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2
Oct
2019

All About Claims Forms

Filling out a dental claim form can be a bit of a challenge. In most cases, help is available from your human resources department or the customer service contact at your benefit plan provider. However, what you may not be aware of is that there are laws governing how a claim form may be used by an employer or plan provider.

In this section we’ll highlight some important things you should know, which will help you protect your privacy and security and that of any family members who are covered under your benefits.

Assignment of Benefits

The “assignment of benefits” is when a dental patient instructs an insurance carrier to make a payment of allowable benefits directly to the dentist. This has obvious appeal to a dental patient because the patient often does not have to pay the dentist up front, and then go through the process of filing a claim with their insurance carrier and wait to get reimbursed.

Why the ODA Opposes Assignment

The ODA is opposed to assignment of benefits and actively encourages dental plan sponsors to make their dental plans “non-assignment” plans. Many people wonder why the ODA would oppose a process that many find convenient.

The answer lies in the fact that “non-assignment” dental plans can be less expensive than those that allow assignment, simply because the act of a patient paying for their dental care makes them financially involved in their oral health care. This provides very a good incentive for the patient to use their dental plan wisely.

Dental claim reimbursement is much faster than it was years ago, and patients are finding that when they pay the dentist directly their reimbursement cheque is received quickly; greatly minimizing the time they are out of pocket. It is not unusual to see the dentist on Monday and have the reimbursement cheque before the end of the week, thanks to electronic claims submission.

Also, many dentists accept credit cards, which typically have a monthly billing cycle. If complex treatment is necessary, dentists can arrange a payment schedule that allows a patient to budget for expenses and get reimbursement that is more conveniently timed.

Active decision-making about oral health care by patients and meaningful involvement in the financial matters of dental care, including the dental plan, is an important part of achieving excellent oral health care.

Co-Pay

 

Many dental plans have co-payments, or in other words, a percentage of the claim amount that is not covered by the dental plan. These co-payments are usually 20 to 50 percent — or more — of the claim amount.

Many dental patients believe that the dentist can waive these amounts so the patient doesn’t have to pay the money. This is not the case and the consequences to dentists for not making a reasonable attempt to collect the co-payment are very serious.

Patient Fact Sheet: “Waiving the Dental Plan Co-Payment

Under the Dentistry Act, 1991 (Regulated Health Professions Act) dentists are required to make a reasonable attempt to collect the co-payment portion of dental fees for which the patient has payment responsibility.

The profession’s regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO) is responsible for ensuring dentists adhere to this requirement.

When collection of co payment is not possible

In short, the dentist has a professional obligation to collect the co-payment. On some occasions, the dentist may run into difficulties doing so. On these occasions, the term “reasonable” should be noted, by taking into account the circumstances of the situation. This includes occasions when it is clear to the dentist that the patient cannot afford to pay the co-payment.

The dentist may then decide to cease pursuing the collection. The following options are open to make sure that the dental plan administrator is not misled:

1. Citing the reasons why this decision has been made, the dentist can advise the dental plan administrator of the situation and obtain his or her consent in writing to cease attempting to collect the co-payment and;

2. Also stating the reasons why, the dentist could advise the dental plan administrator that he or she does not intend to collect the co-payment, and that he or she will accept as full payment, the amount the plan administrator will pay under the plan.

In either of these scenarios, no attempts to mislead the dental plan administrator have been made. Intentional misrepresentation by the dentist can result in discipline by the RCDSO, loss or suspension of dental registration and criminal proceedings for insurance fraud.

Insurance companies also reserve the right to request that the patient provide proof that the co-payment has been paid. If the patient is unable to provide that proof, the insurance company may demand the patient make financial restitution to the insurance company or it may apply the overpayment to future claims.

Clearly, waiving the co-payment and misleading the plan administrator jeopardizes everyone involved — the dentist, the plan administrator and the plan sponsor.

“Please Pay Subscriber”

Printed in capital letters at the top right hand corner on the ODA Standard Dental Claim Form is a box stamped, “Please Pay Subscriber.”

Although it may appear to be just a stamp on a form intended to conform to the rigor of a well-thought out administrative process, its history and meaning go far deeper. It is there to encourage the patient to be an active participant in his or her dental care, in a system where a plan sponsor and an insurance carrier is involved.

By not signing this box, the patient pays the dentist for the care received and then submits the completed claim form to the insurance carrier for reimbursement for the eligible benefit amount. The carrier then pays that amount directly to you, the plan member or subscriber.

Although the stamp has lost its place with the advent of electronic transmissions, the philosophy behind it remains. If the claim is electronically transmitted by the dental office to the carrier, then — unless otherwise agreed — the patient pays the dentist and the carrier will send the reimbursement to the plan member.

This process is called non-assignment. In other words, the subscriber did not assign his or her insurance benefits to the dentist, nor did the dentist accept assignment. This simple process has far-reaching benefits. The patient is aware of the cost of the dental service and will be more likely to:

  • comply with treatment regimens;
  • acquire knowledge about the nature and extent of dental benefits;
  • become a better consumer of dental care and wise user of dental benefits;
  • develop an important comfort level for discussing fees with the dentist;
  • identify areas in the design of a dental plan that could be improved and apprise dental plan sponsors in response.

The ODA has a long-standing philosophy encouraging non-assignment dental plans for the simple reason that when patients have a meaningful financial involvement in their dental care, better decisions are made.

Information About Using Claim Forms

Using Your Social Insurance Number as Identification

In the early ’90s, Bill C-18 amended a 1988 Income Tax ruling that specified that it is an offence for a person or employer to use an employee’s Social Insurance Numbers (SIN) for any purpose other than income tax reasons, unless authorized by the individual.

The modified provisions contained in C-18 extended liability to include consulting firms and insurance companies that use SIN numbers for group benefit administration. This meant that employers obtain either written permission to use SINs from each employee, including retirees, or they must devise a different numbering scheme.

The patient must provide his or her certification, SIN or identification number in Part 2 of the ODA Standard Dental Claim Form. Patients who are unsure of their identification number should refer to their employee benefits card or consult the Benefits Department at their place of employment.

Privacy Concerns

The standard dental claim form conforms with the Personal Information Protection and electronic Documents Act (PIPEDA), a federal privacy law. The release on the claim form reads as follows:

I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to my dentist for the entire treatment. I acknowledge that the total fee of $ is accurate and has been charged to me for services rendered.

I authorize the release of information contained in this claim to my ensuring company/plan administrator. I also authorize the communication of information related to the coverage of services described in this form of the named dentist.

The Canadian Dental Association (CDA) is in the process of notifying dentists, dental plan administrators, printers and software vendors of this change. By January 1, 2007 dentists should be using the revised form.

The Canadian Dental Association is also amending the standard dental pre-treatment form to reflect the same wording change.

Dentists using CDAnet, will also be required to update each patient (parent/guardian) signature on file. For each patient participating in CDAnet the following wording must accompany the signature:

I authorize release, to my dental benefit plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

The signature on file must be updated every three years.

The signature serves two purposes: it authorizes the dentist to submit the claim/estimate electronically and it authorizes the plan administrator to send the electronic explanation of benefits (EOB) or pre-determination of benefits (POB) or claim acknowledgement back to the dental office. Dentists are obligated to give the EOB, POB or claim acknowledgment to the patient prior to leaving the office.

If you have any questions about the claim form, the pre-treatment form or the signature on file, please contact the ODA’s Advisory Services Department at advisoryservices@oda.ca.

Co-Payments

Many dental plans have co-payments, or in other words, a percentage of the claim amount that is not covered by the dental plan. These co-payments are usually 20 to 50 percent — or more — of the claim amount.

Many dental patients believe that the dentist can waive these amounts so the patient doesn’t have to pay the money. This is not the case and the consequences to dentists for not making a reasonable attempt to collect the co-payment are very serious.

Patient Fact Sheet: “Waiving the Dental Plan Co-Payment

Under the Dentistry Act, 1991 (Regulated Health Professions Act) dentists are required to make a reasonable attempt to collect the co-payment portion of dental fees for which the patient has payment responsibility.

The profession’s regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO) is responsible for ensuring dentists adhere to this requirement.

When collection of co payment is not possible

In short, the dentist has a professional obligation to collect the co-payment. On some occasions, the dentist may run into difficulties doing so. On these occasions, the term “reasonable” should be noted, by taking into account the circumstances of the situation. This includes occasions when it is clear to the dentist that the patient cannot afford to pay the co-payment.

The dentist may then decide to cease pursuing the collection. The following options are open to make sure that the dental plan administrator is not misled:

1. Citing the reasons why this decision has been made, the dentist can advise the dental plan administrator of the situation and obtain his or her consent in writing to cease attempting to collect the co-payment and;

2. Also stating the reasons why, the dentist could advise the dental plan administrator that he or she does not intend to collect the co-payment, and that he or she will accept as full payment, the amount the plan administrator will pay under the plan.

In either of these scenarios, no attempts to mislead the dental plan administrator have been made. Intentional misrepresentation by the dentist can result in discipline by the RCDSO, loss or suspension of dental registration and criminal proceedings for insurance fraud.

Insurance companies also reserve the right to request that the patient provide proof that the co-payment has been paid. If the patient is unable to provide that proof, the insurance company may demand the patient make financial restitution to the insurance company or it may apply the overpayment to future claims.

Clearly, waiving the co-payment and misleading the plan administrator jeopardizes everyone involved — the dentist, the plan administrator and the plan sponsor.

“Please Pay Subscriber”

Printed in capital letters at the top right hand corner on the ODA Standard Dental Claim Form is a box stamped, “Please Pay Subscriber.”

Although it may appear to be just a stamp on a form intended to conform to the rigor of a well-thought out administrative process, its history and meaning go far deeper. It is there to encourage the patient to be an active participant in his or her dental care, in a system where a plan sponsor and an insurance carrier is involved.

By not signing this box, the patient pays the dentist for the care received and then submits the completed claim form to the insurance carrier for reimbursement for the eligible benefit amount. The carrier then pays that amount directly to you, the plan member or subscriber.

Although the stamp has lost its place with the advent of electronic transmissions, the philosophy behind it remains. If the claim is electronically transmitted by the dental office to the carrier, then — unless otherwise agreed — the patient pays the dentist and the carrier will send the reimbursement to the plan member.

This process is called non-assignment. In other words, the subscriber did not assign his or her insurance benefits to the dentist, nor did the dentist accept assignment. This simple process has far-reaching benefits. The patient is aware of the cost of the dental service and will be more likely to:

  • comply with treatment regimens;
  • acquire knowledge about the nature and extent of dental benefits;
  • become a better consumer of dental care and wise user of dental benefits;
  • develop an important comfort level for discussing fees with the dentist;
  • identify areas in the design of a dental plan that could be improved and apprise dental plan sponsors in response.

The ODA has a long-standing philosophy encouraging non-assignment dental plans for the simple reason that when patients have a meaningful financial involvement in their dental care, better decisions are made.

Information About Using Claim Forms

Using Your Social Insurance Number as Identification

In the early ’90s, Bill C-18 amended a 1988 Income Tax ruling that specified that it is an offence for a person or employer to use an employee’s Social Insurance Numbers (SIN) for any purpose other than income tax reasons, unless authorized by the individual.

The modified provisions contained in C-18 extended liability to include consulting firms and insurance companies that use SIN numbers for group benefit administration. This meant that employers obtain either written permission to use SINs from each employee, including retirees, or they must devise a different numbering scheme.

The patient must provide his or her certification, SIN or identification number in Part 2 of the ODA Standard Dental Claim Form. Patients who are unsure of their identification number should refer to their employee benefits card or consult the Benefits Department at their place of employment.

Privacy Concerns

The standard dental claim form conforms with the Personal Information Protection and electronic Documents Act (PIPEDA), a federal privacy law. The release on the claim form reads as follows:

I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to my dentist for the entire treatment. I acknowledge that the total fee of $ is accurate and has been charged to me for services rendered.

I authorize the release of information contained in this claim to my ensuring company/plan administrator. I also authorize the communication of information related to the coverage of services described in this form of the named dentist.

The Canadian Dental Association (CDA) is in the process of notifying dentists, dental plan administrators, printers and software vendors of this change. By January 1, 2007 dentists should be using the revised form.

The Canadian Dental Association is also amending the standard dental pre-treatment form to reflect the same wording change.

Dentists using CDAnet, will also be required to update each patient (parent/guardian) signature on file. For each patient participating in CDAnet the following wording must accompany the signature:

I authorize release, to my dental benefit plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

The signature on file must be updated every three years.

The signature serves two purposes: it authorizes the dentist to submit the claim/estimate electronically and it authorizes the plan administrator to send the electronic explanation of benefits (EOB) or pre-determination of benefits (POB) or claim acknowledgement back to the dental office. Dentists are obligated to give the EOB, POB or claim acknowledgment to the patient prior to leaving the office.

If you have any questions about the claim form, the pre-treatment form or the signature on file, please contact the ODA’s Advisory Services Department at advisoryservices@oda.ca.

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