HIPAA-Potamus!
We are the two non-negotiables!
What are name and dob?
This program is one in which providers contract with a dental benefit company to provide specified dental services covered by the plan to subscribers in return for payment on a monthly, per‐capita basis. Payments are usually Prepaid, before services are rendered.
What is capitation?
Tammy is calling from Dr. Brinkerhoff's office, stating they keep receiving incorrect fees for services rendered. This route would be best to address the root of the problem.
What is a fee schedule discrepancy?
Unless an adult dependent or a spouse has verbal authorization to make a PCD assignment/change, this is the ONLY person, who can make that change on the account.
What is the policyholder/subscriber?
Susie is calling from the Foster Care Agency and she must provide you with this, before disclosing any information.
What is the maximus pin?
A provision in a dental plan contract that allows the payer to determine the benefit based on another procedure that is generally less expensive than the one provided or proposed.
What is an alternative benefit?
A member is calling about their appointment being canceled 8 times with current provider. They are frustrated, but only want this documented, and do not wish to make a formal complaint at this time.
What is a same day grievance (informal complaint)?
This group allows each dependent to be assigned to separate PCD's and each request must be routed.
What is UFT (United Federation of Teachers)?
I am the only other caller for Foster Care accounts that is not required to provide a maximus pin, on a member call.
What is Department of Social Services (DSS)?
The percentage or portion of a covered dental expense that a beneficiary must pay after the benefits plan has paid its portion of the treatment cost and deductibles have been satisfied. This usually applies to Fee‐for‐Service plans based on Scheduled or UCR Fees.
What is coinsurance?
A provider is calling regarding a claim processing error. The claim processed for an extraction of tooth number 8, but should have processed for tooth 18. When you check the ADA claim form, tooth number 18 is listed. This route type is warranted in this situation.
What is a claim adjustment?
After asking the member “Have you or your dependents been seen by the current primary care dentist this month?” and there answer is Yes, this would be the effective date for the change.
What is the 1st of the following month?
We are alternate pieces of information that can be used to authenticate a call.
What are address, phone number & member ID?
The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. This may be an annual or one‐time charge, and may vary in amount from program to program.
What is a deductible?
Heather is calling because her crown was denied for medical necessity, citing the tooth has extensive decay. Heather does not feel the denial is appropriate, because her provider advised her this was necessary to restore her dental health. Heather wants a higher level review of her denial. You can take this route and let them know this process can take up to 30 days.
What is a standard appeal?
If a PCD change is being requested on the 1st-15th of month, this would be the effective date of the assignment.
What is the 1st of the current month?
My name coined the acronym for this act created in 1996.
What is the Health Insurance Portability & Accountability Act -HIPAA!
Court orders from the groups, unions or the members indicating that the policyholder is ordered to provide health and Dental coverage for their dependents
What is QMCSO or Qualified Medical Child Support Order?
Jacqueline called in to say that her PCD was causing severe pain while rendering treatment. When Jacqueline started crying from the pain, she states her provider told her to "stop being such a baby and tough it out". Jacqueline wants this situation looked into immediately. You can take this route and advise Jacqueline to follow up with her written statement to ga@healthplex.com.
What is a formal complaint?
Daily Double***
Suffolk County Municipal Employees member Mary, wants her daughter to be assigned to Pedodontist Dr. Luden for the 1st of next month. Mary has a PPO and this is what you advise.
What is PPO plan does not require assignment?
Also acceptable. Assignments are not made for specialist.