Obtain preauthorization: All dental surgery CBCT claims require pre-authorization from the medical plan and dentists must obtain the authorization before the procedure is performed. Pre-auth involves contacting the insurer by phone and explaining the procedure and the date. Not obtaining pre-auth can result in claim rejection.
Insurance verification: The patient’s dental eligibility should be verified, that is, collect information on the patient’s coverage and how the insurer will pay for surgery.When a new patient calls to make an appointment, collect the following information:
 Patient’s name and date of birth
 Name of the primary insured
 Social security number of primary insured
 Insurance carrier
 ID number
 Group number
Contact information for the insurance company including phone number, website and address for submitting claimsWith this information in hand, contact the insurer to verify the patient’s eligibility for insurance coverage, effective dates, in-network or out-of-network coverage, whether surgery needs pre-authorization, and co-pays, coinsurance and deductibles. Collecting information on what their insurance will cover will help patients planfor their out-of-pocket payments. Hiring an insurance verification specialist or outsourcing can make these tasks easier. You will also need to have ICD10 codes available to use for confirmation on the WHY this patient is medical.

Two important facts to understand when choosing codes to pre-certify are:

1. The patient tells you why they are coming to your office.  Example  Pain, swelling, referral for atrophy.

What tests will you obtain to diagnosis the symptoms so you can diagnosis?  CBCT, X-Rays, Medications, 

When you are ready to obtain the pre-authorization for all treatment you will need diagnostic codes from ICD10 that tell the company the results of the test.

Example:  You confirmed with medical history the patient takes medication for heart condition.  You confirm sever atrophy, You confirm partial loss of teeth due to periodontal and caries lesions.

Then and only then can you apply for all the treatment.

See example of questions 

Insurance Verification of Eligibility and Benefits:

Call members medical insurance. Have all the patients’ demographics and their insurance at this time. If you proceed with this list, you will have all the needed information to bill claim correctly. Remember insurance cannot determine treatment or scope of license. As long as the treatment is being completed within the head and neck your doctor is able to perform these services. Don’t allow them to tell you otherwise when the check the NPI and say you are a dentist.
If insurance is, only in network ask if your office can accept in network benefits (medigap) since you are one of the only doctors who can supply patient this appliance for miles required for them to provide a doctor.
At that time as to fill out form to provide benefits with medical. Some will allow you to provide benefits since they cannot find a provider within the mile radius.
Have your codes ready before you make call. They do not have to be what you end up doing just a diagnosis and treatment that may take place after you finish your diagnostic tests.
Diagnosis Codes:
Treatment Codes:
Insurance Verification of Eligibility and Benefits

Date: ______________ Verified By: _________________ Time of Call: _______________

Patient name: ________________________________________ DOB: _____________________

SSN/ID: __________________ Address: ______________________________________

Subscriber name: __________________________________ DOB: _____________________

Employer: __________________________________ Group #: __________________

Insurance Company: _________________________________ Phone #: __________________

Claims Address: _____________________________________ Fax #: _____________________

Elec Payor ID: _______________________________________ Call Ref #: _________________

Effective Date: ______________________________________ Out of Network Benefits Y N

Deductible: _____________ Met to date: _______________ Calendar Plan: ______________

Out of pocket: ___________ Met to date: _______________ Office Co Pay: ______________

DME Ded: ______________ Met to date: _______________ Calendar Plan: ______________

Agent Name/ID: _____________________________________ Pre Auth #: ________________

Covered Benefits:

If there are exclusions, what is the specific written exclusion from the policy? If treatment is excluded in policy, there is no hope for coverage.

Are there policy limits or pre-certification requirements? If yes, what are they?

Can benefits be assigned to the doctor?

Is pre-certification required? Can I fax to provide treatment within next week?

 

 

 

 

 

 

 

 

 

 


Christine Taxin
Links2Success
36 Abington Avenue
Ardsley, New York 10502
United States of America