07/10/2015

The top reasons for claim denials

By Greg Alterton, CDA Dental Benefit Plan Specialist

Medical/dental necessity will always be the rationale for most dental care, but medical/dental necessity may not be the basis of how plans pay.

Dentists often wonder what the top reasons are for claims being denied.

Well, it is simple: Make sure claims include your name, address, tax ID number or national provider ID number (in some cases, both), date of service, and accurate patient and teeth information. Make sure you’re using current CDT codes, especially if the treatment provided relates to a perio, endo or oral surgery procedure – these have been the most dynamic areas in the CDT codes in recent years. 

Be aware of what plans are looking for when adjudicating claims.  Lack of documentation or insufficient documentation to justify the procedures or treatment being claimed will often sink a claim. Dental plans typically declare by some means what documentation is required for what procedures in a “dentist handbook,” newsletter announcements or provider information on their websites. On scaling and root planing, for example, plans usually require perio charting and X-rays showing bone loss. When in doubt, err on the side of more information, not less, when filing a claim and explain why you did what you did in regard to treatment. Also, when in doubt, give the dental plan a call and ask what documentation they require for a procedure. 

Plans have gotten away from providing pre-authorizations, in favor of pre-determinations — confirming whether the patient is enrolled in the plan, whether the treatment proposed is covered by the patient’s plan, and what limitations or exclusions may apply. Pre-determinations may not guarantee payment, but that’s usually due to the patient having fallen out of coverage between the date the pre-determination was made and the date of service. Pre-determinations help make the case that procedures shouldn’t have been denied if the plan in fact does deny something that has been submitted in advance.

X-Rays

Regarding X-rays, if what you’re seeing isn’t obvious on an X-ray, provide a narrative to explain what it is you’re seeing. If you send digital X-rays, you can provide a printed version of an X-ray with a circle around what you’re seeing and arrows pointing to it with a short notation that explains what justifies the treatment and the claim.

Narratives are also attachments and while they shouldn’t be overused for basic care, they do provide rationale for why you did the treatment. Narratives may provide the evidence plans need, even when an X-ray is inconclusive.   

Whatever evidence you provide must be consistent in order to justify the claim: the narratives, the required documentation and X-rays. All must tell the same story and when they do, they make a good case for claims being paid.

X-rays are key to showing the necessity for the care you provided. Make sure X-rays are properly mounted and labeled with patient name and date. Unlabeled or unmounted X-rays might mean your claim will be denied. Plans will return your X-rays, if you specifically ask, but some won’t. Be aware that increasingly plans are not returning X-rays, so don’t send originals. Make this part of your routine in determining eligibility – will the plan return X-rays, and if so, what are the conditions? 

Similarly, limitations and exclusions factor in on claim denials. The plan may cover replacement crowns, but only every five to seven years. A plan may pay for a partial denture, but not if it has a missing tooth exclusion clause. 

If you’re contracted with the patient’s plan you should have that plan’s provider handbook, which will state whether the procedures you intend to provide are covered benefits, what limitations and/or exclusions apply and so forth. 

If you can, or if you must, get a copy of the patient’s evidence of coverage documents, or certification of insurance (the same thing), which spells out the scope of benefits, limitations and exclusions of their plan.

When a Claim is Denied

When a claim is denied, it’s standard to submit the claim again, addressing whatever was deficient in the first claim. If the claim is denied a second time, you can request to speak with a dental consultant with the plan to better understand why payment was denied. That consultant will have access to your claim and the rationale for the plan’s denial. If there’s a problem on their end that is revealed by your conversation with the consultant, they may be able to change their determination right there. It’s important to have that one-on-one conversation because something you think is obvious in the claim and the documentation may not be so obvious to the plan’s claims department. 

If you submit a claim for a second review, include the entire package that was sent with the first claim (and any additional documentation or notes that should have been sent with the first claim). It’s likely that the consultant who reviews your resubmitted claim won’t be the same one who looked at the original, so make sure the claim package is comprehensive.

If problems persist after resubmitting the claim with bolstered documentation:

  • Contact the plan and ask to speak with a consultant.

  • Brief your patient about the problem you’re having. Patients can be great allies, and they have more leverage when appealing with the plan or the plan’s regulator. Get to know the appeal rights of patients and enlist them in your cause.

  • File a formal appeal with the plan for their denial. A formal appeal forces the plan to look, yet again, at the claim and its documentation. Dental offices often engage in a series of phone calls with plan representatives when there’s a payment problem. Even when those phone calls seem like they might lead to some positive resolution, ultimately they mean very little. A formal appeal to the plan in the form of both a provider and patient grievance requires a formal response from the plan. If those appeals don’t turn around the plan’s denial, the formal grievance to the plan is the required step to filing an appeal to the plan’s regulator.



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