Appealing Medical Claims
Patients can utilize their medical insurance to pay for some procedures at the dental clinic. Medical insurance may provide more coverage than dental insurance. Albeit, medical insurance companies may deny claims for a variety of reasons. In response, dentists and patients could appeal the claims.
By doing so, dentists and patients can overturn the denial in order to approve coverage. Patients must make an appeal within six months (Fitch 2014). Dentists and patients should understand the reason for the denial, the insurance company’s classification of medical necessity for procedures, and the benefits included in the policy (“How to Appeal a Health Insurance Denial”). The dental practice must remain updated on these claims and persist in appealing it (“Billing Medical Insurance for Dental services” 2016). The practice and patient should address and fix any errors in the claims, such as incorrect codes, “a misspelled name, insurance ID number, or the wrong date of service” (Andrews 2011; Fitch 2014; “How to Appeal a Health Insurance Denial;” Varga 2013). In these cases, either the dentist could send a claim with the correct information or the patient could call the insurance company to fix the error (Fitch 2014; “How to Appeal a Health Insurance Denial;” Varga 2013). A record of the patient’s letter of medical necessity, which contains information about why the patient needs certain treatments, could also help appeal the claim (“Writing Letters of Medical Necessity” 2011). When a claim is denied due to the lack of medical necessity, dentists could send a claim with more information and documentation, such as “medical history, prescriptions, referrals, and dates of service,” to prove the treatment’s medical necessity for the patient (Apex EDI 2016; Bergthold 2011).
Patients can go through different processes to overturn the denial. Patients can go through an internal appeal process, where the insurance company “[conducts] a full and fair review of its decision. If the case is urgent, [their] insurance company must speed up this process” (“How to appeal an insurance company decision”). Alternatively, they could go through an external review process handled by an independent third party and “the insurance company no longer gets the final say over whether to pay a claim” (“How to appeal an insurance company decision”). Patients with an employer’s health insurance policy or an individual health plan can appeal the claim through their state’s appeals process, whose rules may vary from state to state (“How to Appeal a Health Insurance Denial”). Those on Medicare must go through a federal appeals-review process (“How to Appeal a Health Insurance Denial”).
To avoid denials, dentist practice staff members should remain updated on the diagnostic ICD and procedure CPT codes and their rules and regulations every year (Varga 2013). When insurance companies deny claims, dentists and patients can succeed in appealing the claim in a variety of ways, depending on the situation. Dentists should help patients appeal these claims in order to approve their coverage, allowing patients to financially access any necessary procedures (Varga 2013).
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