Handling Dental Claim Denials or Rejections – How to Appeal

by | Published on May 20, 2019 | Insurance Verification and Authorizations

Handling Dental Claim Denials or Rejections How to Appeal
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Dealing with insurance companies and claim denials is a frustrating task for all dental offices. Often claims get rejected due to missing patient details, errors in submitted codes, lack of verifying patient’s dental eligibility and more. In case of any claim denial or rejection, dental practices must make sure to check the claim first and evaluate the correction to be made. If there is no error in the claim, prepare an appeal.

ADA’s Recommendations on How to Appeal a Dental Claim

A proper appeal involves sending the carrier a written request to reconsider the claim

  • Include additional documentation that provides the carrier a clearer idea of why the treatment is recommended
  • Provide the dentist consultant as much information as possible, as they will only be checking the dental claim form
  • Follow specific instructions provided by the particular carrier including the submission of the appeal in writing within the time allowed by the carrier.
  • Send your appeal letter to the specified department of the carrier and it must be in the form the carrier requires
  • Include the word “appeal” in the title and the text of the document and in any cover letter that accompanies the appeal document

Four Major Dental Claim Rejections and How to Respond

1. Patient ineligible for the procedure

Patient eligibility verification is a key factor in preventing claim denials. As insurance policies and plans change constantly at the insured level as well as for the insurer, it is important for the provider to verify eligibility each and every time services are provided.
For new patients, all insurance information including patient’s name and date of birth, name of the primary insured, social security number of primary insured, insurance carrier, ID number, preauthorization and group number should be collected and verified before their visit. Outsourcing dental insurance verification tasks helps hospital staff to focus on their core task and practices can also save time and money.

2. Coverage on periodontal scaling and root planing (SRP)

Frequencies for denial are more with certain procedures such as periodontal scaling and root planing (SRP) than other procedures or requests.

  • D4341 periodontal scaling and root planing – four or more teeth per quadrant
  • D4342 periodontal scaling and root planing – one to three teeth per quadrant

Both patients and dentists must be clear that while SRP may be necessary, the plan will only provide benefit when its particular clinical indicators are present. Insurance carriers failing to release specific payment guidelines or processing policies for specific procedure codes is a major factor that creates confusion in actual benefits.
In cases where the claim has not been properly adjudicated, you can appeal the benefit decision. For SRP claims, try including documentation of radiographic evidence of bone loss, periodontal charting and a narrative description of procedures.

3. Limited benefits for periodontal maintenance

This procedure performed following periodontal therapy and at varying intervals is frequently denied because many carriers have limited benefits for this procedure.

  • D4910 Periodontal maintenance

Carriers have different policies or limitations for this procedure. While some payers have limited this procedure to be paid as a benefit only within 2 to 12 months of SRP, other payers have qualified periodontal maintenance by denying benefits for this procedure unless two or more quadrants have received prior therapy. For this procedure, dentists must make their patients aware that all procedures are not covered by some plans, for extended periods of time. While appealing for periodontal maintenance claim denials, include details on radiographs, periodontal charting and a description of the treatment.

4. Core buildup procedure

Core buildup procedure performed prior to restoring a tooth with a crown is often reported to be denied for its lack of benefits.

  • D2950 core buildup, including any pins when required

Making patients understand the limitations of their plan prior to treatment may help dentists avoid problems. Dentists are also confused about the policies of bundling these procedures and the total fee for the procedures. ADA recommends including radiographic evidence of the need for a buildup, while appealing for this procedure.

Other Tips to Prevent and Resolve Such Claim Errors

Use the right CDT codes without errors
Use the correct, current code set to identify the diagnosis, services rendered, and procedures performed. HIPAA recommends using the version of the CDT Code in effect on the date of service, no matter when the claim is submitted. Review the denied claims to check whether the procedure codes reported are correct. If there is a coding error, prepare and submit a corrected claim.
Provide a clear narrative
Narrative description in the document should include the clinical condition of the oral cavity, description of the procedure performed, reasons why extra time or material was needed, how new technology enabled the procedure to be delivered as well as any specific information required under a participating provider agreement.
Determine the date of service
While assigning a single code for a procedure that requires multiple appointments, ADA encourages third party payers to use the date of impression as the date of service. However, some state laws and third party carrier processing policies and contract provisions specify the completion date as the date of service.
Dental billing services provided by experienced medical billing companies can help dental practices meet their medical billing and claim submission requirements. Such companies will provide the services of skilled AAPC-certified coders and expert billing specialists who can ensure that your practice has only fewer accounts receivable and unresolved dental claims.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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