Top Reasons Dental Claims are Delayed or Denied

by | Published on Sep 14, 2018 | Specialty Billing

Reasons Dental Claims Denied
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Dental billing is complex and errors can mean thousands of dollars in lost revenue. Dental billing services are available to help practices stay ahead of the game. Nevertheless, it is important that providers know the top reasons why dental claims are delayed or denied.

  • Lack of complete information and documentation: Lack of sufficient information is the most common reason for a delayed or denied claim. In addition to complete and accurate patient and teeth information including enrollee’s ID number, and the date of service, the claim form should be submitted with the treating dentist’s information, including the provider’s name, address, license number, and tax identification number (TIN, EIN or SSN). Dental plans also require specific documentation for procedures. For instance, in the case of scaling and root planing, plans typically require perio charting and X-rays showing bone loss. A Dentistry IQ article points out that some plans may require full-mouth series or periodontal charting from the last six months for periodontal, endodontic, and orthodontic procedures, and other basic and major services. It is always advisable to provide more information (rather than less) about what was done in regard to treatment when filing a dental claim. Reliable dental billing companies will call up the plan and enquire what documentation they require for a procedure.
  • Late claim submission: Claims should be filed as soon as possible after the dental services are provided. Insurance companies may deny a claim on the grounds that it was not submitted in a timely manner. For PPO plans, the general rule is that the claim should be filed within one year from the date of service. Other plans may have a shorter time filing period of 90 days. For instance, Delta Dental of California states that, generally, claims received more than 12 months after the date of treatment may not be paid.
  • Lost claims and lost X-rays: The American Dental Association (ADA) states that one of the biggest complaints with regards to third-party claim payment is lost claims and lost X-rays. Dental offices often send claims or X-rays several times before the payer will acknowledge receipt. Though X-rays are submitted with the claim, the dentist will receive an explanation of benefits (EOB) requesting the X-rays. The lack of standardization for attachments from carriers and the inability to reference attachment requirements for multiple carriers in a central location is the main reason for the confusion. The ADA recommends that each office contact each carrier individually to determine claim processing requirements. The California Dental Association (CDA), provides the following additional advice on sending X-rays:
    • Include a narrative that explains what the X-ray shows, which will provide a rationale for why the treatment was provided. Narratives can provide the evidence even when the X-ray is inconclusive.
    • For digital X-rays, provide a printed version with a circle around what you’re seeing and arrows pointing to it with a short notation that explains what justifies the treatment and the claim.
    • X-rays should be properly mounted and labeled with patient name and date.
    • Don’t send originals as many plans do not return X-ray.
  • Limitations, exclusions, frequencies: Limitations, exclusions and frequencies vary from among insurance plans and impact claim reimbursement. How much a dental policy will pay depends on limitations such as annual or lifetime maximums. With frequencies, patients can be covered only for certain procedures a few times a year or every few years. For instance, a plan may cover replacement crowns only every five to seven years. The most common frequency limitations are for examinations (usually twice a year), prosthetics, and periodontics (such as limitations on how often periodontal scaling, root planing and other periodontal surgical services can be performed on the same arch or teeth within the arch). Another contractual limitation is related to the patient’s age. Many employer group contracts have restrictions on certain procedures on patients based on their age. Examples include fluoride, sealant, crowns, removable/fixed prosthesis and orthodontics. Exclusions help reduce payouts for the insurance company. Obtaining a copy of the patient’s certification of insurance that spells out the scope of benefits, limitations and exclusions of their plan is important prior to performing any procedure.
  • Invalid or inaccurate CDT codes: There have been frequent changes to perio, endo or oral surgery procedure codes in recent years. Claims for dental procedures should be billed correctly using the latest CDT procedure codes. Using codes old or discontinued codes will result in denials.

With such complexities involved, billing dental procedures would be much easier with help from an expert. Experienced medical billing outsourcing companies provide dental insurance billing can ensure accurate and timely submission of claims electronically. They can provide dental billing services to meet payer policies and guidelines. If a claim is denied, they will investigate the reason for the denial and resubmit after addressing the deficiency. Their teams are adept at following up claims with insurance companies and will work to improve accounts receivable days to result in speedy resolution of claims and increased cash flow for the dental practice.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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