Treatment and cost plan
A treatment plan ( HKP ) for dental - prosthetic services was in Germany a planned dental-care and the estimated cost of a detailed account of He fulfills two functions, one he is writing dental performance of a treatment plan is and also an estimate.. It is used to make costs transparent for the payer and to clarify the extent to which costs are to be borne by the patient, by health insurance companies , by private health insurers , by the allowance or by the social welfare office . Treatment and cost plans must be drawn up for statutory and privately insured patients according to different provisions.
Treatment and cost plan for those with statutory health insurance
form
Pursuant to Section 87 (1a) SGB V, the contract dentist must prepare a free treatment and cost plan prior to the start of treatment, which includes the findings, standard care and the care actually planned (also in the cases of Section 55 (4) and (5) SGB V) in terms of type, scope and costs. Information about the place of manufacture of the dental prosthesis must be given in the treatment and cost plan. The treatment and cost plan must be checked as a whole by the respective health insurance company before treatment begins.
Finding and planning
The starting point is the diagnosis of the entire set of teeth from which the treatment plan results. This field shows the dental scheme of the permanent dentition. With the introduction of the fixed subsidy system on January 1, 2005, subsidies for a health insurance company are based on the findings and no longer on the treatment carried out. The advantage for the patient is that regardless of the type of care chosen, he or she retains his right to the diagnosis-based fixed allowance. Therefore, the diagnostic scheme has been expanded by two lines each for the upper and lower jaw: the "R" line for "standard care", which is the basis for reimbursement, and the "TP" line for "therapy planning", if one of the Therapy deviating from standard care should be carried out if the patient does not opt for standard care. The findings and planned services are entered in these lines with abbreviations, the meanings of which are printed on the form.
After the dental prosthesis consultation and the patient's consent to the form of care, the dentist enters the current findings in this scheme (line "B"). The eligible standard pension is entered in the "R" line. This standard care is stipulated by Section 56 of Book V of the Social Code (SGB V) and the associated denture guidelines and is based on the condition and number of existing teeth as well as their distribution, i.e. the size of existing gaps. If the patient wishes to have a denture that goes beyond the standard supply ( similar or different type of supply ), the dentures actually planned are also entered in the "TP" line. In addition, the dentist enters the estimated costs for the dental services and the material costs . In the case of extensive dentures, a cost estimate is requested from the dental laboratory .
| top right | top left | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TP (therapy planning) | KM | BM | KM | |||||||||||||
| R (standard supply) | KV | B. | K | |||||||||||||
| B (finding) | f | k | ww | x | kw | f | ||||||||||
| 18th | 17th | 16 | 15th | 14th | 13 | 12 | 11 | 21st | 22nd | 23 | 24 | 25th | 26th | 27 | 28 | |
| 48 | 47 | 46 | 45 | 44 | 43 | 42 | 41 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | |
| B (finding) | f | ) ( | f | |||||||||||||
| R (standard supply) | ||||||||||||||||
| TP (therapy planning) | ||||||||||||||||
| bottom right | bottom left | |||||||||||||||
For the meaning of the abbreviations, see the following tables. Findings abbreviations are entered in lower case letters, planning abbreviations in capital letters.
| Abbreviation | meaning |
|---|---|
| a | Adhesive bridge (anchor, span) |
| b | existing pontic |
| e | already replaced tooth |
| ew | replaced tooth in need of renewal |
| f | missing tooth |
| i | existing implant with intact superstructure |
| ix | implant to be removed |
| k | existing clinically intact crown |
| kw | Crown in need of renewal |
| pw | tooth worthy of preservation with partial substance defects |
| r | existing post cap |
| rw | Root post cap in need of renewal |
| sw | Superstructure in need of renovation |
| t | existing telescope |
| partly | telescope in need of renovation |
| ur | insufficient retention |
| ww | tooth worthy of preservation with extensive destruction |
| x | tooth not worth preserving |
| ) ( | Gap closure |
| Abbreviation | meaning |
|---|---|
| A. | Adhesive bridge (anchor, span) |
| B. | Pontic |
| E. | tooth to be replaced |
| H | complete cast holding and supporting device |
| K | Crown |
| M. | Fully ceramic or fully veneered restoration |
| L. | Fired ceramic shoulder |
| O | Attachments, bars etc. |
| PK | Partial crown |
| R. | Post cap |
| S. | Implant-supported superstructure |
| T | Telescopic crown |
| V | Vestibular veneer |
Fixed grant
Based on the documented findings, the respective health insurance company determines the findings-based fixed allowance . The fixed allowance is 50% of the costs of standard care. It is calculated from the fee items for the necessary dental prosthesis services plus the associated dental technology costs for a basic dental prosthesis. The amount of the amounts due for the standard care from January 1, 2007 is determined in accordance with Section 56 (4) SGB V. For your own efforts to keep your teeth healthy, the fixed allowances increase by 10 percentage points to 60 percent. The increase does not apply if the insured person's dentition does not reveal regular dental care and the insured person did not take advantage of the dental examinations every six months of the calendar year during the five years prior to the start of treatment and not at least once every six months after reaching the age of 18 Calendar year has had a dental check-up. The fixed allowance increases by a further 5 percentage points to 65 percent if the insured person has regularly cared for his teeth and has made use of the dental examinations without interruption every year for the ten calendar years before the start of treatment.
Children and adolescents from the age of 12 must be able to present at least one entry in the bonus booklet for individual prophylaxis per calendar half year .
The fixed allowance of 50 percent doubles for patients who have been classified as hardship (because of proven low income) in accordance with Section 55 of the Social Code Book V.
The respective health insurance company has the right to have the findings and the treatment planning checked by a dental expert .
If it turns out during the treatment that the treatment and cost plan needs to be changed, this must be submitted to the health insurance company again for approval.
The treatment and cost plan is subject to approval . If dental prosthesis treatment is started before the health insurance company has approved the treatment and cost plan, the insured person loses his right to a fixed allowance. This also applies to treatments in other EU countries. Treatments and repairs to existing dentures that cannot be postponed are excluded.
Approval deadlines
According to Section 13 (3a) SGB V, a health insurance company has to decide on a treatment and cost plan within three weeks. In the event that a health insurance company commissions a planning report from the medical service of the health insurance company , the approval period is extended to five weeks. If a dental expert procedure provided for in the federal contract for dentists (BMV-Z) is carried out, the health insurance company has to make a decision within six weeks of receipt of the application. If the health insurance company does not meet the deadlines and does not give the patient important reasons for this before the deadline expires, the patient can procure the service himself and claim the costs from the health insurance company by way of reimbursement. However, if the health insurance company has given the patient important reasons before the deadline expires, no grace period is provided within which it has to make a decision on costs.
Corona pandemic
Treatment and cost plans that were approved by the health insurances in the period from September 30, 2019 to March 31, 2020, remain valid up to and including September 30, 2020. For care that is not carried out by September 30, 2020 a new treatment and cost plan must be drawn up.
Types of supply
A distinction is made between standard supply , similar supply and different supply .
Standard supply
Standard care is a sufficient, practical and economical solution. This is not necessarily the best possible and most comfortable dental prosthesis. The diagnosis-related fixed subsidy from the health insurances is based on the fixed treatment costs for standard care. Findings-related means that the subsidy is not based on the selected form of care, but on the underlying dental findings.
Similar care
The same type of supply is a standard dental prosthesis measure with additional services. This can include veneering of the dental prosthesis (tooth-colored ceramic or plastic coating), the additional costs of which are to be borne by the insured person. The health insurance companies also pay the subsidy for standard care for this, but not for the additional services, neither the fee nor the material and laboratory costs.
Different care
This type of supply always exists when it comes to measures that deviate completely from the standard supply. If the standard care to replace missing teeth is a partial denture, but a dental prosthesis using implants is planned, then the health insurance company will in turn reimburse the costs for the standard care, i.e. the partial denture here. The insured person has to bear the additional costs for the implant treatment.
Additional cost calculation
If the patient chooses a supply that goes beyond the standard dental care to which he is entitled as a health insurance patient, which is entered in the therapy planning line , he must bear the resulting additional costs himself. The dental fee for standard care is calculated according to the nationwide evaluation standard (BEMA), while the dentist calculates the fee for services exceeding this care according to the fee schedule for dentists (GOZ) and deducts the fixed allowance ( § 56 SGB V)
This must be documented on page 2 of the treatment and cost plan, on which the costs are compared and the estimated total costs are determined.
Dental insurance
Numerous supplementary dental insurances that are offered on the German market reimburse additional costs in different amounts, depending on the tariff concluded.
Declaration by the insured
With his signature on the treatment and cost plan, the insured person must confirm that he has been informed about the type, scope and costs of the planned standard care, the “similar” or “different” dental prosthesis and that he wishes to be treated in accordance with this treatment and cost plan.
price comparison
The patient is free to seek advice from several dentists about the expected costs. As far as standard care is concerned and the dental prosthesis planning is the same, there will be no difference in costs, because the fee for this is set nationwide. In the case of additional services, so-called non-contractual services or similar or different types of dental prosthesis, as well as dental technology costs, different calculations may occur. The above-mentioned fee schedule for dentists (GOZ) and the so-called increase factors for the dental fee form the framework.
Patient information
On a patient website, the National Association of Statutory Health Insurance Dentists (KZBV) offers patient information on types of dentures and the associated costs - including an overview of advice services offered by the dental self-administration.
Billing
After the dental prosthesis has been incorporated, the treatment and cost plan also serves to settle the services via the Association of Statutory Health Insurance Dentists (KZV) with the respective health insurance company. The dentist sends the patient a separate invoice for the private portion, deducting the fixed allowance (health insurance portion). The place of manufacture or the country of manufacture of the dental technology is noted by the dentist on the treatment and cost plan. At the same time, the dentist confirms that the dentures were made and incorporated in accordance with this treatment and cost plan.
Treatment and cost plan for privately insured persons
For a privately insured person , a treatment and cost plan is drawn up in accordance with the provisions of the Dental Fee Schedule (GOZ). The dentist has no contractual relationship with the patient's payor, be it a private health insurance or an aid agency . The contracting partner of the dentist is the patient, who must try to get a reimbursement promise himself. If desired by the patient, a separate HKP can be created for all other planned services, for example for tooth-conserving or implantology services. Special forms are not provided for this, but numerous formal requirements must be observed. In addition to each individual planned service, the expected material and laboratory costs must be specified. Since the GOZ amendment came into force on January 1, 2012, additional regulations for dental technology costs apply:
(2) Before the treatment, the dentist must offer the payer a cost estimate from the commercial or the practice's own laboratory for the likely costs for dental services and, upon request, submit it in text form, provided that the total costs are likely to exceed an amount of 1,000 euros. For treatments that are planned on the basis of a treatment and cost plan for a treatment period of more than twelve months, sentence 1 only applies if costs of more than 1,000 euros are expected to arise within a period of six months. The cost estimate must indicate the expected total costs for dental services and the materials used. The type, scope and execution of the individual services, the basis for calculation and the place of manufacture of the dental technology services are to be explained in more detail to the debtor upon request. If the costs stated in the cost estimate are expected to be exceeded by more than 15 percent, the dentist must inform the payer immediately in writing.
Private treatment and cost plan for those with statutory health insurance
If the insured person wishes dental prosthesis services or additional services that go beyond the standard care or the catalog of services of a health insurance company, they will receive a private healing and cost plan for these services in addition to their medical and cost plan for health insurance treatment in accordance with the GOZ regulations (see above) .
costs
A private treatment and cost plan is according to the GOZ nos. 0030 or 0040 chargeable. According to the state aid guidelines, aid agencies usually do not reimburse the costs for a private treatment and cost plan.
See also
Web links
Individual evidence
- ↑ Treatment and cost plan: Explanation of the abbreviations used , National Association of Statutory Health Insurance Dentists
- ^ Federal Social Court, judgment of 30 June 2009, B 1 KR 19/08 R
- ↑ Validity of treatment and cost plans for dentures , KZV B.-W., May 13, 2020. Accessed on May 13, 2020.
- ↑ Information on dentures , National Association of Statutory Health Insurance Dentists. Retrieved November 26, 2015.
- ↑ § 9 GOZ 2012 (PDF; 298 kB)
