Dental Terminologies II

Age Limitation:

Some procedure can be performed on patient's only up to certain age limit. Hence most of the Benefits Breakdown forms will have questions relating to Age limitations. It is very imporatant that we update the details exactly as sthe rep says it. Because sometimes they may use the statements like "covered up to the age of 14", which would mean that it is only covered till the time the patient is 13, once they turn 14, the insurance will not pay for it. Sometimes they say "COvered through the age of 24", which would mean thaey will pay for te treatment even if the patient is 14. Hence paying close attention to the insurance rep / web page / fax copy is very essential.

Downgrade / Alternative benefit:

Sometimes if the provider bills out a certain procedure code the insurance may downgrade it to a cheaper procedure code. This is a common scenario with a Composite Filling (Tooth color filing) that are done on Posterior teethe (Behind Teeth), wherein the insurance will downgrade it to an Amalgam Filling (Silver Filling), which is cheaper in cost.

It is essential that we take down this information correctly so that the dental office can advice the patient that they would be responsible for the diference between the Compostite Filling and the Amalgam Filling.

Waiting Period:

Certain treatment can be performed only after the expiration of certain time (some times 6 months or 12 months or more depending on the insurance & plan of the patient) from the effective date of the plan, this is termed as Waiting Period (WP).

Perio, OS or Ortho will also have a waiting period clause  that needs to be satisfied before the insurance will pay for that treatment.

E.g., If there is a WP of 12 months for all Major services, and the patient's  effective date is 01-01-2017, this means the insurance will pay for Major treatments that are done after 01-01-2018. If any Major treatments are performed prior to 01-01-2018 it will be denied by the insurance and the patient will be responsible for the paying for it.

Note: It is very essential to take down the correct information regarding the waiting periods, because if we make a mistake here, it could lead to the de3nial of the patient's high dolled value claim, which in turn will cause major issues to us as well.

ways to ask this question: Are there any waiting periods?(Y/N). If the answer is Yes then we need to ask, "on what procedures is it applicable?" and "how long is it for?"
[Tips: When they tell you there is no WP, it is also advised to ask, "So the WP is not applicable to this particular patient also, correct? Some times WP may not be applicable to the group but it could be applicable to a particular patient, especially if the patient is a Late Entrant, which means the PT was added to the plan after the subscriber was. The rep may not always tell you this info. Another important question for WP would be,"when will the WO be met?", because the plan could have a WP and so the Rep will say "Yes there is a WP" but they may not tell you that the WP is already met, so this question will make things more clear.]