Eligibility/Benefits
If a member calls in, how many pieces of information is needed to complete verification?
Answer: 3
Full Name, DOB or Full Address, Member ID or SSN
True or False?
Timely Filing Limit for claims is 365 days.
Answer: False
Correct Answer: 365 days from Date of Service
What kind of ortho code is D8999?
Answer:
A non-payable Continuation of Care code
What report in Skygen informs you of any payment made to ADV from a group?
Answer:
Cash Receipts Report
What is the fax number to send ACH forms?
Answer:
18004904526
How many different (general) types of Tier One plans are available?
Answer: 6
Basic, Core, Elite, Standard, Advantage, Premier
What documentation is required for SRP, Perio Maintenance, Full Mouth Debridement?
Answer:
Pre-op x-rays, Periodontal charting, Narrative
True or False?
Box 42 of the ADA claim form should include the remaining months of ortho treatment?
Answer: TRUE
True or False?
Mailing adress for group payments is
PO BOX 745777
Atlanta, GA 30374
Answer: False
Correct Address:
PO BOX 746777
Atlanta, GA 30374
True or False:
Novanet (Connection Dental) take precedence over Dentemax?
Answer:
False. Sequential Order of Network Precedence:
Proprietary (Aflac)
Dentemax
Novanet
OON (Out of Network)
Which Tier One plan(s) have a 6 month waiting period?
Bonus Points (10 points): For each plan, clarify what services have a 6 month waiting period?
Answer: Basic, Core, Elite, Advantage, Premier
Bonus Answer:
Basic, Core, Elite- Basic Services
Advantage, Premier-Major Services
Which version of the ADA claim form has a specifc box where the last date of SRP goes and what is the box #?
Bonus (5 points): Where should the last date of SRP be listed on any other version of the acceptable ADA claim form?
Answer: 2024 ADA claim form/Box 39A
Bonus Answer: Box 35: Remarks Section
Which ADV plan(s) has a 12 month orthodontic waiting period?
Answer:
Non-Takeover Everwell Plans w/ Ortho coverage
What numbers listed below are used when calculating Weekly, Biweekly, & Semi Monthly deductions?
A. 23,24,53,12
B.13,52,26,27
C.24,12,26,54
D.52,26,12,24
Bonus (10 points): Explain the 3 ways to calculate deductions?
Answer:
D. 52,26,12,24
Bonus Answer:
Weekly- Take the amount shown in Everwell, Multiply by 52, Divide by 12 to get the monthly rate
Biweekly-Take the amount shown in Everwell, Multiply by 52, Divide by 12 to get the monthly rate
Semi Monthly-Take the amount shown in Everwell, Multiply by 52, Divide by 12 to get the monthly rate
What 2 change in residence events qualify as a life changing event?
Answer:
1. Moving to a new state
2. Moving to a different ZIP code or county
List all four rules for COB (Coordination of Benefits) in chronological order.
Bonus (5 points): How can the 3rd rule be overridden?
Answer:
-If the member is active on two policies, the plan in which the member is the subscriber is primary.
-If the member is the subscriber on multiple policies, the plan that became effective first is primary.
-For dependents, there is the "birthday rule": the policy under the parent whose birth month comes first is primary.
-Medicaid and Tri-Care is ALWAYS the last insurance billed.
Bonus Answer: A Court Order or Custody Agreement
What are the two options a member or provider has to submit a second level appeal?
What to do if the provider or member requests a second-level appeal:
1. Verbal request through the G&A form if supporting documentation can be attached
2. Mail the request to the Tampa office along with the appeal statement and any supporting documentation.
True or False?
For new (non-COC) ortho claims, the dollar amount should be the monthly cost of treatment.
Answer:
False. The dollar amount should be the total cost of treatment.
Who sends out the invitations to agents and coordinators for the producer portal and how long are the invitations good for before they expire?
Answer:
Market Director
Invitations expire after 7 days
Who can perform balance billing, INN or OON providers? Why?
Answer: OON providers
** Balance billing occurs when providers bill a patient for the difference between the amount they charge and the amount that the patient's insurance approves.
Providers that are in-network have agreed to accept the insurance payment as payment in full (less any applicable copays, deductible, or coinsurance, which are billed to the patient), and are not allowed to balance bill the patient.
Math Word Problem:
A claim for a year 1 tier one (Core) member with an efffective date of 04/15/2026 was processed and paid out to an INN provider. The codes processed on the claim were 0120,1110,0210, & 2740. With the details given below, please answer the following questions:
Details: The bill amounts for each code were as follows:0120-$57.00,1110-$73.00,0210-$120.00,2740-$350.00.The allowed amounts for each code were as follows: 0120-$57.00, 1110-$65.00, 0210-$108.00, 2740-$0.00.
1.) What is the Net Paid Amount for the claim?
2.) What is the provider write off amount?
3.) Was a deductible applied to any code? If so what was the deductible amount that applied and to which code? Was there a remaining deductible and if so, what was it?
4.) Which code would have been denied and why?
Answer:
1.) Net Paid Amount: $122.00
2.)$8.00
3.)Yes! Code:0210, $54.00 was applied. Yes! Remaining ded:$21.00
4.) 2740- 12 month waiting period not met