INSURANCE CLAIMS RECOMMENDATIONS FOR SIX MONTH SMILES PROVIDERS

INSURANCE CLAIMS RECOMMENDATIONS FOR SIX MONTH SMILES PROVIDERS

GENERAL INFORMATION: Claims need to be accurate and submitted with the correct corresponding documentation. Six Months Smiles should be covered under dental insurance plans that offer orthodontic coverage to the same extent as orthodontic treatment appliances or techniques. Orthodontic treatments are based on the dentition and scope of treatment, not the specific appliance or technique. Never submit general dentistry treatment with orthodontic treatment on the same claim form. Always file for orthodontic treatment on a separate claim form. Reimbursement is normally spread over the course of treatment. Differences in carriers: Some carriers pay automatically Others require a monthly (or other interval) claim form submission. Annual deductible may apply with some plans. For short-term treatment such as Six Months Smiles, the lifetime orthodontic maximum may not be reached. Some plans may require twelve months or more of active treatment in order to gain reimbursement of the full lifetime orthodontic benefit Orthodontic records such as diagnostic casts (D0470), oral images (D0350), or appropriate x-rays (cephalometric (D0340), full series D0210) or pan (D0330)), should NOT be submitted unless requested by the insurance company (they are generally not requested). Some offices charge a separate records, case, and retention fee. Others charge an all-inclusive fee for the case. Insurance companies try to control orthodontic fees of its dentist network, it is recommended that records, case and retention fees be billed separately. Records fees (if filed separately up front) may or may not be counted against the typical $1,500- $2,500 orthodontic lifetime maximum. Cash flow is faster with payment for the records submitted up front. If you file separately you will get to see how the insurance company handles the record claim form prior to active treatment so you can experience how and if the records and case are paid. Retention may be listed as a separate service with a separate fee on the pre-authorization form for insurance reimbursement purposes. Be aware that PPOs may or may not recognize a separate retention fee. Prior to financial discussion always collect information on the patient s coverage and insurance company s payment policies. The biggest difference between processing claims for orthodontic treatment and claims for general dental procedures is how benefit payments are broken down and dispersed across the course of treatment. This is managed differently from insurance company to insurance company, with many insurance carriers paying benefits automatically at regular intervals, after the initial claim is filed. Others require monthly, quarterly, or other filing interval claims during the active treatment duration. High school and college student dependents (up to age 21-23) are often eligible for orthodontic benefits. Approximately 15% of adults with dental insurance are also eligible for orthodontic benefits. REJECTED CLAIMS If your claim is rejected, the vast majority of claim rejections are based on improper coding or incomplete documentation. Review the most recent CDT codes (currently CDT-2009/2010), carrier guidelines, and this document to verify proper coding. Adult coverage is reimbursed only a small percentage of the time. 2

PRE-ORTHODONTIC TREATMENT VISIT Reasons to pre qualify your patients: Determine eligibility and benefits available Ortho benefits differ on every policy You will be able to present an organized case presentation Evaluate financial options Determining if students and adults are eligible depends on the company Insurance companies require claims to be filed at different intervals and calling with prequalification will help you determine the required paperwork You must determine the requirements of your patients insurance prior to treatment. Record of Services Provided: Procedure Explanation ADA Code Form Steps/Fees Pre-Orthodontic Evaluation Case Presentation Is Treatment for Orthodontics? Date appliance placed Months of treatment remaining Consultation Visit, prior to taking orthodontic records or starting active treatment Discuss Six Month Smiles treatment options D8660 D9450 Check Yes Block Leave blank on this form Leave blank on this form It is recommended to always get a pre-authorization for Orthodontics. Write Pre-Authorization on the top of the paper claim. Six Month Smiles candidates are generally seen during a periodic evaluation (recall) visit and often consultations are complimentary. Both codes are permitted for consultation/evaluation. Orthodontic records are generally charged at the above or a subsequent visit. 3

REPORTING THE RECORDS VISIT Record of Services Provided: Procedure Explanation ADA Code Form Steps/ Fees Oral/Facial Images D0350 Diagnostic Casts Cephalometric Film OR- Full Series OR - Panoramic Radiographs, oral images or models enclosed/ Number of enclosures Is Treatment for Orthodontics? Date appliance placed Months of treatment remaining D0470 D0340 D0210 D0330 Enter 00 in each Block Check yes Block Leave blank on this form Leave blank on this form Most cases require only a full series or pan for the Six Month Smiles technique, since molar relationships do not change. Recent panoramic film or full series may have already been taken at the patient s routine evaluation visit (paid out of the general dental benefits). If so, these recent x-ray procedures may not be required to be taken on the orthodontic records date Some state boards require a cephalometric film for standard care. Confirm with your state board. You may submit records procedures on either general benefits or orthodontic benefits if available; this will reduce the amount of ortho benefits for the case. Be aware of the benefits available for each patient. If the patient is due for a full series/pan (every 3-5 years) anyway for general restorative care, then the x-rays could be placed on a standard claim form for non-ortho reimbursement. Oral images (D0350)/diagnostic casts (D0470) would be entered on the orthodontic claim form for reimbursement. Oral Images are not generally paid by general dental benefits. Some dentists do not report a separate records fee, but an all-inclusive case treatment fee. However, it helps cash flow to file reimbursement for records up front when initially taken. The second advantage is to see if the claim is paid as expected, prior to active treatment. This approach provides an early warning. If the records are paid, most probably the case fee will be paid. The third advantage is that the records fee in some instances is funded separately, in addition to the orthodontic lifetime maximum. The fourth advantage is that if a PPO (such as Delta) controls the fees for non-covered procedures then the separate, allowed fee for records will be in addition to the case fee. It is in your interest, with nothing to lose, to file the records separately and up front. 4

ACTIVE TREATMENT START CLAIM FORM Record of Services Provided: Procedure Explanation ADA Code CASE Limited orthodontic treatment of the CLASSIFICATION Adolescent dentition - indicates permanent D8030 Limited Orthodontic dentition, but growth is not complete. Treatment of the Adolescent Dentition Form Steps/Fees OR Limited Orthodontic Treatment of the Adult Dentition Orthodontic treatment of a patient having only fully developed permanent teeth/jaws. Treatment is intended to correct limited problems. An example of this procedure might be correcting the alignment of one to a few teeth to improve the appearance of the smile, but without performing more comprehensive tooth movement aimed at establishing a proper bite relationship between all of the upper and lower teeth. Radiographs, oral images or models enclosed/number of Enclosures D8040 Enter 00 in each Block Is Treatment for Orthodontics? Check yes Block Date appliance placed Enter mm/dd/yy Total months remaining for active treatment2 Case Fee Enter the # months of active treatment remaining at the start of treatment. Active treatment includes banding and removable retainers, which are actively moving teeth. If using Third-Party Finance or Payment In- Full and the patient has no monthly payments, write $0, but note that the patient has paid his/her co-payment amount. Enter # months remaining $X,XXX Retention Fee $X,XXX Patient s down payment $X,XXX Monthly payment terms3 $XXX Case Diagnosis Case Diagnosis - Angle Class I, II, or III malocclusion Angle Class I, II, or III malocclusion Other documentation as required by carrier other information as required 5

PERIODIC ORTHODONTIC TREATMENT VISIT CLAIM FORM Record of Services Provided Procedure Explanation ADA Code Periodic orthodontic treatment visit Radiographs, oral images or models enclosed / Number of Enclosures Is Treatment for Orthodontics? Periodic Orthodontic Treatment Visit(as part of contract) D8670 $$$ Enter 00 in each block Check yes Block Form Steps/ Fees Date appliance placed Months of active treatment remaining1 Enter total estimated months of active treatment. This treatment time number will decrease with each subsequent claim form submitted after the case start date, if the third-party requires a monthly or quarterly claim form. The total payout of the case may be limited to the active treatment time listed on the claim form. For instance, a $1,500 lifetime orthodontic limit may be prorated over twelve months or longer period and only pay $750 or less in the case of six months of active treatment. Be sure to inquire about the required payout period, if any. Enter mm/dd/yy Enter # months remaining Important! With Six Months Smiles, the dentist might treat a case six months with the patient wearing brackets/bands, and then follow six months of removable active appliances for a total twelve month active treatment case compliance period. Passive retention, either fixed or removable, would then finish the case. The clinician should establish the total treatment period for each case. Some plans require a monthly or quarterly ongoing claim for payment. Others send automatic payment. Be sure to call the insurance company for its policy (see Benefits Qualification Sheet). This information is entered on the periodic treatment visit claim, if required. 6

ORTHODONTIC RETENTION CLAIM FORM After active appliance- Retainers placed after active treatment phase Procedure Explanation ADA Code Form Steps/ Fees Orthodontic Retention Radiographs, oral images or models enclosed / Number of Enclosures If a separate retention fee is reported at the end of active treatment, in the Record of Services Provided area of the claim form, enter the following: D8680 Enter 00 in each block This global fee is for both upper and lower retention, whether removable or fixed. Is Treatment for Orthodontics? Check yes Block Date appliance placed Enter mm/dd/yy Months of active treatment remaining2 The months of active treatment remaining will decrease on each claim as the case progresses. The months of active treatment remaining will be 0 when the passive retention (fixed and/or removable) is placed at the end of the active case. Enter # months remaining In the months remaining box, zero should be entered as active treatment is terminated, and the final holding (passive) retainer is placed. Note: Since non-covered procedures fees (such as adult orthodontics) are controlled by Delta Dental or other insurance companies, it is important to bill records and case fees separately. Thus, there will be less fee write-offs for in-network providers. 7

ANCILLARY CLAIM/TREATMENT INFORMATION: Record of Services Provided Procedure Explanation ADA Code Form Steps/ Fees Treatment for orthodontics? Date appliances placed (#41) Months of treatment remaining This number will decrease with each claim form submitted after the case start date, if the payer requires a monthly or quarterly claim form for payment. Check the block (#40) Yes mm/dd/yy (Start date of active appliances) [ X ]* (Months remaining for active treatment (#42) 8

Benefits Qualification Sheet Patient Name: Date: / / Insurance Company 1. Who is eligible under the plan? Self Spouse Dependent Student 2. Is the patient covered for Adult Orthodontic coverage? (State patient s age) Yes No up to age yrs If the adult patient is covered, answer the following a) What is the orthodontic lifetime dental plan benefit $ lifetime benefit amount? (typically $1,500-$2,500 lifetime for ortho) b) What is the co-pay percentage? (Typically 50%) % co-pay c) Has the patient had previous claims against their Yes No $ orthodontic lifetime maximum? If so, what amount of orthodontic benefits have been used? d) Is there a specific waiting period for orthodontic Yes No months benefits? If so, what is the waiting period? e) Is the orthodontic coverage benefit totally Yes No independent from the general dental benefit or coordinated? If orthodontic benefits are coordinated with general dental benefits how and at what limits? (Watch out on this general dentistry treatment payout will delay/deny orthodontic coverage. Explain: f) Does the plan require treatment by an in-network Yes No PPO/HMO plan dentist for orthodontic benefit coverage? Be careful on this. If the dentist is out of network, is there a reduction in Yes No $ the fee paid, if any? Amount to be paid? 9

g) If the dentist is a member of the orthodontic patient s network carrier, does the plan control the maximum fee that the dentist may charge by contract, even though there is no adult orthodontic coverage by the plan? (Delta is phasing this policy in nationally by 1/1/11). Or, can the dentist charge full fee and the patient pays Yes No the balance? Will the dentist be reimbursed separately for the Yes No retention fee? If Yes and the plan pays a retention fee, then split out Yes No the global case fee. If No, and the plan only allows a case fee, then submit the global case fee, which includes retention. h) Is additional documentation required on the case start Yes No claim form? (Beyond listing the case and retention fee, type of malocclusion) If Yes, what additional documentation is required: Explain: i) Are benefits paid automatically after the initial claim Yes No for active treatment? _ Yes _ No If not, what are the intervals that periodic claims Monthly Quarterly Other must be filed? _ Monthly _ Quarterly _ Other j) Important! Does the plan have any payout Yes No limitations (of lifetime maximum) for six months of active treatment? What is the minimum treatment period to receive the full lifetime maximum? (It could be 12 months or longer) Explain: 10

Frequently Asked Questions 1) Is everyone covered for adult orthodontic benefits? There must be an orthodontic rider purchased by the employer for ortho coverage. Dependents up to ages 21-23 may be covered. Adults are covered about 15% of the time. 2) Is pre-authorization necessary for adult coverage? YES! Call and verify eligibility, deductibles, exclusions, limitations, lifetime maximum benefit, and any orthodontic benefit already used. Also determine if dental and orthodontic coverage are coordinated with an upper limit (maximum) for both. This may reduce the orthodontic benefit dollar-for-dollar, you must be aware of this specific limit. Sometimes a maximum is listed, but only a portion is available even if the general dentistry portion is not used. For instance, the ortho benefit is limited to $500 out of a total $1,500 benefit if $1,000 is reimbursed for general dentistry. This is not common but it does happen. Another reason for the written pre-authorization in orthodontics is to see the maximum fee allowed if participating in a PPO. There may be a separate retention fee is allowed or if a total fee is only allowed for both the case fee and retention fee. In some cases a fee for tooth whitening upper & lower arch (D9972) maybe charged separately. List D9972 two times (with the one-half of the fee apportioned to each arch). 3) Is there a difference in reimbursement for Six Months Smiles system? If the patient is benefited, there is usually no difference in reimbursement. The only difference is that the payment of the lifetime orthodontic benefit might be less for short term treatment (six months active treatment). Important! With Six Months Smiles, the dentist might treat a case six months with the patient wearing brackets/bands, and then follow with six months of removable active appliances for a total twelve month active treatment case. Passive retention, either fixed or removable, would then finish the case. Therefore, the clinician should establish the total treatment period for each case. 4) When submitting claims to insurance is Six Months Smiles coded the same as regular orthodontics and do you use the same procedure codes? No, the same CDT-2009-2010 codes are utilized for all types and approaches of active orthodontic care. The case code is usually D8030 (adolescents) or D8040 (adults) would apply for an upper/lower arch case. 5) For a typical patient, what is the orthodontic lifetime limit? Most orthodontic lifetime limits are $1,500. Some have $1,000 or as high as $2,500 or more. Benefits are usually paid at 50%. Some plans have recurring annual deductibles ($50 - $150) during the course of orthodontic treatment. The typical coverage of a lifetime $1,500 benefit is generally all-inclusive and includes records, active case treatment and retention. It may also include orthodontic-related procedures such as extractions, fiberotomies, frenectomies, miscellaneous ortho-related procedures, and surgical access to an unerupted tooth (generally not required procedures for the Six Months Smiles technique). These orthodontically-related procedures may not generally be covered under regular dental benefits (if related to orthodontics) and the claim form should indicate they are orthodontic-related procedures. And should be marked yes on the form. However, if the orthodontically-related benefits are paid out of general dental benefits, the UCR could be paid at 50% rather than 80%. 11

The orthodontic lifetime limit is often in addition to the regular dental benefit limit for the majority of plans. In some cases, the maximum annual limit is fixed at $1,500 for both orthodontic and regular dental coverage in the same plan year. Thus, if the regular dental benefit is used, then the orthodontic benefit available may be reduced dollar-for-dollar for that treatment period. In other cases, a maximum (for instance $1,500) is stated but only a portion is available for orthodontic reimbursement, even if the general dentistry portion is not used. For instance, the ortho benefit is limited to $500 of the $1,500 total benefit. With so much variability of benefits, you must call to determine eligibility and benefit coverage for each case! See the Benefits Qualification Sheet. 6) Are annual deductibles required for orthodontic benefits? It depends on the policy; some have recurring annual deductibles during ortho treatment. Be sure to use the e Benefits Qualification Sheet for each patient to confirm benefits. 7) Do I need to get pre-authorization for adults orthodontic coverage? YES! Always call and verify. 8) What are the ADA reporting codes for the typical Six Months Smiles cases? Adolescent case D8030 Limited orthodontic treatment of the adolescent dentition (permanent dentition but growth is not complete). Adult case D8040 Limited orthodontic treatment of the adult dentition (growth is complete). The adult case (D8040) will generally be reported, provided both arches are treated. 9) Does the insurance company impose any maximum orthodontic fee limitations? NO! If the dentist does not participate in any third-party contracted plan. Yes! the maximum fee that may be charged for an orthodontic case by its providers if the dentist is a participating provider for a PPO/capitation plan with an orthodontic benefit which sets, by contract. The PPO/capitation plan will pay up to their lifetime maximum while simultaneously controlling the out-ofpocket paid by the patient. Therefore, the total fee collected is limited by the PPO plan contract. Yes, if the dentist participates in a plan (including Delta Dental national phase-in by 1/1/11 check with your state s Delta Dental for your state s implementation date) which by contract sets the maximum orthodontic fee that may be charged the patient even though the plan itself pays no orthodontic benefit. This is not good for the provider. 10) Do I need to discount my case fee if the table of procedures lists $3,500 for an adult full case. My fee for Six Months Smiles fee is $4,850. YES! Your participating contract requires you to provide the orthodontic service for $3,700, even though the insurance carrier does not pay any benefit toward treatment. This is a bonus to the patient/employer and limits your fee since you are a participant. You may be able to decrease your case fee and charge a separate retention fee resulting in a higher overall fee reimbursement, if allowed. Also, a lower case fee with separate arch tooth whitening fee may result in a higher overall global fee allowed. It is Important to remember to file tooth whitening as D9972 upper arch (1/2 fee) and D9972 lower arch (1/2 fee) for best results. 11) If I offer a cash bookkeeping adjustment to my patents, what amount goes on the insurance claim form? You must enter the amount you are charging the customer. That is what they are obligated to pay. You cannot enter the discounted amount on the form, as it could be entered as fraud. 12

12) I have a patient that requires a frenectomy, graft, and transeptal fiberotomies for the orthodontic treatment plan. Do I submit that for orthodontic care or is it covered with the regular dental benefit reimbursement? Generally, if these are orthodontic related procedures required for the orthodontic case, regular dental benefits do not reimburse. They may however fall under the 50% of UCR out of the general dental benefits. If reimbursed, these procedures would generally be subject to the lifetime maximum orthodontic benefit limitation (typically $1,500). Make sure the patient is informed that the orthodontic maximum benefit limitation for these orthodontically-related procedures and the active case orthodontic treatment. If the purpose of the associated clinical procedures are for orthodontic purposes, then the insurance claim form question, Is this for orthodontic treatment? on the ADA claim form must be checked yes. Do not ever mix orthodontic and general dental procedures on the same claim form. 13) What are orthodontic records and the codes used for reimbursement? The records reimbursement is often included in the lifetime maximum (typically $1,500) orthodontic benefit, not in addition. Always file orthodontic records up front. Oral/facial images (D0350) Diagnostic casts (D0470) X-rays (either cephalometric film (D0340), full series (D0210) or panographic (D0330)) - The full series (D0210) or pan (D0330) may be reimbursed by the general dental benefits (if eligible) and is generally not submitted against the orthodontic benefits. Cephalometric film (D0340), oral images (D0350) and diagnostic casts (D0470) would always be submitted up front, With Six Months Smiles, a cephalometric film may not be required and a full series/pan may be sufficient. However, some state boards may consider a cephalometric film to be the minimum standard of care for an orthodontic case. Check with your state board. 14) Are panoramic film D0330 and/or intra-oral complete series D0210 reimbursable? These films routinely taken for dental care and generally covered under the regular dental coverage. The panoramic or complete series x-rays are generally payable at the initial comprehensive evaluation (D0150) patient visit and thereafter on an every three or five year basis, based on policy limitations. As long as they have not been taken in the previous three or five year period by a different dentist. Only a full series or pans are covered, you must do one or the other in a benefit period. When taken as a part of orthodontic records, not routine care, they may come out of the life-time orthodontic lifetime maximum and paid at 50%, it will reduce the orthodontic benefits available. Be aware of this and avoid it if possible. 15) Is the reporting of any CDT-2009/2010 code limited to the orthodontic Specialist? Any practitioner providing a dental service within the scope of his or her licensure may report any CDT-2007/2008 procedure code for reimbursement not limited to the orthodontic specialist. 16) Is orthodontic reimbursement completed differently on the standard ADA claim form? Yes. The following questions need to be answered: Is treatment for orthodontics YES, for any procedures for orthodontic coverage (orthodontic records, active treatment, retention, and any other orthodontic related procedures.) Oral Images And Models oral images, diagnostic models, and radiographs are generally not required and should only be submitted upon request. Date Appliance Placed Months Treatment Remaining 13

17) Is there a location to list Six Months Smiles on the claim form and do I need to list it on the form? NO, Orthodontic procedures are reported, not specific clinical techniques or methods to accomplish a given procedure. All ADA coding is for the purpose of reporting a procedure. The particular method, materials, and technique to accomplish a given orthodontic treatment procedure are immaterial. Only two orthodontic codes differentiate appliance types for removable appliance: Therapy code (D8210) Fixed appliance therapy code (D8220) These codes are listed under minor treatment to control harmful habits, such as thumb-sucking or tonguethrusting. Limited orthodontic treatment of the adult dentition is not different between appliance-type, methods, or materials 18) What types of financial options are recommended? Offer several alternatives to the patient and let them choose which is best for them The following financial arrangements are suggested for Six Months Smiles : Option 1 - Cash: A 7% reduction in the total fee is offered for payment up front. If the case fee is $4,850, then $4,511 goes on the insurance claim form. The actual fee paid by the patient is entered on the claim form as $4,511. Option 2 - No Interest and Accepting Insurance Assignment: Apply insurance assignment, if any; apply down payment level, as desired by the patient. The remaining balance is financed (at zero interest for the patient) up to 18 months. The dentist receives the balance financed, less an upfront discount (for example 10%-12%) paid to the third-party financing company. Option 3 - Extended Payments with Interest and Accepting Insurance Assignment: Apply insurance assignment, if any; then 0% down, with extended 24 to 48 month financing with approved credit through thirdparty financing. With the 0% down approach, the patient does pay an interest rate for the loan, depending on the amount, term, credit worthiness and particular lender used. The dentist receives the total case fee, less an upfront merchant discount (for example, 3.5%) paid by the dentist to the third-party financing company, and less the insurance assignment. Option 4 - Alternative In-Office Carry: Large down payment, and the balance (less insurance assignment, if any) over estimated treatment (6-12 months) with zero interest. The entire balance must be paid by the end of active treatment and before the passive retainers (fixed and/or removable) are delivered. Run credit check (new patients) or examine general dentistry payment history (existing patients). If a patient gets behind with payment, encourage them wear current aligners (to hold treatment) until the monthly payment is up to date (if it is permitted in your particular state). 19) If using a third party financing, like Care Credit, can a co-signer be used? In some cases, the patient may enlist a co-signer to gain loan approval. 20) Can patients finance their treatment through any other method? There are some personal options available. 1) Home equity line there are some tax advantages in borrowing against a home equity line (the interest is deductible and the interest rate is low 2) 401k retirement plan - A loan could also be made against a but the interest would be considered personal, 14

and non-deductible 3) Educational loan- If the adult patient is a college student, very low interest rate are often available and the case fee is paid up front, the size of the amount may be deductible for income taxes as a medical expense. Always have the patient check with their personal financial advisor before making any decisions. 21) Is there secondary coverage for adults? NO! Only accept primary coverage, never secondary. Secondary is totally unpredictable. Set up your financial arrangements solely based on the primary coverage. Secondary coverage, if any, goes directly to the patient. Always place your full fee, not a discounted fee, on the claim form if a participant of a PPO. INFORMATION FOR OUR INSURANCE PATIENTS If your employer has provided orthodontic coverage, we would like to assist you in maximizing your benefits. The total fee quoted to you is $4,850, inclusive of orthodontic records, retention, and tray tooth whitening. It is a flat fee for treatment in our office, and is a comprehensive service. For purposes of allocating the treatment, we might list the following insurance codes to appropriately bill the case, depending on the insurance company s policy: Category Option 1* Option 2** Oral Images (D0350) $75 $75 Diagnostic casts (D0470) 125 125 Limited case (D8040) 4,050 4,350 Retention (D8680) 300-0- Tooth whitening (D9972) upper arch 150 150 Tooth whitening (D9972) lower arch 150 150 TOTAL $4,850 $4,850 *Option 1 illustrates submitting the claim with a separately billed retention fee. **Option 2 illustrates submitting the claim with a higher case fee and no charge for retention. Note the bottom-line total fee is $4,850 for both Option 1 and 2. 15