dental insurance

• 4 fee guides used Sfg/Pbc/MssMss Emg/FNHA
• Where Vac claims are sent

  Medavie Blue Cross
• Remp and their dependants are not covered under the same insurance plan
• Types of insurance plans

  • Member-Atlantic Blue Cross
  • Family-Canada Life
  • Retired-Sunlife
• 3 types of financial limits for plans

  • Cal/Benefit/Roll years
• 3 categories of dental insurance coverage

  • Basic
  • Major
  • Ortho ABC
• UTD

  Used to Date-Plan limits
• Factors that can affect UTD that we may be unaware of

  • Treatment elsewhere
  • Referral to Specialist
  • Changes
  • Termination
• When receiving dental insurance information, eligibility should always be confirmed and plan breakdown details should be obtained
• HSA

  Health spending account-reimbursement to policyholder
• COB

  Co-ordination of benefits - 2 or more plans co-ordinate to a maximum 100%
• When submitting to a dual plan, the primary remittance or EOB must accompany the claim
• EOB

  Electronic/Explanation of benefits - Guarantee of Payment
• Claim acknowledgement

  Sent electronically but has not been processed - No Guarantee
• When primary and dual insurance plans are the same, claims should be sent together or with the EOB from the dual plan
• No COB means the plan won't pay as dual
• Mas fee schedule

  Has separate fees based on adult and child
• Treatments where sedation is generally covered

  • Perio
  • Oral Surgery
• Pbc does not cover deep conscious oral sedation
• Treatments that must always be preauthorized

  • Majority involved things unsure of
  • Crown & Bridge
  • Denture
  • Molar composites
  • Veneers
• Treatments that may be preauthorized to insurance via Edi

  • Nightguards/Composites
  • Recalls
  • Single crowns/Panoramic
  • Ortho workup/Treatment plan
  • Consult
• Dr or office verification signatures are required on a preauthorization
• Supporting documents needed for preauthorization of different treatments

  • Veneers (Photos)
  • Crown & Bridge (X-rays)
  • Partial or Complete Dentures (Panoramic x-rays)
  • Root Canal Re-treatments (none)
  • Wisdom Teeth Extractions (none)
  • Exceed Scaling & Root planing limits (perio chart and x-rays)
  • Ortho Treatment (treatment plan)
  • Ortho Work-up (none)
  • Nightguard (none)
• Vac treatments over $1500 need to be approved by the National Dental Consultant
• Vac recall limit

  9 Months
• Units of sealing allowed for FNHA, Vac, and Mss

  • FNHA (13)
  • Vac (8)
  • Mss (12)
• FNHA recall polish & fluoride limits

  2 per year
• Mss client ID #

  Health Care Card #
• Age fluoride is covered with Mss

  19 and under
• Mss recall & polish limits

  19 and under - 2 per year

  19 and over - 1 per year
• Criteria for sealants to be covered on Mss

  15 and under, on permanent caries free teeth 4-8
• Mss Emg dental coverage

  2 teeth per visit
• Plans that do not require patient signatures are Mss, Vac, and FNHA for those 17 and under
• To obtain eligibility when calling an insurance company, the group #, ID #, policyholder name, and policyholder birthdate are needed
• Patients should generally be seen for a recall appointment every 6 months, but this can vary based on patient need
• The general rule for sealants is 1 per 2 years per tooth
• The general rule for fillings is the insurance % of the fee guide value of a 5 surface filling every 2 years
• The general rule for x-ray limits is the insurance % of the fee guide value of a full mouth series per year for Mss, and per 2 years for other plans
• Generally, the price of a root canal includes x-rays and pulpectomy
• Pulp caps are generally not covered when done with a filling, but Mss and Pbc may cover them