A Treatment Plan That Starts in November Has Two Sets of Rules

The first visit draws on this year’s plan. The later visits depend on a plan nobody has confirmed yet.

A treatment plan that starts in November has two sets of rules to follow. The first visit draws on this year’s benefits. The later visits fall in January, under a plan that may be the same, may be different, or may carry a waiting period for certain services.

A single patient portion for the whole plan treats those as one number. There are at least two.

Which Date Decides the Year

Crowns and bridges raise the first question. A crown involves a preparation visit and a seat visit, sometimes weeks apart, and the plan counts one of those dates. Billing guidance from Dental Claim Support notes that the ADA has encouraged insurers to consider the prep date, and that most insurers pay on completion, which is the seat date.

When prep happens in December and the seat visit happens in January, the date the carrier uses decides which year’s maximum, deductible, and percentage apply. The answer is in the carrier’s provider manual, and it differs from one carrier to the next.

Open Enrollment Changes the Starting Point

Many employers run open enrollment in the fall, and some patients choose a different dental plan for January. A new plan can mean a different network, different percentages, and a waiting period for services such as crowns and bridges.

The patient may not mention it, and the plan on file in the chart can show last year’s carrier until someone asks.

Three Questions That Belong in the Chart

Prep date or seat date?

Some plans apply crown benefits on the seat date. The answer decides which year pays, and it should be recorded for each carrier the practice sees often.

How much is left this year?

The remaining maximum decides how much of the first visit the plan can cover. It also shows whether moving a visit across the year line changes the patient portion.

Is the plan changing in January?

Asking at the treatment planning visit puts the question before the estimate, when the patient can still check with their employer.

A patient portion stated for each visit gives those patients a number they can plan around, with one estimate for each plan year.

Who Records the Answers

A dental insurance verification virtual assistant, a pre-assessed professional working virtually inside the practice’s own systems, can record the answers to all three questions in the chart before the treatment coordinator presents the plan. Each visit gets its own date, its own remaining amount, and its own patient portion. Anything that changes the schedule goes to the treatment coordinator.

For a practice that wants to try this before November ends, the starting point is the list of patients with treatment plans that cross into January. Those are the charts that need two sets of answers.