Tuesday, November 27, 2012

ClearDent Tip of the Day #3: Composite on Molar Issue

The phrase “composite on molar” typically refers to when insurance will not pay for white filling (composite) on molar tooth.  Instead, the insurance will only pay the cost of silver filling material. Thus, even when the coverage is set to 100%, in practice, it’s actually 100% of the lower price (silver filling), and the difference will be charged to the patient.

Let’s illustrate how it can be setup in ClearDent.  Before we start, one thing to keep in mind is that ClearDent has already preset this rule for major insurance companies such as Pacific Blue Cross, but as this configuration is changeable by the user, if it somehow is not working as you expect, you can follow the example below.

Composite code (corresponding silver code)
23321 to 23325 (21241 to 21245)
23511 to 23515 (21121 to 21125)

To set it up, you need to create additional customized fee guide, and name it accordingly, such as naming it with the phrase “Composite" at the end of the fee guide name to differentiate it from standard fee guides.
  1. System > Configurations > Fee Schedule

  2. Add new fee schedule > choose current standard fee guide as base so all the codes and prices will be copied to this new fee guide

  3.  Write down prices for 21241-21245 and 21121-21125, and enter those prices into their corresponding codes in the range of 23321-23325 and 23511-23515 (as described above), save it. You can close fee guide configuration windows now.
  4. Go back to that patient's insurance policy, modify it, on the left hand side, you will see that you can choose that new guide you created as the price guide line this insurance policy follows.
  5. You are done. In the future, you can use the same fee guide for any policy that follows this same coverage rule, just repeat step 4 for those policy. (Note: You will need to re-create these new custom fee guides every year after we update your system with new fee guides, such as for 2013.)
Once setup, office will bill 23321($135), but even with 100% coverage, insurance is only responsible for $102 (price of 21241), and patient will be responsible for $33.

NEW in ClearDent Version 8.4
As you can see, the method above is simple to follow, but it does require going to a couple different windows to do the setup.  In version 8.4 and later, the process has been vastly simplified and you can enter “composite on molar” or any other types of exceptions right where you setup a patient’s new insurance.

To illustrate the flexibility, let’s look at another common insurance rule – coverage for scaling and root planing are different.

Example: Root Planing is at 80%, but Scaling is at 100%.

You can Enter 80 in SC/RP first.

Next go to exception tab and enter range of 11111-11117 (meaning from code 11111 to 11117) that is covered at 100%

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