Insurance Department New PA Training
· Using the G:Drive to find Insurance Department Documents
This section covers how to use the G:Drive to look up fee schedules , limitations and exclusions, and other helpful info for administering all types of plans. The focus is on how to navigate to the G:Drive itself and then how to access the DMO Administration Guides which outline the various guidelines set forth by our DHMO payers.
o How to open the Insurance Department folder on the G:Drive
o General format of G:Drive folders within the Insurance Department Folder
§ Admin – Fee Schedules – Active – Archive – Etc
o DMO Administration Guides
· Crown Enhancements
This section covers the available enhancements available for the two major insurance types: DMO and PPO. It should be noted that even though all enhancements types are available for DMO plans each DMO’s limitations and exclusions are different and many enhancements may not be allowed on any given plan. (This circles back to looking up the DMO Administration Guides on the G:Drive). Also note that no enhancements are allowed on PPOs except the Specialty Crown and Porcelain Margin.
o DMOs
§ Porcelain Crown/Bridge – 10100
§ Metal Crown/Bridge – 10101
§ Complex Rehab Crown/Bridge – 10102
§ Specialty Crown/Bridge – 10103
§ Lab Fee – 10166
§ Porcelain Margin Crown/Bridge – 10168
o PPOs
§ Specialty Crown/Bridge – 10103
§ Porcelain Margin Crown/Bridge – 10168
· Insurance Verification for non IVT offices.
This section highlights three very important pieces of information that need to be collected during insurance verification outside of the normal verification info
o Always ask what PPO fee schedule the plan follows even if it seems obvious.
§ Many companies are partnering for administration these days. So it may not be as obvious as it seems
o Always ask if there is an office visit copay for DHMO patients
§ This can be as high as $40 or as low as $5 either way it is important to find out so you are not leaving that money on the table.
o Always check the comments in the green comment box.
§ These are typically left by the IV team in GA for offices on the IVT model. Always double check that they match the info you received from the insurance company. If anything is different note it in the white “Patient Comment” box
· Codes that charge out UCR
This section contains a brief overview of what to do in a situation where a patient account is charging out at full UCR
o There are only a handful of scenarios where it is ok for a procedure to charge out full UCR
§ Patient has no insurance
§ Patient has an indemnity plan
§ Treatment is not a covered benefit under the insurance plan the patient has
o If an account is charging out at UCR and does not fit into one of the scenarios described above report it to the Insurance Department as soon as possible for investigation.
· Submitting Plan Request and System Corrections
This section briefly defines plan requests and system corrections and outlines important details that need to be addressed when submitting one or the other.
o Plan Request
§ Please allow for 48 hours to complete. Most will be completed well before that, but some may require additional info gather or data entry.
§ Please search by carrier, employer, and group number before requesting a new plan. This will help make sure we are not creating duplicate plans.
o System Corrections
§ System corrections are corrections to patients accounts that need to be made within current the current month
· Ex: Duplicate charge outs, incorrect billed amounts, certain transfers between patient and insurance.
§ Typically completed with in a few hours
§ Payment deletions of $50 or more require a doctor’s signature to be faxed to the insurance department.
· Discount Plans
o Every discount plan that we participate with has been loaded in DV so that the first word of the employer for every plan is “Discount”. Every discount plan can be pulled up by search the insurance profiles by employer for the word “Discount”