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By Cindy Hartwell, dental benefits analyst at CDA Practice Support
CDA Practice Support receives infrequent member requests for assistance concerning dental plan claim denials. We understand that claim denials are very frustrating, and in the past, there were no laws allowing dentists to file formal disputes that required dental benefit plans to respond. Today there is such a law, and while it is a powerful tool, it is a right often overlooked and underutilized by dental practices.
It is important that dentists and their teams know and understand their rights when appealing a claim denial and how the law can protect you and your patient.
The main provisions of the law include:
As mentioned earlier, the provider dispute process is a powerful tool to be used to dispute a denial. To minimize the frustration of dealing with a claim denial, it is important to understand how a lot of claims are processed today.
Many plans use auto-adjudication to process their claims, which means the claims review is performed by a computer that has been programmed to automatically pay or deny payment for a service based on the processing policies contained in the patient’s policy. As the result of auto-adjudication, many claims are not reviewed by a human being.
For more information on the auto-adjudication process, I encourage you to read Auto-adjudication can expedite claims processing, but it can also confuse dentists.
This is where you will find the plan’s clinical policies. If you do not have a handbook, reach out to the plan to get it. By not having the plan’s handbook, you may be unaware of the policies you agreed to when you contracted with the plan.
Use the information provided in the dental plan handbook to prove clinical need for treatment and how it met the plan’s guidelines. Re-appeal with this new information.
The policyholder should file a complaint with their human resources department which informs plan representatives that the individual is being denied their coverage. The patient can also file a written enrollee grievance with the plan.
Writing an appeal may seem like a time-consuming task, but it really should not take more than a few minutes to complete.
The following steps can help you appeal the denied claim with the plan:
Following these simple steps often leads to claim payment. For additional information on dealing with claim denials, access the CDA Practice Support resource, Dental Benefit Plan Handbook Chapter 10: Understanding the Claim Appeal Process.