Dental Terminologies I

Maximum:

This is the Maximum amount that the insurance will pay for a given contract year. If the patient does treatment over this maximum amount they would need to pa y for the rest. 

A contract year can be a Calendar Year, Fiscal year, Benefit Year so we need to find that out also.

Remailing Max/ Benefit Used : Remaining Max is the Amount that is still remaining out of the patient's Maximum amount. Benefit Used means how much of the patient's maximum has been used.

              We need to be careful when asking this question, because some of our client's breakdown forms may need you to find out the remaining Max, some may ask for Benefit Used.

             The insurance rep may also give out the Benefits used when you ask for remaining Max or vice versa. So it is important to pay very close attention to what they are saying and then interpret it accordingly on the breakdown form.

Note: If your breakdown form ask for "Remaining Max" and the rep says benefits used is $100, you need to deduct $ 100 from the patient's total Max and update the difference.

            And if your breakdown form ask for " Benefits Used" and the rep say "the PT has a remailing max of $900" here too you will need to deduct $900 from the total Max amount.

Frequency:

Frequency means how often a procedure can be performed and the insurance will cover it. Some Dx can be done more often than others. Here we need to understand what is 2 per year and 1 per 6 months in case of some codes.

2 per Year means, " You can perform this procedure 2 times in a year, e.g., you can do 1 in Marh and the other in May and the insurance will cover it."

1 per 6 months means, " You can do once in every 6 months, e.g., you can do 1 in Jan and the next can only be done in July of after July. If you do the second treatment in May, that will be denied y the insurance. Hence it is very important we listen to exactly what the rep is telling us. SOme procedure are covered once in a Life time too.

There are some procedure codes that will be included with the frequencies of some other codes. One such common examples is 4910 Perio Maintenance, some insurance carriers will include the frequency of 4910 along with the frequency of a regular cleaning (known as Phophy 1110). So if your breakdown form has a frequency is included with the frequency of a Prophy and update form accordingly.

Replacement Period:

Replacement period is a similar to Frequency. The difference is Replacement Period refers to Procedures like Crowns, Bridges and Dentures (including Partial Dentures). Replacement Period refers to "How often can we replace a Crown, a Bridge or Denture?" Generally are either 5 or 10 Years.

History:

When you are looking for histories for certain procedure, what you need to find out is "when (last date) that particular procedure was last performed?" The history of a particular procedure is tied up to the frequency of that procedure. Depending on the Frequency and History the Dental office an determine whether or not the patient's insurance will make payment for that procedure. If the insurance will not make payment due to these condition, then that can charge the patient at the time of treatment.