Question

Q: How should I respond to “Do you take my Insurance?” when we are out-of-network?

A: Respond as follows – “While we do not participate as an in-network provider with your particular dental
plan, our knowledgeable business team is dedicated to assisting you in obtaining the maximum amount
of reimbursement using any out-of-network benefits you may have available. If I may, I will be happy to
reserve a time with our doctor for a comprehensive oral evaluation. At that first visit, one of our business
team members will review any treatment recommendations and dental benefits available. If out-of-network
benefits are not an option, we also have various other flexible payment options available.”

Q: We have a new associate joining our practice at the end of the month who currently works at another local office. Some of his current patients have called to request appointments for treatment he has already diagnosed. May we schedule treatment with him for these patients without performing an additional oral evaluation in our practice, since the associate has previously performed an evaluation with a diagnosis and treatment recommendations in his current practice?

A: Since the new associate is the doctor who performed the evaluation and also made a diagnosis and treatment recommendations, an additional oral evaluation fee is not necessary when he joins your practice. However, the associate should document his previous evaluation and diagnosis. The doctor should review the old file (if obtained from the former office) or the current radiographic images and other findings prior to performing treatment in the new office. Thus, the fee for a new oral evaluation for these patients could be waived.

Q: Am I required to allow service animals in the operatory during patient care?

A: Federal, state, and local laws may require a dental practice to allow animals in the office if the animal
meets the Americans with Disabilities Act’s (AwDA) definition of a service animal. Currently, only dogs are
recognized as service animals under the AwDA. Additionally, federal, state, and local laws may limit what
questions a dental team member can ask a disabled person when presenting for dental care with a service
animal. Contact your State Dental Board for guidance regarding specific state and local laws. Violations of
the AwDA may result in monetary damages and penalties.

Under the AwDA, patients and service animals must be allowed in any area of a dental office where patients are permitted, regardless of any “No Pet” policy established by the practice. Service animals are not considered pets. If a patient enters the building with an animal, a staff member may ask the patient if the animal is a service animal and what service the animal is trained to provide. The team member may not ask the patient specific details about the disability that requires the service animal, nor request any type of documentation, such as an ID card or service animal certification.

The dentist is responsible for determining if the service animal’s presence presents a risk to the health and
safety of others. This determination is based on the professional judgement of the dentist, relying on current medical knowledge or the most available evidence as the attending provider. Allergies and/or fear of animals are generally not a justifiable reason to deny access or refuse dental care to a patient with a service animal. If the dentist determines that dental care cannot be provided due to a risk to the health and safety of others, and the provider is unable to eliminate this risk by procedure modification, the disabled patient must be provided an option to receive care without the service animal in the operatory but remain on the premises.

Visit https://www.ada.gov/service_animals_2010.htm for additional information regarding service animals
in the dental office.

Q: Is the payer required to honor a request from a dentist to speak to the dental benefits consultant who reviewed the claim and made the reimbursement determination?

A: No. Most payers will honor this request, but others may have a policy against (or disallowing) this.

Q: What is a “take back code”?

A: Whenever a procedure is performed and reimbursed prior to the definitive procedure (such as pulpal
debridement D3221), the payer may reduce the benefit paid for the subsequent definitive procedure (such as root canal therapy). This usually occurs when the same billing entity (even though different providers) submits the initial and subsequent, definitive procedure.

Q: When is a pre-operative radiograph or periodontal charting and probing considered current?

A: Most payers consider radiographs and periodontal charting and probing current up to 1 year after image
capture.

Q: For orthodontic treatment, what is considered the “start date” of treatment?

A: The start date for orthodontic treatment is the date appliances are delivered (e.g., clear aligners, Herbst, etc.) or placed (e.g., brackets, etc.).

Q: As a PPO provider, may we limit or stop accepting new patients?

A: Refer to each PPO contract and Processing Policy Manual in which you participate. This is PPO contract specific. Some PPOs may require notification if the provider is no longer accepting new patients and may also require that this hold true for all new patients, not just new PPO patients.