As per the American Dental Association’s council (ADA), it is vital to educate dentists and dental offices to handle claim submissions to avoid rejections from third-party payers. Claim denial and claim rejection get used interchangeably.
It is crucial to disseminate the difference between a claim rejection and a claim denial: the claim rejection never requires adjudication by the insurer, as they get rejected before. The claim denial gets indicated on the Explanation of Benefits (EOB) to follow the appeal process.
There are myriad reasons for the rejected claim:
- Claims fail to follow the guidelines,
- Errors in the submitted claims before processing,
- Coding error, inaccurate ICD codes, misunderstood procedure and termed patient policy
- The claim that is not in the computer systems bounces back,
- Incorrect patient’s insurance ID number, and
- Inaccurate documentation.
How to avoid rejections of dental insurance claims?
At times, dentists may not understand why claims get rejected. To think like an insurer, validate your Is and cross your Ts to avoid them.
Accurate information from the provider
- The dental claims get rejected and bounce back to the dental office. That results in the pending status of the claim, which means revenue loss.
- One of the main reasons is a lack of information, such as the last six-month periodontal charting, detailed narratives with medical necessity, pre-authorization, and other necessary visual representations.
- Take time to focus on the details and scrutinize the updated patient information. Using a patient portal can bring some relief in the process. A small error can lead to rejection. You are there to focus on the patient’s treatment, and these instances take time and money loss.
- To improve the data quality, train the office staff accordingly and help them familiarize themselves with the updated policy.
- Eligibility verification before service will help you both look out for the benefits breakdown.
Familiarizing with the deadlines
- Timely filing claims, as every insurer has separate deadlines, and failing to submit the claim on time, is the only cause for rejection.
- According to the insurer’s policy, following the deadlines plays an important role.
- The PPO plans require claim submission within a year from the rendered date.
- Some union plans come with comparatively shorter filing periods, like 90 days.
- If these claims pass the deadlines, then your dental claim will be under the category of untimely filing. You can expect it to be either denied or rejected.
- In case you resubmit or request an appeal, most of the time, the request might get rejected. Hence meet the deadlines, and train the staff to follow the same.
Limitations, frequencies, and exclusions
- The dental plans depend on the patient’s employers, and that limits in a certain way, such as lifetime maximum or annual maximum.
- The frequencies in the dental plans limit the usage of covered and non-covered procedures by the insurer for a few times a year or every few years.
- It’s often evident and challenging to down code or exclude, as it may minimize the insurance payout.
- The list of limitations, frequencies, and exclusions vary depending on the dental plan.
- Before offering any treatment, it is vital to determine what under-covered services are and what is not covered to avoid rejection.
- Submit a predetermination before offering costly procedures
- Always make sure to minimize human error, which results in fewer rejections.
- EHR solutions with the latest software result in decreased claim rejections and increased payouts at the first attempts.
- Automated coding or self-coding without any flaws has a positive impact on the RCM.
Learn the Claim Format
- Mostly, the billing companies follow a standardized format to send the claim. Following the claim format can make it easier to rectify the errors.
- Many billing companies prefer submitting the claims in ANSI837 instead of HCFA1500.
- After submitting the claim, train your office staff to make regular follow-ups to avoid getting the claim sidelined or misplaced.
- The rejected claim gets resubmitted on a scheduled appeal. Timely resubmission can help the dental office to find the mistake and correct it.
- As a result, the provider can concentrate on better patient care, and revenue loss won’t occur.