Q: If you do not accept assignment of reimbursement but file insurance claims for patients, do you still have to notify the insurance company that a courtesy was given to the patient?
A: Yes, anytime a discount/courtesy is given to the patient, notification was being given to the carrier to show that the actual fee charged was not the actual fee collected.
Q: If you are contracted with an insurance company and a patient has met their annual maximum, a claim has been filed, are you still required to do the write-off?
A: Yes, your contract will have a clause in it that even after the patient has reached its annual maximum, the difference between the allowed amount and the actual fee charged must be written off. In other words, you are to accept only the allowed amount from the patient, not the UCR fee.
Q: If an office is contracted with insurance companies, is it best to only submit their allowed amount or should our regular UCR fees be submitted on claims?
A: It is best to always submit your regular UCR fees when filing claims for several reasons: The first is because it shows the insurance company what your actual UCR fees are and they may increase your allowed amount because of the UCR fee. The second reason is that you will have a better idea annually as to how much the practice is writing off per insurance company and how much percentage is being lost annually because of being a PPO provider.
Q: Can the code D0170 be used at the same visit of an existing patient, seen within the last 12 months comes in with a broken tooth that will have a crown or a filling done the same day?
A: Yes because the patient was informed during that time the tooth was "sick" needed treatment, patient did not schedule and has returned with a problem now and is getting "definitive" treatment completed.
Q: What code should be used for a difficult prophy?
A: At this time, there is not a specific code to use so it is recommended to use D1110 if patient has no signs of Perio disease, bone loss, mobility and recession. The fee is usually higher and it is important to put a narrative as to why this fee was charged. The narrative might be that the Patient has not been to the dentist for the past year, is a smoker and suffers with heavy stain, plaque buildup and was not a routine prophy.
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