How to Appeal A Denied Claim

How to Appeal A Denied Claim

By: Natalie Lucken, Account Manager

Beginning your claims submission with a clean dental claim is key to getting efficient processing underway once the insurance company receives it. But what happens when the insurance decides to deny coverage to your patient? The best way to approach an appeal differs according to the reason for denial, and some may not be good candidates all together.

Timely filing of correctly coded procedures on all your claims is step one to getting efficient payment for your hard work. CDT codes are updated and changed every year, and there are online services and software for dental practices that want to keep up with the changes, without having to purchase a new coding book every January.

Typically, claims are denied for one or more of the following reasons:

  • Non-covered code–This means that the particular code that was used on the claim is not listed on the individual plan’s fee schedule and is not payable
  • Frequency limits–These are limitations, according to each individual plan, which define the number of services (or the amount of time between identical or related services)  that can be performed with benefit payment in the plan year or calendar year
  • Missing information–Certain claims need to have additional information included each time they are filed, which could be as simple as attaching a current x ray or specifically spelling out (narratives) why a procedure was the best way to treat the patient
  • Incorrect code–This means that the code selected does not exactly match the treatment
  • Age limitation- According to the provisions of the plan, the procedure was performed after the patient was over the pre-set age limit (i.e. code D1208 for topical fluoride)
  • Timely filing–Every policy has a limitation on how much time can elapse before the claim is initially filed with the insurance company

 

The insurance carrier’s written contract spells out exactly what the date or time limits are for each procedure, and those who have signed that agreement, namely the subscribers and the employers who opt-in to the plan,  must abide by the rules within it. Often, there is room for additional evidence, corrections, or finding a little “wiggle room” to make your case for payment.

Once an official denial EOB or letter of denial is received, you can begin to formulate your approach with the included instructions on where to submit an appeal. You should gather as much information as possible from your clinical notes on the day of service. Hopefully, you have already set up a note template for each procedure that will help you document (daily) the key information you may need in the appeals process.

When beginning your letter of appeal, there are basic questions you can ask yourself to plan the format:

 

  1. Ask yourself if there are details about this patient’s overall health conditions that could be compromised by a less expensive treatment, and consider how this would affect your patient.
  2. Perhaps your treatment went above and beyond to save the patient’s tooth or preserve their smile? The more evidence you provide in support of your treatment choices, the less room an insurance reviewer will have to delay processing due to unanswered questions.
  3. Consider the contents of the patient charts: intraoral images, X-rays, current and past periodontal charting, and caries risk-assessment readings are great evidence of what led you to the chosen treatment.

 

There is another advantage to going through the appeals process that cannot be understated. When new technology becomes more widely used in the dental field, dental insurance carriers will start to pay attention, as they see a particular code being used more and more often, on incoming claims. Slowly, they begin to consider newer technology for payment, when it becomes clear that their customers (patients) are already seeing the merits of such treatment. Many of us remember when sealants were not covered by any insurance plans, for example. As the general population learned about the merits of sealing certain teeth as soon as they erupted, they began to ask for coverage considerations for them.

Appeals are often painted as being “too much trouble” for the average dental practice to take on. But, they can be successful when clinical  documentation is present, and the letter requesting review of your claim has all supporting evidence attached.  eAssist Dental Solutions can give you peace of mind, knowing that our dental billing experts are filing claims and appealing  denials on your behalf. Practice makes perfect, and learning from what has been successful for your patients in the past can help the office staff to hone their narrative skills, and create their own custom templates to streamline the process.  

eAssist Helpful News and Billing Tips; Edition #114

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