Dental denials and rejections may not be an easy task to handle; it’s indeed frustrating to many dental practitioners as well as healthcare revenue cycle management companies to avoid rejections and denials. Often dental claims are rejected and denied for various reasons by insurance companies. But there are ways to get your revenue payments on time without any obstacles.
In case of any dental denials or rejections, dental professionals must ensure to check and evaluate the claim with corrections and if no errors found, they must get ready for an appeal. Healthcare revenue cycle management companies usually has a team to follow the above process and start appealing the denied claims if there are no errors.
How to appeal a Dental Claim?
- An accurate and proper appeal starts by sending insurance companies a request in written format to reconsider the claim.
- Dental practitioner or healthcare revenue cycle management companies should provide the required additional documentation that convinces the insurance payer and brings a clear idea on necessity for the treatment.
- Provide the insurance companies as much as information required as they will check the entire claim for errors and misinformation.
- Each insurance company will have certain rules and regulations to follow. Identify the insurance companies’ specific instructions that include appeal submission process in written format within the time allocated.
- Prepare to send the appeal letter to the specified department of the insurance companies within format the payer requires.
- Don’t forget to include the word ‘appeal’ in the title as well as the text of the document or in any cover that involves an appeal document.
4 Major Dental Denials and ways to respond:
- Patient not eligible for procedure
- Periodontal scaling and root planing coverage
- Limited benefits for periodontal maintenance
- Core build up procedure
1.Patient not eligible for procedure:
- Eligibility verification behaves as a key factor in preventing denial and rejections of a claim.
- It’s well known that policies and plans of insurance companies often change and doesn’t remain constant for long time. It’s the duty of dental provider and healthcare revenue cycle management companies to verify patient eligibility each and every time the services are rendered to the patient.
- In the case of new patients, all the detailed information that includes date of birth, patient’s name, name of primary insured, social Security number of Primary insured, insurance carrier, ID number, pre-authorization as well as group number must be verified thoroughly before each visit.
- Healthcare revenue cycle management companies’ dental insurance verification makes it easy for dental professionals to handle their core tasks without any trouble which also saves money and time.
2.Periodontal scaling and Root planning coverage:
- With certain procedures like periodontal scaling and root planning, frequencies of denials are more compared to other procedures.
- D4341 periodontal scaling and root planning- for four or more teeth per quadrant.
- D4342 periodontal scaling and root planning- for one to three teeth per quadrant.
- It’s important for dental professionals and also patients to understand that SRP might be necessary and this plan will only benefit when the clinical indicators are mentioned.
- Insurance companies often fail to release particular payment guidelines for specific procedure codes which turn out to be the biggest issue that confuses the actual benefits.
- There are ways when the claim is not properly adjugated, dental professionals can go for an appeal.
- Especially for SRP claims, including documents of radiographic evidence of bone loss, periodontal charting and narrative description of procedures can provide additional benefits.
3.Limited benefits for periodontal maintenance:
- Certain procedures will have limited benefits like periodontal therapy at various intervals are often denied due to insurance companies limited benefits to particular procedures.
- D4910- Periodontal maintenance: Insurance companies have various policies and limitations for this specific procedure.
- While few insurance companies decide to limit this procedure to be paid as a benefit only within 2 to 12 months of SRP, other insurance companies have qualified periodontal maintenance by denying benefits for this particular procedure unless two or more quadrants have received before the therapy.
- Dental professionals and healthcare revenue cycle management companies must be aware that not all procedures are covered under insurance plans and must make certain arrangements for those procedures by making an appeal.
- For periodontal maintenance appeal process, all the documentation including radiographs, periodontal charting and description of treatment is necessary.
4.Core build up Procedure:
- Usually core build up procedure is performed before tooth restoration process with a crown and it’s often denied with a statement, lack of benefits.
- D2950- core build up procedure including any pins when necessary
- Making a clear statement with the patients regarding this lack of benefits for such procedures can help to get out of such problems very easily.
- As dental professionals also face certain issues in understanding about the policies and bundling of these procedures and the fee to be paid for the procedures, it’s difficult to avoid denials.
- So, most of the healthcare revenue cycle management companies recommend and follow radiographic evidence for such lack of benefits procedures while appealing these procedures.
Few tips to prevent dental claim denials and rejections:
- Use appropriate and accurate CDT codes
- Describe the procedure with proper narration
- Determine the date of service
- Understand the policies and plans of insurance companies
- Be aware of lack of benefits
- Ensure patients are aware of such limited benefits.
- Don’t forget to document all the requirements by insurance companies.
- Outsource your dental billing process to follow hassle free practice.
What is Dental Necessity?
- When a claim for particular dental treatment is not included in the plan but not especially excluded as well is allowed to raise a request based on the urgency, which otherwise is known as Dental Necessity.
- These dental necessity provisions are a part of few dental contracts and not all of the others. These contracts differ from medical necessity.
- In case if a claim contract had dental necessity, the dental professional is allowed to review the previous denied claim to ensure whether documents support reimbursement.
- Most common reasons for dental necessity denials are extraction of asymptomatic third molars, osseous survey of bone exhibition, and crown buildups.
- There should be special care taken during claiming process just to include the evidence of the performed services.
- Detailed and accurate documentation is very crucial for periodontal treatment.
- Many contracts are considered to be valued service and helps healthcare professionals deal with insurance companies.
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