Who do you Blame for Rejected and Denied Insurance Claims?

Before you blame the payers for denied claims check your offices processing systems for errors and omissions.

Rejected claims are different from denied claims. Rejected claims were never adjudicated by the insurance company because they were rejected before they were received. They were rejected because something wasn’t entered correctly on the claim or what is on the claim doesn’t match the subscriber or patient information on file. The claim needs to be corrected and re sent.

A denied claim was received but is denied for any number of reasons that the insurance company indicates on the Explanation of Benefits (EOB). These denials must be appealed by following each individual insurance companies appeal process which is usually on their website or more conveniently on the back of the EOB. Follow the process completely or it will be denied again.

To lessen the rejection cycles please do the following:

Eligibility verification prior to service and benefits breakdown for the patient to understand
Enter coverage data correctly into software system.
File all claims electronically to the proper clearinghouse ; call your dental software provider for current list/check submission reports
Filing claims correctly include choosing the correct payer ID with using the NPI number of provider of care to selecting proper codes and being aware of coding additions, deletions and revisions. Most dental software updates will give you updated code additions but not deletions or revisions (that has to be done manually)

Reduce denied claims by:

Having access to clinically excellent supportive material such as clinical notes in the form of SOAP notes, (Subjective, Objective, Assessment, Plan)
diagnostic quality radiographs
supportive oral photo images
periodontal charting within the last year
precise narrative which contain the information that the insurance companies deem necessary to support the policy provisions not the necessity of the service