Introduction

As a [dental practice name] office team member, you need to know how to quickly process dental insurance claims for our patients.

After you complete this subject, you'll be able to:

• Describe the costs of services we provide
• Submit a claim to a patient's insurance
• Describe cases where we may bill a patient's medical insurance
• Fill out our billing forms
• Process refunds

Tip: If you forget anything that you learn in this subject, you can go back and look at it at any time! And check it out on the go with the Trainual mobile app for iOS or Android.

Our Costs of Care

Preventative Care Costs

Learn about the cost of each kind of preventative service we provide. Note that this is the cost of each service without insurance.

Teeth Cleaning

[Cost per service]

Oral Exams

[Cost per service]

X-Rays

• [Cost for full set]
• [Cost for Bitewings]
• [Cost for Periapicals]
• [Cost for Panoramic]
  

Fluoride treatment

[Cost per service]

Sealants

[Cost per tooth]

Reconstructive Care Costs

Learn about the cost of each kind of reconstructive work we provide. Note that this is the cost of each service without insurance.

Veneers

[Cost per tooth]

Bonds

[Cost per tooth]

Tooth Replacement & Bridges

[Cost per tooth]

Fillings

[Cost per tooth]

Crowns

[Cost per tooth]

Emergency Services Costs

Learn about the cost of each kind of emergency service we provide. Note that this is the cost of each service without insurance.

Emergency Visit

[Cost per visit]

Additional Emergency Services

The following services can be provided at an additional cost to the base emergency visit cost.

Toothache relief

[Cost per service]

Swollen jaw relief

[Cost per service]

Cracked tooth

[Cost per tooth]

Repair of lost or loose fillings

[Cost per tooth]

Sore gum relief

[Cost per service]

Root canal therapy

[Cost per service]

Dental repair

[Cost per tooth]

Insurance Claim Submission Process

What is a Claim?

An insurance claim is what we submit to a patient's insurance company so that we can get paid. Claims show the medical services that were provided to the patient.

Claims ensure we get paid, the patient's insurance pays covered benefits, and the patient gets billed for the remainder.

Information Needed

When a patient books an appointment with us, we need to request the below information from them. They can retrieve all of this information off of the front and back of their insurance card.

Information to collect:

• Insurance company
• ID number or social security number
• Group number (if they have it)
• Patient’s employer
• Policyholder information (name, date of birth, and relationship) if the patient is not the policyholder themselves
  

We need all of this information to confirm the patient's insurance status (to make sure the policyholder's insurance is active). And to retrieve their estimated cost of service.

Tip: Ask for both the patient's dental and medical insurance info. Their medical insurance might come into play, depending on the care needed (more on this later).

Coverage Verification

When a patient books an initial appointment with us, we need to contact their insurance company. That way, we can verify their insurance coverage prior to their visit.

Call the insurance company at least 72 hours before a patient’s initial visit. This will ensure that you have all the information you need long before the patient walks through our doors.

Verification Checklist

When you get ahold of the insurance company, document the following items in the patient's records:

• The policyholder (and relationship to the patient), policy number, and group number
• Claims address
• Confirm if the policy active or inactive
• If active, confirm the policy's end date
• If the dentist the patient plans to see is in- or out-of-network
• When the patient is next eligible for routine cleaning coverage
• Coverage for other services we provide
• The patient’s copay and/or coinsurance
• The patient’s deductible
• If the patient requires referrals, pre-authorizations, or certificates of medical necessity for reimbursement
• If there are any coverage limitations or documentation requirements the office needs to be aware of
  

Use the information gathered to bill the patient according to their services before they go into the back to be seen.

Submit the Claim

After the patient's appointment, you will send the insurance company a claim (AKA a bill) for the patient's charges of service. The bill will not include any charges paid via co-pay upon check-in.

Submitting ASAP

It's important that you submit the claim ASAP. After all, our office doesn't get paid for our services until we bill the insurance company and/or the patient.

So be sure to submit the claim for a patient visit by the end of the business day on their day of service.

You'll simply fill out all sections of our dental claim form. Then, send it (preferably via email) to the patient's insurance company.

What the Insurance Company Does

A claims processor will check the submission for completeness, accuracy, and whether the service is covered under the patient's plan.

The insurance company will pay the portion of the claim that is covered in the patient's plan.

Adjust Billing as Needed

While the insurance company has paid the portion of the claim that is covered in the patient's plan, they might not cover the remainder of the service charges. If that's the case our office will need to collect the rest of the cost for service.

The patient is responsible for paying any remaining charges, so we will send them a final bill for any costs that still need to be covered.

Sending a Final Bill

To send the patient a final bill (if needed), simply fill out the final billing form. Then, send it via email or mail to the patient, depending on their preference outlined in their profile.

Medical Billing

Billing Medical Insurance

There are some services we provide that can be billed to a patient's medical insurance rather than their dental insurance.

Billing a patient's medical insurance can be helpful when...

1. They lack dental insurance
2. Their dental coverage has lapsed
3. Their dental insurance maximums have been reached
   

A patient who is having a procedure might be interested in looking into their medical insurance options for any of the above reasons. At that point, you'll need to contact their medical insurance prior to treatment to determine their eligibility and benefits.

Services Covered by Medical Insurance

While there's no guarantee of medical coverage until you reach out to a patient's medical insurance, here are some services that a medical insurance company may possibly cover.

1. Sleep apnea appliances (dental sleep medicine)
2. TMJ appliances and headache treatment
3. Oral infections, cysts, oral inflammation
4. Exams for services that are covered by medical insurance
5. Panorex x-rays for services covered by medical insurance
6. CBCT (cone beam) and tomography for services covered by medical insurance
7. Frenectomy/tongue ties for infants and children
8. Accidents to teeth requiring medical diagnosis
9. Mucositis and stomatitis (from chemotherapy and other treatments)
10. Facial pain treatment
11. Dental implants and bone grafts
12. 3rd molars or wisdom teeth extraction
13. Biopsies
14. Clearance exams before chemotherapy or surgery
15. Botox injections for bruxism and jaw pain
16. Congenital defects triggered by other health deficiencies
17. Emergency trauma procedures
18. Treatment related to inflammation and infection
19. Exams for oro-facial medical problems
    

Keep this list handy to help you navigate conversations with patients.

Coding Medical Insurance

We normally use our dental codes, CDT codes, when submitting claims to dental insurance companies. Medical procedure codes are called CPT codes.

Similar to the dental procedure code set, the codes are divided into categories, which are as follows:

• Evaluation and management
• Anesthesia
• Surgery
• Radiology
• Pathology and laboratory
• Medicine

Cross-Coding

When you apply a medical code to a dental procedure, it's called cross-coding. The difficulty of cross-coding is that very few CPT codes exactly parallel dental procedures.

That's where modifiers come in.

Modifiers

Within each CPT code set is a subset of codes called modifiers. Modifiers are used to supplement the information or adjust care descriptions to provide extra details concerning a procedure or service.

There are many modifiers and it is important to do your research on the CPT you're trying to use to know the specific modifiers you'll want to apply.

Tip: There are some insurance carriers that will accept CDT codes on the medical claim form (just ask them!).

Billing Forms

Invoice

Here is the invoice we use to bill our customers.

[Embed PDF of empty invoice]

Check out the [video or screenshots] below to learn how to correctly fill it out.

[Embed video and/or images that guide team members in how to fill out the invoice]

Refunds

How to Refund Card and Check Payments

If the patient has overpaid us using a credit or debit card on file, or even using a check, we can issue payment back to the original payment method in just a couple of clicks!

[Embed a Loom video or screenshots of how to do this in your practice's software system]

How to Refund Cash Payments

It's a little more time-consuming to process a refund to a patient who paid in cash.

If the patient has overpaid us using cash, we will simply send them a check via mail. You can grab the refund documentation that you'll fill out later in this subject.

Refund Notification

Patients will automatically be notified of their refund via email if they paid using a card or check. The patient can keep this for their own reference. The email notification itself is not the patient's refund nor is it a check.

Check Refunds

If the patient is refunded via check because they paid in cash, you'll need to send them our refund email on the same day the check is sent, attached below.

[Embed PDF of example refund email]

Recap

Congrats — you've finished the Dental Care Billing subject! 🎉

You should now be able to:

• Describe the costs of services we provide
• Submit a claim to a patient's insurance
• Describe cases where we may bill a patient's medical insurance
• Fill out our billing forms
• Process refunds

If you are unclear about how to do anything listed above, go back and review the previous topics.

Remember: If you forget anything that you learn in this subject, you can go back and look at it at any time! And be sure to download the Trainual mobile app for iOS or Android for when you're on the go.