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What are Dental Claim Processing Policies?

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In the modern era, everyone relies on insurance to cover their dental charges. The dental practice is not only about providing service and receiving payment for the same. In most cases, it is the dental professional’s responsibility to manage the dental claims process. End-to-end dental claims processing involves several policies  which one needs to adhere to in order to ensure an efficient revenue cycle. This article focuses on enlightening dental professionals about such dental claim processing policies. 

1. Insurance Contract: Patients mostly prefer visiting in-network dentists & dental specialists. Being an in network dental professional widens the range of potential patients. To fulfill this criterion, a dental  professional has to sign a contract with the insurance company. This contract is legally binding, and dental professionals are required to adhere to the requirement of insurance contracts. Furthermore, by signing  these insurance contracts dental professionals accept the predetermined charges as full payment for the  provided services. Apart from facilitating providers benefits, these insurance contracts also provide dental practice coverage  such as medical malpractice, employee benefits (health, disability, life), provider benefits, property and casualty benefits among others 

To protect dental professionals from making any regrettable mistakes, American Dental Association (ADA)  offers contract analysis programs in conjunction with the regional dental association. This reviewing  process takes approximately four to five weeks, and the findings are forwarded to the dental  professionals. 

Below are some points that a dental professional should confirm before signing an insurance contract:  

  • The time period or validity of the insurance contract. 
  • Renewal policies of the insurance contract (Is it an automatic renewal or requires confirmation? Will  you be notified before automatic renewal? Etc.) 
  • Contract termination policies & procedures. 
  • Change/Update criteria of the contract. 
  • List of dental services and their agreed payment. 
  • Payment time period. 
  • Claim denial criteria. 
  • Procedures and policies if the payment is not done within the agreed time. 
  • The requirement of participation in peer review, grievance system, utilization review (frequency of treatment), medical assistance program. 
  • Patient information and file disclosure policies. 
  • Work completion & payment criteria in case of policy termination. 

2. Patient Eligibility: Each patient has their own service eligibility criteria based on the type of their insurance policy. A dental professional is required to know the number of appointments required for the treatment,  if the patient is eligible to get the service on till the last date of treatment, if the spouse, children, and other  dependents are covered under the insurance policy, and their age limit with respect to the dependent’s dental coverage. If there is any uncertainty, the dental professional should confirm the same with the insurance  company. Furthermore, the dental professional should have an idea about the treatment estimate and  out-of-pocket cost to enlighten their patients prior to the treatment. Failure in ensuring any of the above  details can lead to future inconvenience and even claim denials which in turn impact the revenue cycle. 
3. Pre-Authorization: Few dental treatments such as pediatric dental orthodontic benefits require pre authorization by the insurance company. Dental professionals are required to be well-versed with the treatments that require pre-authorization. Failure of getting the authorization before the services are  rendered can lead to claim denials. 
4. Claim Submission: Claim submission is the most crucial step in revenue cycle management and involves  several intricacies. For instance, if the patient’s dental services are covered by more than one insurance  company, the dental claim has to be submitted in both of them. When a dental professional signs a  providers insurance contract, the payer provides claim submission guidelines. These guidelines will  include a list of required documentation, dental codes, required treatment details, etc. 
While submitting dental claims, avoid some common mistakes listed below to avoid claim denials: 

  • Duplicate Claims 
  • Incorrect/ Incomplete patient information and other documentation. 
  • Incorrect CDT Code (Code of Dental Procedures) 
  • Missing claim submission deadlines 
  • Not mentioning tooth number in periodontal procedures 

5. Claim Inquiry, Appeal & Resolution: 
Once the claim is submitted by the dental professionals, dental professionals receive EOB (Explanation of  Benefits), that includes several details such as patient’s coverage, payment sanctioned, and reasons for  deducted payments and claim denials, etc. If a dental professional is still uncertain for the reason of payment deductions and claim denials, they are  eligible to inquire about the same by filing a request to the insurance company. The inquiry can be done  on call as well via e-mail to the appropriate executive of the company. 

In case of claim denials, a dental professional can appeal the rejection within 180 days, along with  supporting documents and other required changes inferred from EOB and claim inquiry. If the claim is  denied the second time, a dental professional can request a peer review. (A peer review involves a group of  dental professionals that agree to review the denied claim and the appeal). However, the decisions made  by peer reviews are not legally binding, and insurance companies are not liable to pay based on their decision. 

If the insurance company finds the claim appeal valid, dental professionals get a written notice, along with  the payment.