Manual Money Management For Canadians All-in-One Desk Reference For Dummies

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A contractual relationship does not change a dentist's full fee. It is always appropriate to report the full fee for each service reported to a third party payer. This may vary widely by geographic region or by benefit plans within a region. It is always appropriate to modify this fee based on the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances.

Usual, Customary and Reasonable Fees —These are three separate terms that are often incorrectly used interchangeably, synonymously or as a single term abbreviated as "UCR" when describing dental benefit plans. See cafeteria plans ; flexible spending account. In return for a financial investment or other consideration, participating dentists may also receive the benefits of media advertising, a national referral system, and financial and management consultation. The cement can be used to restore teeth, fill pits and fissures, lute and line cavities.

It is also known as glass polyalkenoate cement, ionic polymer cement, polyelectrolyte cement. One of the oldest restorative techniques, it is compacted or condensed into a retentive cavity form. Donors may be cadavers, living related or living unrelated individuals.

Also called allogenic graft or homograft. Health Insurance Portability and Accountability Act HIPAA of : A federal law that includes Administrative Simplification Provisions that require all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. Procedures and Nomenclature code set. Paper transactions are not subject to this requirement. Health Maintenance Organization HMO : A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price.

An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time. Healthcare Provider Taxonomy : The code that identifies the type of health care provider involved in furnishing services to beneficiaries. Hold harmless clauses frequently appear in the following contexts:.


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This may include a promise to pay the dental benefit organization's attorney fees and related costs; and. If the dentist takes action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs. It may be intraoral or extraoral.

Some examples of inappropriate fee discounting practices include: issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full; using claim forms which, upon signing, require the dentist to accept the terms of the plan's contract; issuing insurance cards which state that the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract; and sending communications to patients of nonparticipating dentists which state that he or she is not responsible for any amount above usual, customary and reasonable fees as established by the plan.

Most frequently, there is a corresponding percentage reduction in the programs copayment level if the covered individual fails to visit the dentist in a given year but never below the initial copayment level. Indemnity plans typically place no restrictions on which dentist a member may visit. Indemnity plans are also referred to as fee-for-service plans. Individual Practice Association IPA : A legal entity organized and governed by individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations.

It is retained by luting cement. Usually an insurance company. International Classification of Diseases ICD : Diagnostic codes designed for the classification of morbidity and mortality information for statistical purposes; for the indexing of hospital records by disease and operations; and for data storage and retrieval. See Specification No. In gingival health, the coronal portion of the sulcular epithelium may also be keratinized.


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  • See facial. Under a LEAT clause, when there are multiple treatment options for a specific condition, the plan will only pay for the least expensive treatment.

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    The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. See exclusions. The term "managed care" refers to a cost containment system that directs the utilization of health benefits by: a. Maryland bridge : Fixed partial denture featuring conservative retainers which are resin bonded to abutments. Medicaid : A federal assistance program established as Title XIX under the Social Security Act of which provides payment for medical care for certain low income individuals and families.


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    The program is funded jointly by the state and federal governments and administered by states. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing. Medicare : A federal insurance program enacted in as Title XVIII of the Social Security Act that provides certain inpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals. The noble metal classification system has been adopted as a more precise method of reporting various alloys used in dentistry.

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    The alloys are defined on the basis of the percentage of metal content and listed in order of biocompatibility. Sometimes called a mouth protector. An NPI is unique to an individual dentist or dental entity, and has no intrinsic meaning. There are two types of NPI available to dentists and dental practices:. Type 1 Individual Provider —A health care practitioner who is a single human being.

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    Type 2 Organization Provider —A health care provider that is an organization, such as a group practice or corporation. Individual dentists who are incorporated may enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All incorporated dental practices and group practices are eligible for enumeration as Type 2 providers. On paper, there is no way to distinguish a Type 1 from a Type 2 in the absence of any associated data; they are identical in format. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community.

    The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent. Any dentist may accept or refuse to treat patients enrolled in the plan.

    Open panel plans often are described as freedom of choice plans. It is a science that investigates the causes, processes, and effects of these diseases.

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    The practice of oral pathology includes research and diagnosis of diseases using clinical, radiographic, microscopic, biochemical, or other examinations. Federal agency in the US responsible for making and enforcing employee safety regulations. See fixed partial denture or removable partial denture. For matters relating to communication of information and consent this term includes the patient's parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.

    Peer review, when applied to dentistry, is a process, consistently structured and implemented by organized dentistry, in which a dentist's professional equals peers resolve questions or disputes regarding the quality or appropriateness of care provided by the dentist or the fairness of the fee the dentist charged in an individual case by retrospectively evaluating the quality or appropriateness of care in relation to professional norms or criteria or evaluating the fee charged in relation to the dentist's fee for the given complexity and level of care provided. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards.

    Money Management For Canadians All-in-One Desk Reference for Dummies

    This device can either be in the form of an alloy, carbon fiber or fiberglass, and posts are usually secured with appropriate luting agents. See also precertification , predetermination. See preauthorization , predetermination. The payer reviews the treatment plan and notifies the dentist and patient of one or more of the following: patient's eligibility, covered services, amounts payable, co-payment and deductibles and plan maximums. Preferred Provider Organization PPO : A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings.

    Enacted state by state, prompt payment laws set standards for the prompt, fair and equitable settlements of insurance claims by requiring that a set amount of interest be paid on "clean claims" that are paid beyond the established timeframe. These laws need to be analyzed on a case by case basis to determine whether a lawsuit has to be filed by the state department of insurance. Documentary evidence required by a payer to prove a valid claim exists.

    It usually consists of a claim form completed by the patient's treating dentist. It is intended to control local irritational factors. See preauthorization, precertification, predetermination, second-opinion program. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis. See apexification. Relative Value System : Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs.

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