How do I check a patient’s cap balance?
A patient’s benefit cap balance can be checked through Health Professional Online Services at http://www.humanservices.gov.au/health-professionals/services/hpos/or by phoning the Department of Human Services on 132 150. It is recommended that you check the cap balance at each visit.
What dental services are covered by the Child Dental Benefits Schedule?
The Child Dental Benefits Schedule provides benefits for a range of basic dental services.
Each service that can receive a benefit has its own item number. These items and associated descriptors, restrictions and benefits are set out in the Dental Benefits Schedule at the back of this guide.
The Dental Benefits Schedule is based on the Australian Dental Association (ADA) Australian Schedule of Dental Services and Glossary, 10th Edition. The Child Dental Benefits Schedule dental items use an additional two digit prefix of 88. For example, the Child Dental Benefits Schedule item 88011 corresponds to ADA item 011.
However, there are some differences between the Dental Benefits Schedule and the ADA Schedule. You need to read the Dental Benefits Schedule carefully to ensure you use the correct Schedule number; that this number coincides with the service you have provided and that you have understood any restrictions or limitations that apply to providing that service.
Clinically relevant services
The Dental Benefits Act 2008 requires that for a dental benefit to be payable a service must be ‘clinically relevant’. A ‘clinically relevant’ service means a service that is generally accepted in the dental profession as being necessary for the appropriate care or treatment of the patient to whom it is rendered.
Benefits can only be claimed for dental services provided in out-of-hospital facilities. Dental benefits are not payable where the person requires dental services in a hospital.
Many of the dental items have specific limitations or rules unique to the Child Dental Benefits Schedule (e.g. frequency of the service, linkages between items, or other conditions on claiming). These limits and rules are set out in the individual item descriptors in the Schedule.
Dentists should familiarise themselves with Schedule requirements before providing services.
Restorative services / fillings
Under the Child Dental Benefits Schedule, only one metallic or adhesive restoration (88511-88535) can be claimed per tooth per day. Restorations can only be claimed using the relevant item that represents the number of restored surfaces that were placed on that day – this includes if separate restorations are placed on different surfaces of the tooth on that day.
If multiple restorations are placed on the same surface on the same day, that surface can only be counted once.
For example, if two separate two-surface fillings are placed on the same day, but one of the surfaces is common between them, only a three-surface filling can be claimed as three surfaces in total have been restored.
When two materials are used in the same restoration, the predominant material type should be used for claiming the restoration. For example, if:
one adhesive one-surface filling is done on a separate, third surface of the same tooth on the same day; then
only a three-surface metallic filling can be claimed.
This is because three surfaces in total have been restored and the predominant material used is metallic.
The Child Dental Benefits Schedule provides benefits for IV sedation (88942) and inhalation sedation (88943) but these items are used differently compared to the ADA Schedule.
Under the Child Dental Benefits Schedule, IV sedation can be claimed only once in a twelve month period.
For inhalation sedation, the sedative gas to be used is specified as nitrous oxide mixed with oxygen. A benefit is not payable for the use of other sedative gases.
Do I have to quote for services?
Since many Child Dental Benefits Schedule patients are from financially disadvantaged families, it is important that they are informed of the likely costs so they can plan for any outofpocket costs.
If you wish to participate in the Child Dental Benefits Schedule it is a requirement of the program that you inform the patient or the patient’s parent/guardian of the proposed costs of treatment as well as the dental practice’s proposed billing arrangements.
Prior to performing any services, you must have a discussion with the patient or the patient’s parent/guardian about:
the proposed treatment;
the likely treatment costs, including out-of-pocket costs; and
the billing arrangements of the practice (i.e. bulk billed).
After you have informed the patient or the patient’s parent/guardian of the likely treatment and costs, you must obtain consent from the patient or patient’s parent/guardian to both the treatment and costs before commencing any treatment.
Consent from the patient or the patient’s parent/guardian needs to be recorded in writing before the end of the appointment, either through a Bulk Billing Patient Consent Form or a Non-Bulk Billing Patient Consent Form (see ‘When and what Patient Consent Form needs to be used?’ section on page 13).
If you fail to obtain and document consent for services, these services will not comply with the legal requirements of the program.
When should I inform the patient?
It is the responsibility of the billing/claiming dentist that the patient or the patient’s parent/guardian is informed of the likely costs before commencing any Child Dental Benefits Schedule service including examinations, diagnostic services and emergency treatment. This includes services rendered by a dental hygienist, oral health therapist, dental prosthetist or dental therapist on behalf of a dentist. If the dentist has another eligible dental practitioner perform the service the dentist must ensure compliance by that other practitioner.
For example, in the case of an initial examination, the patient or the patient’s parent/guardian needs to be informed that an examination will be performed and the likely cost of the examination and consent is obtained for the dentist to proceed. If, subsequent to that examination, further services are required, the patient or the patient’s parent/guardian needs to be informed of what services are required and the likely cost, and further consent must be given prior to the provision of those subsequent services.
All instances of patient consent must be documented. Instances of consent can be documented together on a single consent form on the day of treatment (see ‘When and what Patient Consent Form needs to be used?’ section on page 13).