It was their mistake ... wasn’t it?

May 1, 2006
Let’s discuss money. I’m talking about cash, green coupons, dead presidents, and our longtime friend and confidant, E Pluribus Unum.

Let’s discuss money. I’m talking about cash, green coupons, dead presidents, and our longtime friend and confidant, E Pluribus Unum. For the time being, we will forget about checks and credit cards. Let’s just talk cash. Don’t you love it when patients pay in cash?

Do you want lots of cash in exchange for very little investment? Then confirm your patient’s eligibility for dental benefits to get paid for the fine dental work you do. If you do not confirm a patient’s eligibility for insurance, neither you nor the patient should anticipate reimbursement from the benefit plan. It’s that simple!

On that same note, if you did get paid and did not confirm eligibility, you might very well be asked to return the money. Rule 5 is where most of our reimbursement challenges will either begin or end. For your review, Rule 5 is “Confirm eligibility with each series of visits.”

The challenge begins

The reimbursement process begins with gathering some very basic data that will eventually lead to a confirmation or declination of eligibility. The bank deposit is close behind. The importance of acquiring and verifying accurate patient information is often overlooked by staff members responsible for billing due to time problems or a lack of perceived value.

Data-gathering is simplified with a comprehensive patient information form. Not only is an appropriate form valuable for gathering important insurance-processing information, but it also is a way of tracking and finding patients who may later become delinquent in their payments. Additional information (such as secondary dental insurance or medical coverage) and special payment circumstances (such as those dictated by divorce decree) also can be noted.

This documentation should not include any confidential information related to the patient’s medical conditions - it is only for payment-related insurance information and/or general marketing data. As an added safety measure, secure a photocopy of both the front and back of the patient’s benefit card, as well as that person’s driver’s license and/or state-issued identification card.

How to confirm eligibility

Be advised ... possession of a benefit card does not guarantee eligibility under the terms of the plan. With most benefit plans, the back of the patient’s card will have a local or toll-free phone number to call to confirm eligibility. This phone number may be linked to a third-party automated processing center or it may go directly to the employer. At this point, your office is only interested in eligibility, not benefit plan specifics. Many eligibility processing centers do not have benefit data because that information is maintained by either the plan administrator or the employer.

Many of the nation’s top benefit administrators and service corporations have automated systems in place to assist plan providers in instantly securing confirmed patient eligibility and benefit specifics. United Concordia has a Web-based system known as XpressClaim ( Providers can confirm, in writing, patient benefits, enrollment, and claim status. The Group Health Incorporated (GHI) automated system is known as myGHI ( This system enables callers to verify eligibility, access basic benefit information, check on the status of claims, and access GHI’s provider directory which contains an up-to-date list of 44,000 providers. Both of these systems are available 24 hours a day, seven days a week. Those of us who provide dental services to the Medicaid population already know the importance of confirming eligibility prior to treatment. To date, some 18 states already provide this information electronically.

You want to know if the patient is actually covered under the terms of the benefit plan. If so, how is the patient identified? Is your patient the insured member, beneficiary, dependent, etc.? This often overlooked piece of information is critical when determining the primary, secondary, and tertiary order of benefit determination. For additional information on coordination of benefits, please refer to Chapter XI of our text titled, “Fee-For-Service Dentistry With a Managed-Care Component.”


Secure some form of reference data or number regarding the actual day, date, and time of the eligibility confirmation to avoid potential and costly overpayments. Filing a claim follows the same rules as paying a bill or making a purchase with a check. The account needs to be active and there needs to be money in the bank.

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of Dental Insurance Today, a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of Dental Insurance and Reimbursement Coding and Claim Submission. He can be contacted by phone at (404) 252-7808. Visit his Web site at

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