The First Step of Dental Insurance Verification: The Verification of Benefits
February 15, 2024
Dental insurance verification involves a complex series of steps. Each step has its own ins and outs that if mastered (or automated) can save a dental practice a great deal of time. We gave a general overview of each step in an earlier post, but we wanted to follow up with a deep dive into each step of the process.
So here’s everything there is to know about step one: the verification of benefits.
Note: This is the first post in a series breaking down the dental insurance verification process. For a list of the steps and that general overview of the process, check out The Dental Insurance Verification Checklist.
A summary of dental insurance verification
If you read our previous post, then you already know these steps. But to recap, here’s the short version of what’s required for a complete dental insurance verification.
- Verification of Benefits: The dental office takes the patient’s information, then contacts the insurance company to verify the patient's coverage. This could be done through an online portal, a phone call, or sometimes via fax. They confirm that the policy is active and that the patient is eligible for the claimed benefits.
- Determine Coverage Details: During the verification process, the office also seeks information on the specifics of the patient's dental coverage. This might include deductibles, co-pays, coverage limits, frequency limitations (like how often a procedure can be done), waiting periods, and any exclusions or restrictions.
- Procedure Authorization: In some cases, especially for major procedures, pre-authorization from the insurance company may be necessary. The dental office submits a treatment plan to the insurer, who then reviews it and determines whether the proposed services are covered.
- Patient Communication: After obtaining all necessary information, the dental office informs the patient about their coverage and out-of-pocket costs. This helps patients make informed decisions about their dental care.
- Billing and Claims: After the dental service is provided, the office submits a claim to the insurance company, detailing the procedures done and the associated costs. The insurer processes this claim according to the patient's coverage.
This post will dive deeper into the first step, the verification of benefits.
What does the dental verification of benefits require?
Verifying dental insurance benefits is crucial before providing dental services, as it ensures that the provider has an accurate understanding of the coverage and limitations of a patient's insurance plan. This helps in minimizing billing disputes and facilitating timely reimbursements.
When performing a dental insurance verification of benefits, the following information is typically required:
1. Patient Information:
- Full name
- Date of birth
- Address and contact details
2. Insurance Details:
- Name of the insurance company
- Policy/Group number
- Member ID or subscriber number
- Relationship to the subscriber (if the patient is not the primary policyholder)
3. Dental Office Information:
- Provider's name or the name of the dental practice
- Provider's NPI (National Provider Identifier) number
- Office contact details
4. Specifics of the Desired Treatment:
- Date of the planned service
- CDT (Current Dental Terminology) codes for the procedures to be performed
- Any relevant diagnostic information or medical history that might be necessary for certain procedures
What happens after dental insurance information is collected?
Once this information is gathered, the dental office will typically contact the insurance company (either online, via phone, or through electronic methods) to obtain the following details:
- Confirmation of the patient's active coverage on the date of service
2. Coverage Details:
- Deductibles: The amount the patient must pay out-of-pocket before insurance begins to cover expenses.
- Maximums: The maximum amount the insurance will pay within a benefit period.
- Coinsurance or copayment amounts for specific procedures.
3. Limitations and Exclusions:
- Frequency limitations (e.g., how often a procedure like cleaning can be covered within a year).
- Waiting periods for certain procedures.
- Age restrictions or limitations for certain treatments.
- Exclusions of specific treatments or services from the policy coverage.
4. Previous Procedures:
- Information on recent dental procedures that might affect coverage (e.g., a patient cannot have two dental cleanings within a short interval).
5. Orthodontic Benefits (if applicable):
- Information on coverage, limitations, and any waiting periods for orthodontic treatments.
By gathering and verifying this information, dental practices can more accurately estimate the patient's out-of-pocket expenses, obtain pre-authorizations if necessary, and ensure smoother billing and reimbursement processes.
What happens if there’s a problem with the patient’s insurance verification?
If there's a problem with the insurance during the verification process or when trying to get a claim reimbursed, several steps may be taken. These problems can range from discrepancies in coverage information, denied claims, lapses in the policy, and more. Here's what typically happens next:
1. Contact the Insurance Company:
- The dental office's billing or administrative team will contact the insurance company directly to get clarification or to address the issue.
- It's important to document all communication, including dates, names of the representatives spoken to, and any action items or resolutions provided.
2. Patient Communication:
- The dental office should inform the patient about the issue as soon as it's identified. This keeps the patient in the loop and allows them to take any necessary actions, like contacting their employer (in the case of employer-sponsored insurance) or the insurance company directly.
- Patients may sometimes have additional information or resources to help resolve the issue.
3. Resubmission of Claims:
- If a claim is denied, it might be due to an error in the submission process, such as wrong codes used, missing information, or misinterpretation of the coverage. In such cases, once the issue is identified and corrected, the claim can be resubmitted.
4. Appeal Process:
- If a claim is denied and the dental office believes it should be covered based on the patient's policy, an appeal can be made. The specifics of this process will vary with each insurance company, but it often involves submitting additional documentation, narratives, or x-rays to justify the need for the procedure.
5. Alternate Payment Arrangements:
- If insurance coverage is not available or is less than expected, the dental office may discuss alternate payment arrangements with the patient. This could include payment plans, discounts, or directing the patient to third-party financing options.
6. Internal Review:
- Dental offices may conduct an internal review to see if administrative errors on their end led to the problem. This could be in the form of incorrect data entry, delays in submitting claims, or not updating patient records promptly.
7. Regular Training and Updates:
- Given that insurance policies and regulations can change, it's essential for dental office staff to undergo regular training. This ensures they are updated on the latest information, reducing potential issues with insurance verification and claims processing.
8. Patient's Role:
- In some situations, the patient might need to be proactive. They could have to contact their insurance provider, provide additional documentation, or even switch policies if the current one doesn't meet their needs.
Resolving insurance issues requires open communication between the dental office, the insurance company, and the patient. The goal is to ensure that the patient receives the necessary dental care while minimizing out-of-pocket expenses and ensuring the dental provider is adequately compensated.
Or, you can automate dental insurance verification to save time and free up staff.
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