The primary and secondary dental benefit plans are determined by the birthday rule. Where both coordinating plans follow the birthday rule, the order of benefits is as follows: Employee/dependent – The plan covering that person as an employee pays benefits first. The plan covering that person as a dependent pays benefits second. Dependent child of… Continue Reading How do you determine primary and secondary coverage?
No. Wis. Adm. Code INS 3.40, permits insurers to coordinate benefits at three levels or options. One level/option is the full coverage level to which you are accustomed. It coordinates up to 100 percent of the allowable expense. The secondary plan pays the difference between what the primary plan pays and the charge, thus giving… Continue Reading As a secondary carrier, do all plans coordinate benefits the same way?
Dental benefit plans that utilize the term UCR are required to maintain a database containing provider fees for designated towns, areas and/or zip codes. This geographic specific data is utilized to determine a plan’s UCR. Under Wisconsin law, an insurer’s UCR database must meet the following conditions: The fees contained in the database should reflect… Continue Reading How do insurers determine UCR?
The insurer must provide all of the following information/resources to policyholders (patients) including: Payment methodology used by the insurer to determine the amount the insurer will pay for specific procedures covered by the plan. If applicable, an explanation of why insurance payments might be less than the provider’s charge for the dental service, thereby informing… Continue Reading What are insurers required to provide to the patient when they are covered under a dental plan?
A sample letter follows. According to a ruling by the Wisconsin Commissioner of Insurance, the potential purchaser of the dental plan, the insured and the provider may request this information. You will have to ask your patient to forward the response they obtain from a third party to you. Because patients do not have access… Continue Reading Is there a sample letter dentists or patients could use when requesting information from the third party payer to explain why a claim was paid at a rate less than the actual charge?
According to Wisconsin Insurance Statute 628.46 (Timely payment of claims): (1) Unless otherwise provided by law, an insurer shall promptly pay every insurance claim. A claim shall be overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and the amount of the loss.… Continue Reading Do insurance companies have to pay claims in a timely manner?
The Health Insurance and Portability and Accountability Act was signed into law in 1996 and it has multiple initiatives that affect providers, insurers, employers, patients and other covered entities. As of December 2002, only the “administrative simplification portion” of the HIPAA regulations applies to dentistry. There are two sections within the administrative simplification portion. They… Continue Reading What is the Health Insurance Portability and Accountability Act (HIPAA)?
Technically, only dental offices that submit protected health information electronically are covered under HIPAA. These offices (electronic filers) must comply with both the security and the privacy rules. However, the ADA and WDA strongly advise all dental offices, including those that file by paper, to comply with the HIPAA privacy rule. The compliance deadline for… Continue Reading Are all dental offices covered under HIPAA?
Members can stay informed via the ADA and WDA monthly publications and websites. Both tools offer concise, dental-specific guidance and up-to-date information. Additional HIPAA information can be found at: www.ada.org/goto/hipaa wda.org www.dentalrecord.com www.hipaacow.org (HIPAA Collaborative of Wisconsin website) www.hipaa.com www.hhs.gov/ocr/privacy
Under HIPAA, all dental offices that submit protected health care information electronically must utilize both the HIPAA compliant format and the most recent dental treatment codes. The HIPAA compliant format will become the only nationwide compliant format used by health care professionals choosing to submit electronic claims to insurers and clearinghouses. This single format will… Continue Reading What does the electronic transactions and code sets rule require?