What happens when a dental claim is denied?

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3D illustration of DENIED stamp title on insurance claim document

A clean dental claim is crucial for the efficient processing of claim submissions. And if the  insurance company decides to deny the coverage to your patient, in that case, the best approach is  an appeal request for reprocessing and reconsideration of a claim.  

Dental claim appeals are necessary for situations where you feel that you should get paid or you  paid less for the rendered services. Timely filing is the foremost step for getting paid for your hard  work. Later, CDT codes keep on updating every year. For efficient payment, instead of purchasing a  new coding book every January, you want to keep up with the offline and online software for the  dental practice. 

The claims get denied for many reasons. Here are the following reasons to win insurance appeals  that save time and money.  

Missing details: some claims need specific information, such as attaching x-ray, spelling out  narratives for medical necessity each time the claim gets submitted. 

Non-covered code: in an individual plan’s fee schedule, if a particular code used on the claim is not  listed, it is not payable. 

Frequency limitations: individual plan limits the number of services within the plan year or  calendar year. 

Age limitation: every policy has the pre-set age limit before filing the claim when the procedure  gets performed. 

After receiving the denial EOB, start formulating the approach for an appeal. There is room for  additional corrections and evidence from your clinical notes on the day of the service that will help  you expedite the appeal process.  

To make your case for payment, abide by the format of a set of questions when beginning your  appeal process.  

  • Is a less expensive treatment a better choice for your patient’s overall health conditions, and how  would it affect the health? 
  • Is there any additional evidence to support the treatment choice if it went beyond and above so  that there is less room for further delay? 
  • Contemplate the patient’s chart such as x-rays, current and past periodontal charting, intraoral  images, and risk assessment readings that led you to particular treatment choices. 

The appeal process is considered too much trouble and also an understated approach. When new  technology is used by more patients and seeing the merit, dental insurance carriers will start paying  attention to a particular code often used on incoming claims. For example, sealants previously were  not covered on incoming claims. However, as soon as the patients learned about the merits and  started sealing certain teeth, they began to ask for coverage in their plan. 

To lessen the denied claims, please do the following: 

  • The eligibility verification process before appointment benefits the practice. 
  • Having access to clinically supportive documents in SOAP notes (Subjective, Objective,  Assessment, Plan) can reduce denied claims. 
  • Supportive images and narratives containing the information necessary to support the policy  provision can speed up the process. 
  • Filing claims electronically with the correct payer ID, NPI number of the provider leaves no  scope for denial. 

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