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How To Properly Submit A Dental Claim During The Credentialing Process

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Dental Claim

The success of the dental practice depends on the dental claims submission. The credentialing process plays a crucial role in the dental professional’s career in deciding to be an in-network provider. To be an in-network provider, they have to credential with the insurance payer. The credentialing process involves many steps and can take time.

Capline Dental Services can handle the credentialing process and submit the claims properly.

It becomes demanding when the treating provider starts working as an associate practitioner. In the credentialing process, the dental practices submit the claims using the already credentialed professionals listed as treating providers to avoid delays. That is an inappropriate activity as the professional may receive the reimbursement he is not entitled to.

A non-credentialed professional can create ill will among the existing patients. As a practitioner, if you want to offer service at the negotiated rates while ensuring the claims do not get submitted as fraudulent activity.
This article will help you identify legitimate claims so that the dental practice receives appropriate reimbursement while going through the credentialing process.

How is the practice name reflected on the claim?

The ADA dental claim form has the practice name on the bottom left and indicates the payer to whom the payment comes. It includes the legal name of the practice, the EIN (Employer Identification Number), and the NPI (National Provider Identifier), a part of HIPAA (Health Insurance Portability and Accountability Act) to avoid any issues.

Treating Provider in the Credentialing Process

The professional providing the treatment or supervisor gets listed on the 2019 ADA dental claim form. List the correct treating provider irrespective of in-network or out-of-network results in the correct claim submission and quicker reimbursement.

Treating Providers Affected in the Credentialing Process if not credentialed When the treating provider does not choose to get credentialed, the claim will be considered out-of-network, and the out-of-network benefits will be applied accordingly. However, it’s important to note that some plans may not have any out-of-network benefits, which could cause reimbursement issues.

If the dental practice fails to assign benefits to the patient, the out-of-network reimbursement may go to the subscriber. That creates a collection concern between the patient and the dental practice. For instance, dental practices fail to assign benefits to patients who have paid the charges.

That leads to payment disputes and can create negative experiences for patients. It’s best to partner with a dental billing company to manage assignments of benefits and avoid surprises. The assignment of benefits can vary from state to state.

Can claims be submitted under the previous dentist in the Credentialing Process?

Submitting the claim under the previous dentist is an inappropriate billing practice. After the sale of the practice, the new name of the practice is present on box 48 of the 2019 ADA dental claim form.

Additionally, if the previous practice owner is now an associate in the new practice, in that case, the new associate will need to be credentialed with the updated billing entity.

PPO payers claim submission during the Credentialing Process

When the dental professional is going through the credentialing with a PPO payer, it may be beneficial to check if there is a provision for submission during this process. One way to do this is to refer to the Provider Processing Policy manual or Dentist Handbook or to look through your PPO contract.

You could also contact the PPO provider relations department to inquire about such provisions. It’s crucial to get informed that each PPO payer may have different requirements and policies, so it’s always a good idea to do the research beforehand.

Challenges in the Credentialing process

Credentialing is a crucial process that demands patience and meticulous attention to detail. It is easy to proceed with the credentialing process early to avoid payment delays. Moreover, understanding and implementing proper dental claim submission procedures is necessary to ensure dental practice receives reimbursement for the rendered service.

The dental practice can either rely on the in-house dental team or contract a credentialing specialist like Capline to accomplish the credentialing process.