Just the Basics
Show me the money!!
There's a discount for that?
What if?
KACE Tickets
100
refers to a provider that has a contract with an insurance plan to provide services to its plan members at a pre negotiated rate. Because of this relationship, members pay a lower cost-sharing when you receive services from the provider.
What is in network
100
This is where I can find the insurance allowable amount for any location
What is the Ortho Fee Schedule Google Sheet
100
Standard discount percentage for PIF
What is 5%
100
What if an insurance discount was not applied during contract entry?
Correction will have to be made after contract has been realized, have the clinic Submit an Rev cycle Ortho KACE Ticket for additional support
100
How long do you have to let the office know you received the ticket and are working on it?
24 - 48 hours
200
This is the total amount insurance will pay towards any orthodontic treatment. Orthodontics is different because this acts as a piggy bank and does not replenish year to year. It is the total amount available for the duration of the insurance plan
What is the Orthodontic Lifetime Maximum (LTM)
200
Non-Participating Provider
Tx Fee $6,000
Ins LTM $1,000 @ 50%
Patients responsibility: ?
Insurance responsibility:?
What is patient responsibility $5000
What is insurance responsibility $1000
200
Maximum discount bundle percentage
What is 10%
200
What if a patient loses coverage during treatment, do we reapply the adjustment discount from their insurance allowable fee? (commercial carriers)
If a patient has active coverage on the date their treatment begins, their fee is reflected based on in network allowable amounts. It does not revert back if the patient loses coverage mid-treatment.
200
If you are waiting on the office to respond back to you, how long do you wait?
Initial contact, 2 more days, email again if nothing 2 more business days after that green note and close ticket.
300
Some orthodontic plans require that patient wait a certain amount of time before they are able to use their benefits.
What is a waiting period
300
Non-Participating Provider
Tx Fee $6,000
Ins LTM $3,500 @ 50%
Patients responsibility: ?
Insurance responsibility:?
What is patients responsibility $3000
What is insurance responsibility $3000
Ins will cover up to 50% of total treatment.
($6000) x (.50) = $3000
300
Mandatory discount that must be applied when applicable
What is an In Network Discount
300
What happens if a patient loses their insurance coverage prior to completion of treatment?
The patient will be responsible for the remaining insurance balance. PPO discount will not be reversed.
300
If you get a ticket for a TTC from the collections team that involves an insurance refund, when do you adjust the ledger?
Once we receive confirmation that the account has been sent to collections, we will initiate the refund. ** There will be one offs to this if the patient decides to pay to restart treatment.
400
The maximum amount that can be charged for a procedure based on the agreement between the Participating provider and insurance carrier. This does not apply to non participating dentists.
What is the allowable amount (Plan, Maximum) reimbursement rate
400
Participating Provider
Treatment fee $6000
Ins LTM $1,000 @ 50%
Insurance Allowable: $4,000
Patients responsibility: ? Insurance responsibility:?
What is patients responsibility: $3,000
What is insurance responsibility: $1,000
400
Are there Exceptions to standard Rock discounts
What is Yes!!
Marketing promotions
Provider Discretion
400
Will the insurance allowables be changing?
Yes, periodically! Please bookmark the live Ortho Fee schedule document
400
Who has the final say on if an RP has money moved to their ledger or if we are writing off as a courtesy?
What is the clinic.
500
This allows two insurance carriers to determine their fair share of the cost for covered services. (Who pays first and how much) Tx Fee $6,000
What is Coordination of Benefits
500
Participating Provider
Tx Fee $6,000
Ins LTM $3,000 @ 70%
Insurance Allowable: $3,000
What is patients responsibility: $900
What is insurance responsibility: $2,100 -Tx Fee $6,000
-PPO Discount $3,000 (Tx fee $6,000) - ($3,000 Allowable)
500
Where are discounts are applied in Greyfinch
What is under the payer section (in contracts)
500
This refers to the rules to follow if there are more than one insurance involved.
What is the COB. These can be standard or non duplicating.
500
When does our verification team submit Kace Tickets?
For Treatment in Progress requests.