Organize Follow-Up
JAN
thru
DEC
16
Minimize YOUR Follow Up
Unless this claim is paid or denied within
30 days we will file a formal written
complaint with the Insurance Commissioner.
www.byrne-consulting.com
17
Receivables Control
Receivables Control
EOB’s
Initial & Ongoing Payments
Terminations / Maximums Reached
Ongoing Confirmation
Amounts Not Allowed in Fee Schedule
Receivables Control
18
Receivables Control
Insurance Communication Protocol
• Upon notice of benefit discrepancy
Receivables Control
Delinquent Communication Protocol
• Upon notice of benefit discrepancy
• 30 Days from Submission
– Ask for assistance from responsible party
19
Receivables Control
Delinquent Communication Protocol
• Upon notice of benefit discrepancy
• 30 Days from Submission
– Ask for assistance from responsible party
• 45 Days from Submission
– Notify of the transfer of benefit
20
Receivables Control
Delinquent Communication Protocol
• Upon notice of benefit discrepancy
• 30 Days from Submission
– Ask for assistance from responsible party
• 45 Days from Submission
– Notify of the transfer of benefit
• 60 Days from Submission
– Demand payment / payment plan
Identify Change
Level of Service
Positioning of the Practice
• Team Training
• Patient Communication
Policy
Claims Management
Receivables Management
Thank You for Attending
Enjoy Seattle!
www.byrne-consulting.com
21
Our office is dedicated to providing a positive orthodontic experience for every patient. That’s why
we’re happy to guide you every step of the way through orthodontic insurance. This gives all of us
something to smile about!
Dental insurance can be very complex. There are many different types of insurance plans, all with
various types of coverage. We are pleased to work with you and your insurance carrier to obtain the
maximum orthodontic benefit for your treatment. As many insurance companies will only release plan
information to the insured member or subscriber, please complete the following information and bring
this form with you to your initial examination appointment.
Personal Information:
Patient:
Today’s Date:
Subscriber or Insured Member Information
Full Name:
Employer:
Birth Date:
ID or SS#:
Plan or Group Number:
Insurance Company Name:
The following information must be obtained by contacting your insurance company or plan
administrator. This will allow our office to estimate your insurance benefit, and submit claims for
orthodontic treatment.
Plan Information:
Claims Mailing Address:
Amount of Benefit: $
Percentage of Fee Paid:
On-going Submission Required:
Payments ‰ Monthly
Made:
‰ Semi-Annual
%
Yes
No
‰ Quarterly
‰ Annually
ORTHODONTIC INSURANCE VERIFICATION FORM
Patient:
DOB:
‰
‰
PRIMARY CARRIER
Subscriber:
/
Date:
/
/
/
SS/ID#:
Group Number:
Insurance Company:
Provider Services Phone:
Verification Date:
/
/
By:
Spoke with:
Mailing Address:
Amount of Benefit:
‰ LTM
$
Paid at:
Benefit Used to Date:
‰ Annual
Deductible $
Age Limit:
Benefits Paid:
/
SECONDARY CARRIER
DOB:
Employer:
/
‰ Other
$
/
/
‰ Provider Network Plan ‰ Requires Pre-Auth
‰ We Participate ‰ We DO NOT Participate
‰ Will Pay Us
‰ Will NOT Pay Us
‰ Quarterly ‰ Semi-Annual
‰ Other:
‰ AUTO PAYMENT
Payment Breakdown:
‰ Per Our Submission
‰ Per Ins Company
Electronic Submission:
‰ YES
Website:
‰ NO
%
Effective Date of Plan:
Waiting Period:
‰ Monthly
‰ Annual
‰ Annual
Specifically:
Payer ID:
ORTHODONTIC INSURANCE VERIFICATION FORM
Patient:
DOB:
‰
‰
PRIMARY CARRIER
Subscriber:
/
Date:
/
/
/
SS/ID#:
Group Number:
Insurance Company:
Provider Services Phone:
Verification Date:
/
/
By:
Mailing Address:
Spoke with:
Amount of Benefit:
‰ LTM
$
Paid at:
Benefit Used to Date:
‰ Annual
Deductible $
Age Limit:
Benefits Paid:
/
SECONDARY CARRIER
DOB:
Employer:
/
‰ Other
Waiting Period:
‰ Monthly
‰ Annual
‰ Quarterly ‰ Semi-Annual
‰ Other:
‰ AUTO PAYMENT
Payment Breakdown:
‰ Per Our Submission
‰ Per Ins Company
Electronic Submission:
‰ YES
Website:
‰ NO
‰ Annual
%
$
Effective Date of Plan:
/
/
‰ Provider Network Plan ‰ Requires Pre-Auth
‰ We Participate ‰ We DO NOT Participate
‰ Will Pay Us
‰ Will NOT Pay Us
Specifically:
Payer ID:
Orthodontics and Fees
Each orthodontic case is different and
fees will vary. Once we know which type
of orthodontic treatment is needed, we
will be able to tell you what the exact fee
is, and approximately how much of that
fee your insurance company will cover.
We can then review the financial
arrangements to determine how we can
make the fees attainable for you.
Co-Payments and Payment Plans
All patients or parents are ultimately
responsible for the entire amount of their
treatment. Since orthodontic insurance
covers a portion of the total fee, each
patient or parent must arrange to make
payment for the remaining out of pocket
expense, referred to as a “co-payment.”
Our orthodontic practice wants to make
your co-payments as easy as possible. We
have several options that make it easy
and affordable to have orthodontic
treatment in our office.
Fortunately, the length of time necessary
for the typical orthodontic case makes it
convenient for all patients to make their
co-payments.
The Benefits of
Orthodontics
Orthodontic treatment is
recognized as a major factor in
promoting oral health for many
children and adults. In addition to
creating beautiful smiles,
orthodontic treatment aligns teeth
correctly so that they are not
damaged by destructive biting and
chewing forces that can also lead
to gum problems, joint pain, or
fractured teeth and restorations.
Our Philosophy
Our office is dedicated to providing
a positive orthodontic experience
for every patient. That’s why we’re
happy to guide you every step of
the way through orthodontic
insurance. This gives all of us
something to smile about!
Dental Insurance can be very
complex. There are many different
types of insurance plans, all with
various types of coverage. This
makes it difficult for most patients or
parents to fully understand the
benefits to which they’re entitled.
Our goal is to do everything we can
to make processing your insurance
claim as easy as possible.
UNDERSTANDING
ORTHODONTIC
BENEFITS
QUESTION & ANSWER SERIES
Orthodontic Insurance Coverage
Insurance for orthodontic services is
provided through a contract between
your employer and a dental insurance
company. The coverage you receive is
based solely on terms negotiated
between these two organizations.
Orthodontic offices are not involved in
determining which services are covered,
the percentage of the fee that’s covered,
or whether a specific service may be
covered at all.
While our goal is to provide you with the
highest possible quality of care, insurance
companies often cover only very basic
services. These covered services are
identified according to the cost of the
insurance policy to your employer and the
amount your insurance company is willing
to pay. For this reason, not all treatment,
including some higher quality care, is
covered by dental insurance.
If you have orthodontic benefits, it’s part
of your overall dental insurance coverage.
However, orthodontic coverage works
differently than your general dental
coverage or your other types of medical
insurance.
While dental insurance companies
clearly acknowledge that
orthodontic services enhance oral
health – and beautiful smiles – they
typically cover only about 25% or
less of a total case fee.
What If My Plan Changes, or
I Have More Than One
Insurance?
Changes in employment, individual
benefit plans, or multiple plan
coverage are specific situations
where benefits will be determined
by the insurance company. It is
best to refer to your Plan Booklet, or
seek information from your Human
Relations department.
Insurance Claims
To make the process easier for you,
our orthodontic office will be happy
to help by submitting insurance
information to your dental
insurance company. If you have
any questions, we will be happy to
answer them and help you through
the process.
Why Won’t My Insurance Plan
Pay the Entire Fee?
Many patients are not aware that dental
insurance usually places a limit on how
much it will pay toward any orthodontic
fee.
The insurance company only covers a
portion of the entire fee up to a lifetime
maximum payment. This means that the
insurance company will cover only part of
the patient’s orthodontic fee and will pay
only once in the patient’s lifetime or for as
long as you have the policy for
orthodontic treatment.
This insurance is one-time coverage and is
separate from the annual maximum that
you use for your general dental visits.
While your general dental policy also has
an annual maximum, every year that
amount is renewed. Unfortunately,
orthodontics coverage is not renewable
from year to year.
Orthodontic insurance usually can be
applied only once per patient, with a
maximum contribution toward the total
fee that dental insurance pays.
ORTHODONTIC INSURANCE BENEFITS
All patients or parents are ultimately responsible for the entire amount of their treatment fee.
Our office is dedicated to providing a positive orthodontic experience for every patient. That’s why we’re
happy to guide you every step of the way through orthodontic insurance. This gives all of us something to
smile about!
Orthodontic insurance can be very complex. There are many different types of insurance plans, all with
various types of coverage. This makes it difficult for most patients or parents to fully understand the benefits
to which they’re entitled.
CO-PAYMENTS & PAYMENT PLANS
Since orthodontic insurance covers a portion of the total fee, our office will, in good faith, “extend an initial
credit” to each patient or parent in the amount that we estimate your insurance plan will pay toward treatment.
ABOUT ORTHODONTIC INSURANCE
1.
You will NOT receive the entire amount of your insurance benefit at the start of treatment. Insurance
companies pay throughout the course of treatment.
2.
A change in employment or loss of benefits during the course of treatment may mean a less than
expected benefit. Failure to promptly notify our office of a change in insurance plan will result in an
immediate demand for payment in full of any credit extended for insurance.
3.
Having more than one benefit does not guarantee complete payment from both companies. For this
reason, our office will estimate the coverage to the best of our knowledge and experience in dealing
with coordination of benefit situations.
4.
The coverage or benefit you receive is based solely on terms negotiated between your employer and
the dental insurance company.
5.
In the event 45 days have passed since claim submission and no payment has been received from your
insurance company, it becomes your responsibility to either pay the entire insurance amount, or
contact your insurance company to make payment to our office.
John Smith, D.D.S., M.S.
Jane Doe, D.D.S., M.S.
123 Main Street
Anytown, MD 45678
456 Center Street
Anytown, MD 45678
FINANCIAL OPTIONS
Orthodontic treatment is an excellent investment in the overall dental, medical, and psychological well being of children and adults.
Financial considerations should not be an obstacle to obtaining this important health service. We are sensitive to the fact that different
people have various needs in fulfilling their financial obligations; therefore, our office provides the following options for payment.
Please select a payment option and contact our bookkeeping office at (123) 456-7890 with your decision prior to the start of treatment.
Patient:
Date:
Treatment Phase:
Treatment Fee:
Estimated Treatment Time:
Retention Phase included for an additional
months
The Diagnostic Records and Treatment planning charge, which is not included in the treatment fee, is:
Our office is pleased to submit and accept assignment of your insurance benefit. If for any reason the insurance does not pay as
anticipated, or is terminated, the unpaid amount becomes the responsibility of the financial party, and is to be paid in full. In good
faith, your insurance benefit is estimated, not guaranteed.
Treatment Fee: $
Less any Adjustments: $
Additional Fees: $
Total investment for orthodontic treatment $
Less credit for insurance benefit $
Patient Fee LESS pre-credited insurance benefit $
Treatment times differ from patient to patient. These financial options do not correspond to the estimated time of treatment, but
are provided for your convenience.
Interest Free Office Plan
With the start of treatment, an initial payment
of 25% is due to our office in the amount of: $
The balance of the fee may be paid in
monthly installments of: $
for a total of
Pre-Payment Courtesy
You will receive a bookkeeping courtesy and a savings
of 5% from the “Non-Insurance” portion of the fee, or: $
When a single pre-payment is made at the start
of treatment, which reduces the total due to: $
Flexible Payment Plan
Capital One Healthcare Finance offers NO initial payment,
with plans from 18-60 months. Monthly payments could
be as low as: $
Please contact Capital One at 877-559-5050, or www.capitalonehealthcarefinance.com
You must apply and have approval prior to the start of treatment.
** Please note the final monthly installment may be slightly less or more.
It may also be necessary for our office to obtain information through a credit report.
If you require additional information, or have questions, please contact our Financial Coordinator at (123) 456-7890.
months**
John Smith, D.D.S., M.S.
Jane Doe, D.D.S., M.S.
123 Main Street
Anytown, USA 45678
456 Center Street
Anytown, USA 45678
FINANCIAL OPTIONS for AETNA PPO PLAN
Orthodontic treatment is an excellent investment in the overall dental, medical, and psychological well being of children and adults.
Financial considerations should not be an obstacle to obtaining this important health service. We are sensitive to the fact that different
people have various needs in fulfilling their financial obligations; therefore, our office provides the following options for payment.
Please select a payment option and contact our bookkeeping office at (123) 456-7890 with your decision prior to the start of treatment.
Patient:
Date:
Treatment Phase:
Traditional Appliances TX Fee:
Estimated Treatment Time:
Retention Phase included for an additional
months
Diagnostic Records and Treatment, not included in the treatment fee, due the day of the appointment is:
‰
$219.00 Full Diagnostic Records
‰
$160.00 No panoramic film needed
Our office is pleased to submit and accept assignment of your insurance benefit. If for any reason the insurance does not pay as
anticipated, or is terminated, the unpaid amount becomes the responsibility of the financial party, and is to be paid in full. In good
faith, your insurance benefit is estimated, not guaranteed.
Aetna PPO Treatment Fee: $
$3173.00 – D8070 Phase I
$3454.00 – D8080 Full / Phase II
$3628.00 – D8090 Adult
Estimated Insurance Payment Pre-Credited: $
Patient’s Co-Payment: $
Contemporary Appliances Fee: $
$900.00 – Damon
$000.00 – Clear Brackets
$000.00 – MARA, CBJ, DJ, PSA, or OTHER
TOTAL Co-Payment + Appliance Fee: $
Courtesy or Other Reduction: $
TOTAL Patient Portion for Payment $
Treatment times differ from patient to patient. Financial options do not correspond to the estimated time of treatment, but are
provided for your convenience.
Interest Free Office Plan
With the start of treatment, an initial payment
of 25% is due to our office in the amount of: $
The balance of the fee may be paid in
monthly installments of: $
for a total of
Pre-Payment Courtesy
You will receive a bookkeeping courtesy and a savings
of 5% from the “Non-Insurance” portion of the fee, or: $
When a single pre-payment is made at the start
of treatment, which reduces the total due to: $
Flexible Payment Plan (CareCredit®)
CareCredit® offers NO initial payment, with plans from18-60
months. Monthly payments could be as low as: $
Please contact CareCredit® at 800-859-9975, or www.carecredit.com
You must apply and have approval prior to the start of treatment.
** Please note the final monthly installment may be slightly less or more.
It may also be necessary for our office to obtain information through a credit report.
If you require additional information, or have questions, please contact our Financial Coordinator at (123) 456-7890.
months**
INSERT PRACTICE NAME
Specialists in Orthodontics
{ MERGEFIELD posting_date }
CONTRACT for Orthodontic treatment of: { MERGEFIELD patient_full_name }
Responsible Party:
{ MERGEFIELD resparty_full_name }
{ MERGEFIELD resparty_address_1 }
{ IF { MERGEFIELD resparty_address_2 } <> "" "{ MERGEFIELD resparty_address_2 }"}{ MERGEFIELD
resparty_city }, { MERGEFIELD resparty_state } { MERGEFIELD resparty_zip }
Type of treatment discussed at conference appointment:
{ FILLIN "Type of treatment?"/d"" }
In order to comply with the “Federal Truth in Lending Act”, and the requirements for “Regulation A,” we are required to furnish the
following information on your account and to retain a signed copy of this payment schedule in your file.
Paid in Full at Start of Treatment with 5% Bookkeeping Courtesy:
(Does not include any amount to be received from Insurance)
$ { FILLIN "Fee if Pd in Full?"/d"" }
OR
Professional Fee:
Treatment Fee Adjustments:
Less Initial Payment:
Expected Insurance Allowance:
Balance to be Financed:
FINANCE CHARGE:
Total of Payments:
$
$
$
$
$
$
$
{ MERGEFIELD contract_tx_fee_includ_ins_amt }
{ MERGEFIELD contract_total_tx_fee_adj }
{ MERGEFIELD contract_total_init }
{ MERGEFIELD contract_tx_fee_insurance_amt } *
{ MERGEFIELD contract_total_period_fee }
NONE
{ MERGEFIELD contract_tx_fee_includ_ins_amt }
*If this is not paid by insurance for any reason, it immediately becomes your obligation. The unpaid amount will be charged back to
your account, and becomes due immediately unless other arrangements are made with our office..
Unpaid balance is payable in monthly installments of ${ FILLIN "Amount of monthly fee?"/d""}, the final payment may be slightly more or less,
all payments are due on the first day of each month beginning { FILLIN "Month/Year of first monthly fee?"/d""} until the total balance is paid in
full. NO interest or finance charges are indicated in the above amounts. Statements will be sent only if an account is delinquent. You may
prepay all amounts due at any time without penalty. There will be a service charge of $10 per month for accounts over 30 days. If at any time
your account should become more than 60 days in arrears, active orthodontic treatment will be stopped until the account is brought up to date.
The total balance is due by the time the appliances are removed.
The fee includes only services rendered in our office. Additional charges will be made for lost or broken appliances, or when treatment is
prolonged due to poor cooperation. A charge will be made for “no show” appointments when a 24 hour notice has not been given, excluding
unforeseen emergencies. In addition, all costs incurred in the collection of overdue accounts will be borne by the patient or if the patient is a
minor, by the parent or guardian. Treatment rendered via a multiphase plan, the fee for each phase will be determined at the time the treatment is
recommended.
In the event of a transfer, the fee will be adjusted according to the treatment rendered. An additional fee will be charged to duplicate transfer
records. Records will be forwarded to the new orthodontist after the account is cleared.
Our office has no legal authority to bill a third party other than insurance, for fees incurred in treatment. If you have an agreement that requires
someone else to pay for dental fees for you or your child, please have that person send a written agreement prior to the start of treatment.
During the course of orthodontic treatment, examinations for cavities and periodontal maintenance are essential and should be provided by your
family dentist on a regular basis. Our appointments will be made at varying intervals. The frequency of visits has no bearing on the fee.
As the financially responsible person, I certify that I have read this agreement and that all diagnostic materials and treatment alternatives have
been explained to me. I also allow the use of this patient’s diagnostic records for research or educational purposes.
Signature of Responsible Party
Date
Witness
I will do everything necessary to assist INSERT NAME Orthodontics in receiving the credited insurance benefits, if any, by completing and
submitting any necessary forms, as well as communicating all and any change in my insurance benefit. I am aware that I, not my insurance
company, am responsible for all balances on the account, whether or not the insurance company pays the full expected benefit allowance. In
addition, this will serve as signature on file for the submission of all insurance claims and assignment of benefit to the above named office.
RELEASE OF INFORMATION
Signature Patient or Parent if Minor
Date
AUTHORIZE PAYMENT DIRECTLY TO DENTIST
Insured
Date
{ MERGEFIELD posting_date }
{ MERGEFIELD resparty_full_name }
{ MERGEFIELD resparty_address_1 }
{ IF { MERGEFIELD resparty_address_2 } <> "" "{ MERGEFIELD resparty_address_2 }
"}{ MERGEFIELD resparty_city }, { MERGEFIELD resparty_state } { MERGEFIELD
resparty_zip }
RE:{ MERGEFIELD patient_full_name }'s Orthodontic Insurance Benefit
Dear { MERGEFIELD resparty_greeting },
As the end of the year approaches, we would like to take this time to thank you for the support
and confidence you have displayed in our team by allowing us to provide orthodontic care for
your family. It has also been our pleasure to work with you and your insurance carrier to assist
you in receiving your maximum benefit.
Many changes can come with a new year, and we would like to make you aware that a change in
your insurance carrier could result in a change to your orthodontic benefit.
Should you find yourself with a new benefit plan for the upcoming year, please promptly notify
our office so that we may submit the necessary information to your new carrier in order to avoid
a delay in your benefit payment.
Our entire orthodontic team wishes you and your family a happy, healthy and prosperous New
Year. We look forward to providing you with the highest level of care and service.
Warm Regards,
Dr. Byrne and Team
Please complete this form and bring it to our office in the event of a change to your insurance
benefit.
Patient:
Effective Date:
Subscriber or Insured Member Information
Full Name:
Employer:
Insurance Company Name:
Claims Mailing Address:
Birth Date:
Plan or Group Number:
ID or SS#:
THE AAO "AT-A-GLANCE" GUIDE TO CDT-2007
VERSION ORTHODONTIC CODES
DENTITION:
Primary Dentition: Teeth developed and erupted first in order of time.
Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines
are in the process of shedding and the permanent successors are emerging.
Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth that
would affect orthodontic treatment.
Adult Dentition: The dentition that is present after the cessation of growth that would affect orthodontic treatment.
All of the following orthodontic treatment codes may be used more than once for the treatment of a particular patient depending on
the particular circumstance. A patient may require more than one interceptive procedure or more than one limited procedure
depending on their particular problem.
LIMITED ORTHODONTIC TREATMENT:
Orthodontic treatment with a limited objective, not involving the entire dentition. It may be directed at the only existing problem, or
at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy.
Examples of this type of treatment would be treatment in one arch only to correct crowding, partial treatment to open spaces or
upright a tooth for a bridge or implant and partial treatment for closure of a space(s).
D8010
D8020
D8030
D8040
Limited orthodontic treatment of the primary dentition
Limited orthodontic treatment of the transitional dentition
Limited orthodontic treatment of the adolescent dentition
Limited orthodontic treatment of the adult dentition
INTERCEPTIVE ORTHODONTIC TREATMENT:
Treatment using codes for interceptive orthodontic treatment are for procedures to lessen the severity or future effects of a
malformation and to eliminate its cause.
An extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or
transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of isolated dental
crossbite or recovery of recent minor space loss where overall space is adequate.
The key to successful interception is intervention in the incipient stages of a developing problem to lessen the severity of the
malformation and eliminate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other
conditions may require future comprehensive therapy.
Early phases of comprehensive therapy may utilize some procedures that might also be used interceptively, but such procedures
are not considered interceptive in those applications.
D8050
D8060
Interceptive orthodontic treatment of the primary dentition
Interceptive orthodontic treatment of the transitional dentition
CDT-2007 ORTHODONTIC CODES REPRODUCED WITH THE PERMISSION OF THE AMERICAN DENTAL ASSOCIATION
THE AAO "AT-A-GLANCE" GUIDE TO CDT-2007
VERSION ORTHODONTIC CODES
COMPREHENSIVE ORTHODONTIC TREATMENT:
These codes should be used when there are multiple phases of treatment provided at different stages of dentofacial development.
For example, the use of an activator is generally stage one of a two-stage treatment. In this situation, placement of fixed
appliances will generally be stage two of a two-stage treatment. Both phases should be listed as comprehensive treatment
modified by the appropriate stage of dental development.
This is used to report the coordinated diagnosis and treatment leading to the improvement of a patient's craniofacial dysfunction
and/or dentofacial deformity including anatomical, functional and aesthetic relationships. Treatment usually, but not necessarily,
utilizes fixed orthodontic appliances. Adjunctive procedures, such as extractions, maxillofacial surgery, nasopharyngeal surgery,
myofunctional or speech therapy and restorative or periodontal care, may be coordinated disciplines. Optimal care requires longterm consideration of a patient's needs and periodic re-evaluation. Treatment may incorporate several phases with specific
objectives at various stages of dentofacial development.
D8070
D8080
D8090
Comprehensive orthodontic treatment of the transitional dentition
Comprehensive orthodontic treatment of the adolescent dentition
Comprehensive orthodontic treatment of the adult dentition
MINOR TREATMENT TO CONTROL HARMFUL HABITS:
D8210
Removable appliance therapy - Removable indicates patient can remove; includes appliances for thumb sucking and
tongue thrusting.
D8220 Fixed appliance therapy - Fixed indicates patient cannot remove appliance; includes appliances for thumb sucking and
tongue thrusting.
OTHER ORTHODONTIC SERVICES AND ANCILLARY CODES:
D8660
D8670
D8680
D8690
D8691
D8692
D8693
D8999
D0150
D0220
D0230
D0330
D0340
D0360
D0362
D0363
D0350
D0470
D7292
D7293
D7294
D9450
Pre-orthodontic treatment visit
Periodic orthodontic treatment visit (as part of contract)
Orthodontic retention (removal of appliances, construction and placement of retainer(s)
Orthodontic treatment (alternative billing to a contract fee) services provided by dentist other than original treating
dentist. A method of payment between the provider and responsible party for services that reflect an open-ended fee
arrangement.
Repair of orthodontic appliance-does not include bracket and standard fixed orthodontic appliances. It does include
functional appliances and palatal expanders.
Replacement of lost or broken retainer
Rebonding or recementing; and/or repair as required of fixed retainers
Unspecified orthodontic procedure, by report – used for procedure that is not adequately described by a code.
Describe procedure.
Comprehensive oral evaluation – new or established patient
Intraoral – periapical first film
Intraoral – periapical each additional film
Panoramic film
Cephalometric film
Cone beam CT – Craniofacial data capture – Includes axial, coronal and sagittal data
Cone beam – Two dimensional image reconstruction using existing data, includes multiple images
Cone beam – Three dimensional image reconstruction using existing data, includes multiple images
Oral/facial photographic images
Diagnostic casts
Surgical placement: Temporary anchorage device (screw retained plate) requiring surgical flap, includes
device removal
Surgical placement: Temporary anchorage device requiring surgical flap, includes device removal
Surgical placement: Temporary anchorage device without surgical flap, includes device removal
Case presentation, detailed and extensive treatment planning – established patient. Not performed on same day as
evaluation
CDT-2007 ORTHODONTIC CODES REPRODUCED WITH THE PERMISSION OF THE AMERICAN DENTAL ASSOCIATION
Doctor Initiated Complaint Form
Date: ________________
Practice: ______________________
Address: ______________________
Address: ______________________
Phone: _______________________
We filed the attached claim form with the _____________________ Insurance
Company on _______________. It has not been paid or denied.
Please accept this letter as a formal written complaint against the ________________
Insurance Company.
Patient Initiated Complaint Form
Date: ________________
Practice: ______________________
Address: ______________________
Address: ______________________
Phone: _______________________
I filed the attached claim form with the _____________________ Insurance
Company on _______________. It has not been paid or denied.
Benefits were assigned to ________________________________ and, as of today’s
date, payment has not been received. I am responsible for payment of this bill.
Please accept this letter as a formal written complaint against the ________________
Insurance Company.
Patient’s Signature _________________________
Notification to Patient
New or Changed Insurance Benefits
For TX in Progress
(Date)
Responsible Party / Covered Party
Address
Address
Re:
Estimate of Benefits, (New or Changed) Insurance
Contract Modifications, if any
Dear
Enclosed you will find a copy of your new insurance carrier=s benefit information for (patient)’s
on-going orthodontic course of treatment.
Per your company=s explanation, the following changes will be / have been made to your
account:
As always, the total balance of your account remains your responsibility, although an insurance
benefit may be credited to your ledger. Please don=t hesitate to contact our office if I can be of
help in answering any additional questions.
Sincerely,
, Insurance Coordinator
cc:
Insurance EOB
Account Summary / Schedule of Payments
New Insurance Claim
No Response – 30 days
(date)
Re:
Insurance Claim for
(patient)
Responsible Party
Address
Address
Dear
We must inform you that we have yet to receive a response from your insurance provider.
It has now been more than 30 days since the origination of your claim, and we must
request your assistance in helping us to have this claim processed. Your immediate
attention to this matter is necessary, as our office, after 45 days of non-payment from
your insurance company, must transfer the credited benefit amount back to you, and
arrange or re-arrange a reasonable schedule for payment.
In cases such as this, we have found it most likely to be resolved when you, the insured
party, directly contact your company’s subscriber services. Upon doing so, you should
request an explanation as to why you/we have not received benefits for provided services,
and insist on immediate action. We trust that in a collaborative effort, we can quickly
resolve this problem.
Please promptly contact me if I can offer you any more information prior to making your
inquiry to the insurance company. I look forward to hearing from you, and of the
response. Thank you so much for your attention to this matter.
Sincerely,
, Insurance Coordinator
New Insurance Claim
No Response – 45 days
(Date)
Re:
Insurance Claim for
(Patient)
Responsible Party
Address
Address
Dear
We regret to inform you that after 45 days of attempting to activate your insurance claim
with (insurance company name), we have still met with no success, or as much as an
explanation from your provider.
As our office policy mandates, insurance credits extended at the onset of treatment, must
now be transferred to you for calculation into a new/ your current schedule of payments.
I would be most appreciative if you could promptly contact me to discuss how we may
arrange for method of payment for the credit transfer of $
.
Thank you so much for your immediate attention to this matter.
Sincerely,
, Insurance Coordinator