The Appeal Process for Dental Claims Can be Complicated

The appeal process is a practice system that is to be expected if you are doing any services other than diagnostic and preventive and even those are subject to limitations.  In many practices patients with dental insurance make up the majority of the active patient base so not appealing claims can be costly all the way around.  To be prepared, the person or people in charge of making patient appointments and entering patient data should be trained in attaining the correct insurance information so that claims will not be denied and will be paid quickly.   Filing claims electronically is a must and soon will be mandatory as more and more insurance companies will no longer accept paper claims.  Update your software so that you have the current ADA 2012 claim form and the current CDT 2015 codes going out on the claims or your claims will be denied. File your standard fee schedule on all claims.  The following is a checklist of why claims are commonly denied.

  1. Wrong or missing information on the claim.  Do you have the correct subscriber identification number on the claim? Check the gender, date of birth, relationship to provider, employer and group number and make sure every field is correctly filled out.
  2. Unreadable claims or documentation.  More insurance companies are using OCR scanners and if they cannot detect hand written notes you will be denied.
  3. Missing Tooth clause.  The patient may have coverage for a fixed bridge but under the condition that the missing tooth was extracted while covered under their policy, if not, no coverage.
  4. Waiting periods.  Often seen on private insurance plans.  A patient has to wait sometimes a year to get coverage for major restorations such as crowns.
  5. Age of patient.  Sealants are commonly denied because the patient was too old to receive a sealant per the contract.  This could also apply to other services too.
  6. Frequency limitations on procedures that are covered by the policy.  Some insurance companies pay for two preventive prophys within a year some will pay for two if they are 6 months and a day apart only.  Frequency limitations apply to most procedures.
  7. Contractual limitations.  Some procedures are not covered at all on some policies even though it is the same insurance company that covered someone else because it is different group coverage.
  8. Student verification.  Some policies will cover older children if they are full time college students.  Usually this is provided by the parent to the insurance but if not on file results in denied claims.
  9. Incorrect CDT coding.  If you haven’t updated your codes to the new CDT 2015 this could get the claim denied as would using the wrong code on a procedure such using a single unit crown code for a prosthetic retainer or using an x999 code without a narrative.
  10. Not indicating whether the prosthetic is an initial placement or a replacement.  In the case of a replacement the reason for replacement must be narrated as well as the date of prior placement.
  11. Documentation such as periodontal charting is not readable.  Computer produced periodontal charting should always be used instead of the paper ones that when scanned are not legible.  Good quality x-rays showing the whole tooth and the apex.  A clear panorex for prosthetics and periodontal services.  Including intra-oral photos can make the difference with conditions not visible in the x-ray.
  12. No follow-up from correspondence to the office.   Insurance companies ask for more information as part of the appeal process.  Many offices do not take the time to appeal claims and that is why thousands of dollars that could have been collected are written off every year.


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