dental insurance chapter 14. 2 dental insurance learning outcomes 14-1locate and describe the parts...
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DENTAL INSURANCE
Chapter 14
Chapter 14 2
DENTAL INSURANCE Learning Outcomes14-1 Locate and describe the parts of the mouth and
the teeth.
14-2 Recognize key words, conditions, and treatments related to dentistry.
14-3 Describe six types of benefits offered by dental insurance plans.
14-4 Discuss the claim form and coding methods commonly used to submit dental insurance claims.
Chapter 14 3
Key Terms ADA Dental Claim
Form Canines Current Dental
Terminology (CDT) Dentin Dentist’s Pretreatment
Estimate Dentist’s Statement of
Actual Services
Enamel Gingivae (sing.,
gingiva) Incisors Mandible Maxilla Maxillofacial surgery Molars Occlusion
Chapter 14 4
Key Terms Oral cavity Oral surgery Palate Premolars Prophylaxes (sing.,
prophylaxis) Prostheses (sing.,
prosthesis) Pulp Uvula
Chapter 14 5
Dental Terms Mouth
Oral cavity consisting of: Gingivae Teeth Tongue Tonsils
Bone structure: Mandible or lower jaw Maxilla or upper jaw
Palate
Chapter 14 6
Dental Terms (cont’d)
Teeth Crown, neck, and root
Enamel Dentin Pulp
32 permanent teeth 4 incisors 2 canines 4 premolars 6 molars
Equal number in mandible and maxilla for a total of 32
Chapter 14 7
Dental Insurance Purchased by individual Provided by employer
Most policies reimburse policyholders for dental expenses
Dental managed care plans available Dentists may be participating (PAR) or non-
participating (nonPAR) Coverage varies by procedure and carrier
Chapter 14 8
Dental Benefits Preventive Benefits
Prophylaxes, or cleanings, at regular intervals Diagnostic Benefits
Diagnostic procedures such as x-rays Basic Benefits
Restorative work Endodontics Periodontics
Chapter 14 9
Dental Benefits (cont’d)
Prosthodontic Benefits Bridges and dentures (prostheses)
Orthodontic Benefits Braces and straightening
Oral and Maxillofacial Surgery Benefits Surgery and anesthesia
Chapter 14 10
Medical Insuranceand Dental Benefits Medicare does not cover dental care
Medically necessary oral surgery is covered Medicaid covers some dental
procedures Fees set by individual states
Blue Cross and Blue Shield policies Most policies include dental coverage
Chapter 14 11
Similar to Workers’ Compensation First Report of Injury
File within 5 days of visit Describes
Condition of patient’s teeth/gums prior to injury Nature and extent of injury Repair/replacement of teeth required and cost
Contains Employer and supervisor’s name and address Date and time of accident Patient's description of injury
Dental Injury Claims
Chapter 14 12
Dental Coding
Maintained by American Dental Association (ADA) Current Dental Terminology, 4th edition
(CDT) Only procedure codes are used; no dx codes Surgical procedures submitted on a medical
claim form
CROWNS––SINGLE RESTORATION ONLY
D2710Crown – resin (laboratory)D2720Crown – resin with high noble metalD2721Crown – resin with predominantly base metalD2722Crown – resin with noble metalD2740Crown – porcelain/ceramic substrate D2750Crown – porcelain fused to high noble meta
Chapter 14 13
D9236
D4670
Dental Coding (cont’d)
5 digits beginning with D 12 categories
Diagnostic Preventive Restorative Endodontics Periodontics Prosthodontics,
Removable
Maxillofacial prosthetics
Implant services Prosthodontics, Fixed Oral surgery Orthodontics Adjunctive services
Chapter 14 14
Dental Claim Forms Dentist’s Pretreatment Estimate
Determine coverage and amount of reimbursement
Submitted prior to treatment Dentist’s Statement of Actual Services
Submitted after treatment
Chapter 14 15
Dental Claim Forms (cont’d)
ADA Dental Claim Form Patient coverage information Details about the examination and treatment
plan Information on billing and billing dentist
Chapter 14 16
Critical Thinking What services may be covered by a
dental insurance policy?
Depending on the individual policy, coverage may include preventive; diagnostic; basic; prosthodontics; orthodontics; and oral and maxillofacial surgery.