What are the different levels of appeal in Dental billing?

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Dental offices find dealing with both insurance firms and claim denials to be a daunting process. Claims are often denied due to missing patient information, inconsistencies in submitted codes, a lack of verification of the patient’s dental eligibility, and other factors. In the event of a claim denial or dismissal, dental practices must first check the claim and assess the necessary corrections. Post such confirmation if there are no discrepancies in the claim, filing for an appeal is the most appropriate step. 

This article will discuss what an appeal is, why it’s required, and how dental practices can appeal during a dental claim denial in order to make sure that they get reimbursed on time for the services rendered! 

What is an appeal and why is it required?

A formal request by dental practices to reprocess the claims with no inconsistencies is simply known as an appeal. A proper appeal involves sending a written request to the insurance company to reconsider the claim. Few general things to remember when appealing a claim:

  • Submitting the appeal within the time frame allowed as per the insurance company norms or state laws
  • Making sure to submit the appeal to the specified department 
  • The written request should clearly mention the word ‘Appeal’ 
  • Give a call to the insurance company to get all the details in case of any confusion

By submitting requested details to a claim support centre or relevant authorities, most claim problems can be resolved quickly. Unless otherwise provided by contract or state statute, practices must appeal within 180 days of obtaining the adverse decision.

Levels of appeals

As a dental practitioner, you have correctly filed a claim and you know you did everything right but the claim still got denied and now you have to appeal the claim. 

  1. The first level of appeal is to follow the appeal protocol of the insurance company that denied the claim. Usually, information related to the same is mentioned on the denial EOB.
  2. You need to create a formal letter on your practice’s letterhead and make sure that all supporting documents are included with the claim. Also, it’s a wise idea to include any relevant information that you may have missed submitting with the original claim.
  3. The next level of the appeal demands you to involve all the possible details on the appeal letter such as your full address, phone, and email address; the patient’s full name, address, contact number, date of birth (DOB), Member ID, claim number, and also a claim reference number if you have one.
  4. Provide more details that support the treatment or medical condition like explaining the procedure and history of the treatment. Make sure these details are additional information and add to the data provided in the original claim.
  5. If you had sent the x-rays as supporting documents while submitting the original claim, try taking a look at them again. Check if they are of good diagnostic quality and show enough visible evidence. 
  6. Do not use the technical language that was used in the denial to describe the condition. Use the regular dental terms that explain the treatment. There have been instances when a single wrong word has triggered a denial. 
  7. You should inform the patient that you are appealing the denial of his/her claim. She/he might like to call the insurance company to know the cause of the denial or why the claim was denied in the first place! 

A few documents that may support your appeal are radiographs, charting, study models, and a narrative description providing as much information as possible. 

As you can see the appealing process is not an easy one and you may like to avoid doing all of this in the first place. Here are a few tips to avoid dental claim denials and rejections:

  • Use accurate dental codes while submitting a claim
  • Explain the procedure with proper treatment notes 
  • Understand policies of the insurance company before submitting a claim
  • A claim should have all the possible information required
  • Outsource dental billing services

The best way to avoid the entire process of claims and appeals is to outsource dental billing services to professionals. CAPLINE DENTAL SERVICES is one such team of dental billing professionals that can take away all your worries related to dental billing and claim denials.