Dental Sleep Medicine Insider March 2016 | Page 24

LESIA CRAWFORD PRE-AUTH, PRE-D, WHAT’S IT ALL MEAN? I n last month’s issue, I provided quite a few key glossary definitions for your Dental Sleep Medicine Billing Dictionary. Well, by popular demand, here are a few more. Whether you manage your own billing or use GoGo, it’s important that you are familiar with some key terms. Remember that we’re not in dentistry anymore, Toto. IN NET BEN’s “In Network Benefits” Describes the benefits levels for coverage and the deducible amount for services rendered by an in network provider. If you know you’re out of network, why do you want to know about these benefits? Silly question! Is a GAP available on the plan? OUT OF NET BEN’s “Out of Network Benefits” Describes the benefit levels for coverage and deductibles for services rendered by an out of network provider. This usually means not much of a benefit at all. High deductibles and lower coverage. UGH! NO OON BEN “No Out of Network Benefits” This is most likely an HMOtype plan where the patient has insurance coverage but only when provided by an in network doctor or facility. In my case, with my new market place HMO medical plan, there is a bus stop with a guy and a hammer and if I get on the wait list for my appointment I am covered… after I meet my $6,500.00 deducible that is. CEO of GoGo Billing GoGo Billing offers help with Tricare registration for no charge and Medicare credentialing services for DME, Part B and Ordering and Referring. Enter code DS3100 for $100.00 off DME and Part B credentialing. Contact me at [email protected] or call [phone] ext. 1. PRE-AUTH “Pre-Authorization” This means the plan requires you prove that the services are medically necessary and back it up with proof. The insurance plan will review the request for the services and decide it they are a covered benefit or not. If a plan requires a Pre-auth, and it is not obtained prior to services being rendered you have turned your insurance payment into a denial of payment. Not good. PRE-D “Pre-Determination” “Pre-Certification” “Pre-Authorization” Essentially they are all the same thing. Send in a request for the services you want to provide and give them all the clinical information to determine that your services are in fact necessary and needed. Some plans will not require Pre-auth but suggest a Pre-determination. This means they can decide to review the clinical information after the claim is submitted and then deny it. Rule of thumb; just get it if its required or available. Failure to do your due diligence prior to a procedure will often result in non-payment. Doing all of the above and benefit verification will frequently allow for better reimbursement of the procedure. Providers as well as patients need to be aware of their contractual agreements with the insurance carrier for the best opportunity for reimbursement. Stay tuned for the April issue of the Insider when I’ll give you the final installment of your DSM Billing Dictionary….. 24