Most dental offices use computerized practice management software that generates and prints claim forms in a standard, ADA-compliant format. If the office does not use computers or the carrier requires the use of a specific form, the administrative assistant can legibly print or type the required information on the claim form. The assistant must review the paper claims, attach any required radiographs, and add documentation where needed. Claims are batched by carrier and then mailed out.
Note: When radiographs are mailed, they must be placed in a container, such a mount or an envelope. The patient’s name, the dental office’s name and address, and the tooth number or the area of the mouth shown on the film must be clearly written on the container. Carriers are not required to return radiographs, so any sent with a claim should be duplicates, and the original should be retained in the patient’s records.
Nearly all dental offices have replaced the pegboard and appointment book with computers and sophisticated practice management software. The percentage of dental offices submitting all or part of their claims electronically continues to rise. Some carriers report that they receive more than 70% of dental claims electronically. As compared with the time and expense of preparing and mailing paper claims, electronic claims submission can be faster, less expensive, and more accurate. E-claims can be submitted through a clearinghouse or directly to the carrier through a web-based portal.
Offices that file e-claims must comply with federal laws governing electronic transactions that include personal health information (PHI). Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all healthcare providers, health plans, and healthcare clearinghouses that transmit PHI electronically must use a universal language, a standard format, and a government-assigned unique identification number. HIPAA also mandates security and privacy standards for electronic transactions, as discussed in Chapter 7.
A clearinghouse is a company that accepts the transmission of raw data, scans it for errors or missing information, and then transforms it into the appropriate data format for submission to the benefits carrier. The clearinghouse charges either a set amount per claim or a monthly fee for this service.
With the use of practice management software, the dental office administrative assistant collects the patient and treatment information that is ready to be billed to a benefits carrier and transmits it to the clearinghouse. The clearinghouse reformats the data and then transmits any claims with missing or incomplete information back to the dental office for correction. The formatted claims are sorted by benefits carrier or insurance company and mass-transmitted to the carrier for processing. The clearinghouse can also print and mail paper claim forms to the few carriers that are unable to accept electronic claims.
The dental office has to be computerized and connected to the Internet to transmit claims directly to benefits carriers. Most major carriers provide this service free of charge. To submit, the administrative assistant goes online to the carrier’s website or portal and enters claim information into an electronic claim form, which can begin processing immediately. Entering claims via the portal eliminates the sorting, scanning, and data entry that a carrier must do with paper claims, so processing time is reduced by an average of 2 to 4 days. In most cases, routine claims are adjudicated and released for payment within 24 hours of entering the carrier’s system. The dental practice’s transaction history—including payments, rejections, and predeterminations—is maintained in a highly secure system; it can be accessed or downloaded only with the use of the dentist’s unique password.
Coordination of benefits (COB) is the procedure used to determine the order of liability when a person is covered by more than one plan. Dental benefits carriers follow rules established by state law to determine which plan pays first (primary carrier) and the financial obligation of any additional carrier (e.g., secondary, tertiary). The objective is to provide the maximum allowable benefit (MAB) without exceeding the actual fee charged.
To identify the primary plan, the administrative assistant needs to know whether the patient is the subscriber or a dependent and whether there are any special COB rules for either plan. The primary carrier must meet at least one of the following criteria: