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What are dental claims adjudication services?

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July 5, 2021
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July 30, 2021

Dental equipment on papers

For uninterrupted cash flow, the claim adjudication process must be error-free and handled by experts. Dental claim adjudication services require accurate evaluations to understand how the insurer determines the claim reimbursement paid, denied, or rejected. There are systematic protocols involved in the process to submit and follow-up dental claims adjudication services. Here are the steps of the dental claim adjudication process:  

The Initial Processing Claim Review 

It is the first and foremost step, where experts check the claims to detect any omissions or simple claim errors. The insurer identifies the problem and denies the request for any of the below mentioned reasons. Then, after the corrections, resubmit the claim for payment within the time frame. 

  • Error or mis-spelling in the patient’s name as per the claim documents 
  • The patient’s gender mismatch as per the type of service 
  • Incorrect place of service code 
  • Error in the service dates 
  • Invalid or inappropriate diagnosis code  
  • Invalid subscriber plan number or identification number 

The Automatic Claim Review 

The second step of the adjudication services detects any incorrect information about the insurance payer’s payment policies. Any invalid submissions then are resubmitted and rectified to save a lot of time. Here are few problems identified in this step: 

  • Already submitted claims (duplicate) either for the same procedure or date are flagged. 
  • Any missed deadline that is 90 to 120-day for initial claims towards an insurance company can lead to disqualification for the claim payments. 
  • The dental procedures performed were not medically necessary, then the insurer can deny the claim. Needless service delivered is not the most effective manner.  
  • Invalid procedure code and diagnosis code entry in the claim determines the claim status. Early correction to mismatched code entry saves a lot of hassle.  
  • Prior certification/authorization is missing. That can lead to confusion as, why the pre certification/authorization does not acquire before the claim submission.  
  • Invalid pre-certification/authorization means the details like date of service, procedure, diagnosis do not tally with the claim submission information.  
  • Any insurance claim after the patient’s eligibility date results in immediate termination of the claim’s process. 

The Manual Claim Review 

The third step includes the authentication of all documents by the claim examiners to crosscheck any invalid, missing, or mismatched data. This mandatory claim process is basically for unlisted procedures to identify medical necessity. Records are requested and checked through the latest tools and also manually review wherever necessary. 

Payment Determination Process 

The three types of payment determination of the claim adjudication process are as follows: 

  • Paid: The insurance payer determines the claim as reimbursable and paid. 
  • Denied: The insurance payer determines the claim as non-reimbursable and denied. 
  • Reduced: If the service bill amount is high for the diagnosis, then by the claim examiner, the procedure code can be down-coded to a low level.

The Final Payment 

The final stage of the dental claim adjudication process includes the final pay-out details. The payment is set forth to the notified office. It is called the remittance advice or explanation of payment. That contains the breakdown of the reimbursement, adjustment, denial, and uncovered charges of a claim. The elucidation of benefits includes the following information like allowed amount, approved amount, covered amount, discount amount, payer paid amount, patient responsibility amount, and adjudication date.  

Why Outsource Dental Claim Adjudication Services? 

Outsourcing to experts can help process more claims in a month with the latest billing technology.  Here are few benefits of choosing a team of dental claim adjudication services. 

  • All the processes are following the HIPAA standards. 
  • All the patient-sensitive data is confidential and protected through strict policies. 
  • The turnaround time for all reimbursement is quick and within the time frame. 
  • Professional dental claim adjudicators ensure a higher success rate than the majority of dental claims. 
  • 24/7 assistance throughout the year.  
  • High-priority and customized services depending on the severity of the claim submission.