How To Appeal Denied Dental Insurance Claims

Appealing a dental insurance claim denial is necessary because nearly half of the practice's revenue depends on it, and payers make it difficult for providers to avoid reimbursing the claim. If the practice believes claim adjudication is inappropriate, appealing is a reasonable resolution with the insurer.

Insurance companies focus on profits by collecting monthly premiums while systematically denying claims. There is always some language in the contracts through exclusions, frequency provisions, or limitations to challenge payment by reducing payouts, leading to higher profit margins. That means using all precise information, supporting documentation, and unwavering confidence in the claim process. Even for seasoned billers, this is daunting and intensive work.

Capline Dental Services provides billing experts to save your team members time from lengthy calls with insurers and focus on patient care. Here are successful tips to tackle dental insurance claim denial and help patients receive the benefits they are entitled to.

Reason for Claim Denial

Before submitting an appeal, review the EOB (Explanation of Benefits) to identify the reason and avoid confusion. Sometimes the words written are tricky. For instance, the language in the EOB says the procedure is inclusive of another, which means insufficient documentation.

Practice should be aware of the jargon when working with insurance. If the reason for the claim denial is indefinite, do not hesitate to contact the insurer for clarification. It maximizes the chances of a successful appeal before formulating the response. Understanding the reason is the key to addressing the issue and avoiding patterns.

How To Submit an Appeal for Dental Insurance Claim Denial

Denied dental insurance claims do not require a new claim. Instead, an appeal for reconsideration to the insurer with the following labels:

• Claim Number of the original case.
• The practice has to specify the direct reason for submitting an appeal.
• The appeal request specifies the explanation of the coding and the medical necessity of the treatment.
• Attach supporting documentation, including photos, radiographs, charting, narratives, and clinical notes submitted with the original claim. The case can get allocated to different reviewers who do not have access to the original case context.
• Mark the original claim as an Appeal or Review Request.
• Mention the contact person details with name and phone number for them to contact, along with the response timeframe.
• Dispatch it to the appropriate address that handles the appeal because the appeal department and the original claim department are different. EOB has the address for sending it to the correct location.

Follow-up for Dental Insurance Claim Denial

The time to respond is 30 days, and if the insurer does not revert, follow up with the appeal department to confirm if they have received the appeal and how long it will take to process. What do you do if the insurer denies the claim a second time? The final opportunity to appeal involves the patient as a benefit of having a dentist-to-dentist discussion between the provider and the dental consultant for better results.

List of Dental Insurance Claim Denials that need appeal:

• Denied because of Downgrades
• Alternate benefits
• Timely filing
• Medical necessity
• Incorrect denials

Close or Recreate the Dental Insurance Claim Denial

There are two options for claim denial. Close the claim and bill the patient, or leave the claim open and appeal it. Choosing the second option is better for the patient and the practice. Close the claim, and recreation prevents the dental software from tracking the original claim submission date. It affects its aging category on the insurance aging report, meaning a delay in payment for the insurer. Recreating can result in the claim getting lost. If the claim is closed, recreate it. So that it does not affect the collection percentage and the dental practice brings the revenue it deserves.

Ways to Make Claims Appealing Faster

• There are several reasons for claim denial, and identifying each before responding to denied claims can strengthen the appeal process. Verifying insurance coverage to understand the covered and non-covered services with definitive exclusions by the insurer.
• Reaching the insurance provider before initiating the appeal allows the practice some information to minimize the chances of claim denials.
• Claim denials always follow a pattern, and identifying the same can categorize these denials to develop targeted strategies for accuracy, eliminate recurring mistakes, and empower the practice.
• Practices must submit appeals within specific timeframes, usually 90 days to one year, depending on the provider. Submitting appeals within the designated time slot maximizes the chances of success.
• Follow-up on each claim appeal ensures the claim stays on track and does not slip through the cracks.

Types of Reviews in the Appeal Process

There are dental plans that outsource claims reviews to consulting firms, and here are the following reviews:

• Informal review – Submissions are straightforward. The review request is in writing, and no specific forms are submitted. It is not a formal appeal, and there is no fee associated with this process.
• Internal appeal – Submit an internal appeal form with no fee to avoid the financial burden.
• External appeal – Submission is through an external appeal form. For more details, please reach out to the plan directly.

Checklist For Maximizing Benefits and Ensuring Revenue

The full potential of insurance coverage is through understanding the terms and conditions, and later educating patients about the benefits and limitations to avoid surprises.

The steps include the following:

• The verification of service dates to stay ahead of it.
• Comprehensive documentation with required details for claim submission to the insurer.
• Using correct CDT codes with claims.
• Timely submission of claims to avoid inconsistency in the revenue.

Although appealing rejected or denied claims can be challenging and time-consuming, they can become a powerful opportunity with a robust strategy, such as minimizing manual efforts and automating follow-ups, to safeguard and enhance revenue streams.

Conclusion: Outsourcing Dental Insurance Claim Appeals

Let the RCM experts at Capline manage the insurance claim submissions and appeals so that the dental practice's staff can focus on the patient and run the office.
The professionals handle the claim with precision the first time. The experts have specific strategies for each insurance company to handle insurance claim appeals quickly.