PIEDMONT ACCESS TO HEALTH SERVICES, INC.
Policy Number:
SUBJECT:
02-11-007
Patients Applying for Sliding Fee Status (DENTAL)
EFFECTIVE DATE:
REVIEWED/REVISED:
04/01/2004
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% selfpay 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.
02-11-007 Patients Applying for Sliding Fee Status (Dental)
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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.
02-11-007 Patients Applying for Sliding Fee Status (Dental)
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SIGNATURES:
_______________________________________________
Chief Executive Officer
___ / ___ /______
Date
_______________________________________________
Chief Operating Officer
___ / ___ /______
Date
_______________________________________________
Dental Director
___ / ___ /______
Date
_______________________________________________
Board Chair
___ / ___ /______
Date
02-11-007 Patients Applying for Sliding Fee Status (Dental)
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APPENDIX A
Procedures Covered by PATHS Community Dental Center’s Sliding Scale Program
Code
Procedure Description
D0120
D0140
D0145
D0150
D0170
D0180
D0210
D0220
D0230
D0240
D0270
D0272
D0273
D0274
D0277
D0330
D0350
D0425
D0460
D0470
D1110
D1120
D1203
D1204
D1208
D1320
D1330
D1351
D1352
D1510
D1515
D1520
D1525
D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
Periodic Oral Evaluation
Limited Oral Evaluation
Oral Eval Under 3 Years
Comp Oral Eval-New/Estab Pat
Limited Re-evaluation Estab Pat
Comp Periodontal Eval
Intraoral-Complete Series (bw)
Intraoral-Periapical-additional
Intraoral-Periapical-additional
Intraoral Occusal Film
Bitewing-single film
Bitewing-two films
Bitewing-three films
Bitewings-four films
Vertical Bitewings (7 – 8 films)
Panoramic film
Oral Photos
Caries Susc. Tests
Pulp Vitality Test
Diagnostic Cast
Prophylaxis-adult
Prophylaxis-child
Fluoride w/o prophylaxis-child
Fluoride w/o prophylaxis-adult
Fluoride
Tobacco Counseling
Oral Hygiene Instruction
Sealant-per Tooth
Preventative Resin Restoration
Space Maint Fixed Unilateral
Space Maint Fixed Bilateral
Space Maint Removable Unilateral
Space Maint Removable Bilateral
Re-cemetation of space maintainer
Removal of fixed spacer maintainer
Amalgam-1 surf prim/per
Amalgam-2 surf prim/per
Amalgam-3 surf prim/per
Amalgam-4+ surf prim/per
Resin-one surface, anterior
Resin-two surface, anterior
Resin-three surfaces, anterior
Resin-4+ w/incis angle-anterior
Resin composite-1s, posterior
Resin composite-2s, posterior
02-11-007 Patients Applying for Sliding Fee Status (Dental)
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D2393
D2394
D2910
D2915
D2920
D2930
D2931
D2940
D2950
D2951
D2954
D3110
D3120
D3220
D4320
D4321
D4341
D2342
D4355
D4910
D6930
D7710
D7111
D7140
D7210
D9110
D9120
D9211
D9212
D9310
D9430
D9440
D9910
D9920
D9930
Resin composite-3s, posterior
Resin composite-4+s, posterior
Recemt inlay, onlay, or partial coverage restoration
Recemt cast or prefabricated post and core
Recement crown
Stain Steel Crown Prim
Prefabricated Steel Crown
Temporary Filling
Crown buildup, including any pins
Pin retention-/tooth, (+ rest)
Prefab post & core in add to cm
Pulp Cap Direct
Pulp Cap Indirect
Therapeutic pulpotomy (exc rest)
Splint (Intracononal)
Splint (Extracononal)
Perio scale & root plan-4+ per quad
Perio scale&root pln – 1 – 3th quad
Full mouth debridemnt, eval/diag
Periodontal maintenance
Re-cement Bridge
Single Tooth
Coronal Remnants
Extract Erupted Tooth or Root
Surgical Extraction
Palliative Emergency Treatment
Sect Fixed Bridge
Regional Block
Trigeminal Nerve Block
Consultation
OV Observation
After Hours Office Visit
Apply Desensitizing Medication
Behavior Management
Post-op Complication
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