Getting Your Claims Paid Promptly

Written by Tamara Grigg

We all know the frustration of getting an EOB back from the insurance and they are asking for more information in order to process the claim.  Let’s talk about how you can minimize or prevent this from happening to ensure you receive your payments from insurance promptly.

As we all know, there are several different requirements for CDT codes submitted and the documentation they require to pay the claim.  The best method to prevent a delay in payment of the claim is to send EVERYTHING possible the 1st time you send the claim. It is necessary that there are also detailed chart notes to pull the information from to send with the claim as well.  This is an area where dentists and all clinical staff need to be aware of what needs to be noted in the chart notes in order for the claims to be paid. For example, if you are sending a claim for a replacement crown and a build-up, the insurance is going to want to know the initial placement date of the crown and the reason a new crown is needed.  The front office staff that sends these claims, need to be able to access that information in the chart note to get your claim paid the 1st time it is sent out. The clinical staff isn’t always aware of what information is needed for the insurance, so it is best to communicate with all staff what is required so that it can be noted in each patient’s chart.  

Here are a few requirements that most insurance companies require to process a claim:

1- Scaling and root planing visits require a 6 point perio chart dated within a year of the treatment date as well as a full series x-rays in the last year to two years.  It is also beneficial if you note the level of calculous present that ranges from mild- heavy, level of bleeding(BOP) and inflammation that ranges from mild-heavy and the need for local anesthetic

2- Crown/BU require pre-op x-rays and if the need isn’t evident in the x-rays, submit a narrative with detailed chart notes such as surfaces fractured and patient symptoms.  Some insurances also require the seat date of the crown to process the claim as it differs if they pay on prep or seat date

3- RCT require pre and post-op x-rays and if fill is short of the apex, include a narrative as to why it is short such as the canal was calcified

4- Surgical extractions require pre-op x-rays and a narrative as to why it was surgical vs. a simple extraction. This is where the doctor needs to be sure to include detailed chart notes on the procedure

5- Partials and dentures require that you list extraction dates for the teeth involved and x-rays and if it is an initial or replacement. If replacement, you will need to provide the seat date of the initial denture

6- Implants will require pre and post-op x-rays and date of extraction of the tooth that the implant is being placed for

This is just a short list of requirements as we all know there are several CDT codes, it is best practice to keep a list of required info in order to get your claims paid quickly.  Please discuss and have open communication between your front office and clinical staff to ensure you receive payments promptly.