Reasons Why Your Dental Claims Are Denied

Hi this is Amber Darst, Solutions Manager here at Managed Outsource Solutions and today I’ll be talking about the top reasons for dental claim denials and how proper insurance verification ahead of the patient’s appointments can prevent these denials.

00:19 Lack of complete documentation

So I’m gonna jump right in with the first point, which is the lack of complete information and documentation. Lack of sufficient information is the most common reason for a delayed or denied claim.In addition to complete and accurate patient and insurance information, various dental carriers also require specific documentation for procedures. For instance, in the case of scaling and root planing plans typically require perio charting as well as X-rays showing the bone loss. It’s always advisable to provide more information (rather than less) about what was done in regard to the treatment when filing a dental claim. A reliable dental billing company will call up the insurance carrier and enquire what documentation they require for a procedure before sending out the claim.

01:12 Late claims submission

Next, we have late claims submission. Claims should be filed as soon as possible after the dental services are provided. Insurance companies may deny a claim on the grounds that it was not submitted in a timely manner. For PPO plans, the general rule is that the claim should be filed within one year from the date of service. Other plans however may have a shorter filing period time of just 90 days.

01:42 Lost claims and loss X-rays

Next, we have lost claims and loss X-rays. The ADA states that one of the biggest complaints with regards to third party claim payment is loss claims and/or lost X-rays. Dental offices often send claims are X-rays several times before the payer will acknowledge receipt. Though X-rays are submitted with the claim, the dentist will receive an explanation of benefits (EOB) still requesting the X-rays. The lack of standardization for attachments from carriers and the inability to reference attachment requirements for multiple carriers in a central location is the main reason for this confusion. The ADA recommends that each office contact each carrier individually to determine the claim processing requirements.

02:33 Limitations, exclusions and frequencies

Next, we have limitations exclusions and frequencies. These vary high among insurance plans and can really impact the claim reimbursement. How much a dental policy will pay depends on the limitations such as annual or lifetime maximums and then was frequencies patients can be covered only for certain procedures a few times a year or every few years. Checking on these factors before the patient’s date of service can help determine whether the patient is eligible for and how much out of pocket they will have before the procedures are performed.

03:10 Invalid or inaccurate CDT codes

And last, we have invalid or inaccurate CDT codes. There have been frequent changes to perio, endo and oral surgery procedure codes in recent years. Claims for dental procedures should be billed correctly using the latest CDT procedure codes. Using discontinued codes will result in denials.

So,with such complexities involved, billing dental procedures would be much easier with help from an expert. Experienced insurance verification specialist will provide accurate benefit break downs and can even handle your dental billing, ensuring accurate and timely submission of the claims filed electronically.

And that’s all! Thanks for listening in.