Subject: Patients Applying for Sliding Fee Status (dental)



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PIEDMONT ACCESS TO HEALTH SERVICES, INC.

Policy Number: 02-11-007

SUBJECT: Patients Applying for Sliding Fee Status (DENTAL)
EFFECTIVE DATE: 04/01/2004

REVIEWED/REVISED: 06/21/2006, 03/03/2009, 03/30/2010, 02/07/2011, 01/05/2012, 01/22/2013,



11/01/2013

___________________________________________________________________________________


POLICY: All patients seen by any PATHS’ health care delivery site are advised of their right to apply for sliding fee status based on net household income and family size. Patients are registered at 100% self-pay status until they apply for sliding fee status. All pay statuses will be reviewed and updated annually, or as needed. PATHS reserves the right to initiate a random pay status review when there is reason to suspect that the income and/or family size provided by the patient is inaccurate, incomplete, or in any way untrue. After a thorough investigation, lead by the Chief Operating Officer (or designee), the pay status of a family, whose responsible party has given false information, will be raised to 100% self pay. The pay status of any family who refuses to cooperate with a review, whether annual or otherwise, will be raised to 100% self pay.
PROCEDURE:
1. Signage will be clearly posted in the dental waiting room announcing the availability of special payment options for those who qualify, and all front desk staff members will be trained to explain that all patients are assigned to 100% self pay status unless the patient applies for sliding scale.
2. It will be explained to the patients who wish to apply for sliding fee status that they must furnish the number of individuals in the family, and the whole family’s gross annual income from all sources, i.e., rent on property owned, interest from savings, investments, etc.
3. All sliding scale applicants must provide proof of income in order to receive sliding scale benefits, such as:

a. W-2 forms from the previous year’s tax return;


b. Copies of recent pay checks/stubs;
c. Copy of welfare checks; and/or
d. Copy of previous year’s tax return.
4. All information will be scanned into the patient’s medical record, and entered into PATHS’ Dental EHR system, which will automatically determine and assign the appropriate sliding fee status.
5. Determining Eligibility: Eligibility will be determined based on the patient’s household income. The definition of household will follow the standard set by legal responsibility. For example, a married couple with three minor-aged children will be considered a household of 5. An unmarried adult (over the age of 18) that lives with someone else (friends or family) with no children/dependants, will be considered a household of 1. Income will be determined based on the total net income of each member of the household, and will be compared to the most recent federal poverty limits. Patients up to 100% of the federal poverty limit will be considered eligible for benefits under PATHS’ Dental Center’s Slide A program. Patients between 101% and 200% of the federal poverty limit will be considered eligible for PATHS’ Dental Center’s Slide B program.

6. Slide A: Patients found to be eligible for “Slide A” will receive a 100% discount for all basic, general dentistry services (listed in Appendix A). These patients will be charged a nominal fee of $50 per visit, regardless of the combination of procedures that will be provided. Each visit will be scheduled to consume no more than one (1) hour.

7. Slide B: Patients found to be eligible for “Slide B” will receive a 100% discount for all basic, general dentistry services (listed in Appendix A). These patients will be charged a nominal fee of $75 per visit, regardless of the combination of procedures that will be provided. Each visit will be scheduled to consume no more than one (1) hour.

8. Patients with insurance are eligible to apply for sliding scale benefits. Any portion remaining as the patient’s responsibility, after determining what their insurance will pay, will be adjusted such that the maximum amount of the patient’s responsibility will be that of the fee scale for which they qualify based on their household income.


9. Any patient seeking services from PATHS Dental Center other than those listed in Appendix A will be offered a discount as follows: Slide A will receive a 50% discount, and Slide B will receive a 25% discount.
10. Any patient found to be ineligible for Slide A or Slide B will be required to pay 100% of any cost per procedure according to the Dental Center’s fee schedule.

SIGNATURES:
_______________________________________________ ___ / ___ /______

Chief Executive Officer Date


_______________________________________________ ___ / ___ /______

Chief Operating Officer Date

_______________________________________________ ___ / ___ /______

Dental Director Date


_______________________________________________ ___ / ___ /______

Board Chair Date


APPENDIX A
Procedures Covered by PATHS Community Dental Center’s Sliding Scale Program


Code

Procedure Description

D0120

Periodic Oral Evaluation

D0140

Limited Oral Evaluation

D0145

Oral Eval Under 3 Years

D0150

Comp Oral Eval-New/Estab Pat

D0170

Limited Re-evaluation Estab Pat

D0180

Comp Periodontal Eval

D0210

Intraoral-Complete Series (bw)

D0220

Intraoral-Periapical-additional

D0230

Intraoral-Periapical-additional

D0240

Intraoral Occusal Film

D0270

Bitewing-single film

D0272

Bitewing-two films

D0273

Bitewing-three films

D0274

Bitewings-four films

D0277

Vertical Bitewings (7 – 8 films)

D0330

Panoramic film

D0350

Oral Photos

D0425

Caries Susc. Tests

D0460

Pulp Vitality Test

D0470

Diagnostic Cast

D1110

Prophylaxis-adult

D1120

Prophylaxis-child

D1203

Fluoride w/o prophylaxis-child

D1204

Fluoride w/o prophylaxis-adult

D1208

Fluoride

D1320

Tobacco Counseling

D1330

Oral Hygiene Instruction

D1351

Sealant-per Tooth

D1352

Preventative Resin Restoration

D1510

Space Maint Fixed Unilateral

D1515

Space Maint Fixed Bilateral

D1520

Space Maint Removable Unilateral

D1525

Space Maint Removable Bilateral

D1550

Re-cemetation of space maintainer

D1555

Removal of fixed spacer maintainer

D2140

Amalgam-1 surf prim/per

D2150

Amalgam-2 surf prim/per

D2160

Amalgam-3 surf prim/per

D2161

Amalgam-4+ surf prim/per

D2330

Resin-one surface, anterior

D2331

Resin-two surface, anterior

D2332

Resin-three surfaces, anterior

D2335

Resin-4+ w/incis angle-anterior

D2391

Resin composite-1s, posterior

D2392

Resin composite-2s, posterior

D2393

Resin composite-3s, posterior

D2394

Resin composite-4+s, posterior

D2910

Recemt inlay, onlay, or partial coverage restoration

D2915

Recemt cast or prefabricated post and core

D2920

Recement crown

D2930

Stain Steel Crown Prim

D2931

Prefabricated Steel Crown

D2940

Temporary Filling

D2950

Crown buildup, including any pins

D2951

Pin retention-/tooth, (+ rest)

D2954

Prefab post & core in add to cm

D3110

Pulp Cap Direct

D3120

Pulp Cap Indirect

D3220

Therapeutic pulpotomy (exc rest)

D4320

Splint (Intracononal)

D4321

Splint (Extracononal)

D4341

Perio scale & root plan-4+ per quad

D2342

Perio scale&root pln – 1 – 3th quad

D4355

Full mouth debridemnt, eval/diag

D4910

Periodontal maintenance

D6930

Re-cement Bridge

D7710

Single Tooth

D7111

Coronal Remnants

D7140

Extract Erupted Tooth or Root

D7210

Surgical Extraction

D9110

Palliative Emergency Treatment

D9120

Sect Fixed Bridge

D9211

Regional Block

D9212

Trigeminal Nerve Block

D9310

Consultation

D9430

OV Observation

D9440

After Hours Office Visit

D9910

Apply Desensitizing Medication

D9920

Behavior Management

D9930

Post-op Complication




02-11-007 Patients Applying for Sliding Fee Status (Dental)

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