How many times should I appeal a claim?

A major keystone to building a profitable practice is the pursuit of reimbursement for dental claims. There are many factors necessary to complete the process of a dental claim. Appealing a denied claim is one of the vital necessities when seeking reimbursement. 

Did you know that only 33% of appealable claims are actually appealed? 

Properly following up on denied claims can make or break the profitability of your practice. Let’s explore the most common denial types. 

What are different types of denied claims? 

1. Rejected Claim: A claim that returns because it can not be processed as submitted. This is due to missing or incorrect information. 
2. Disallowed Service: A service that does not qualify for reimbursement due to being a non-covered benefit. 
3. Denied Claim: A claim that does not qualify for reimbursement and is either appealable or billable to the patient. 

Rejected Claim

Claims are often rejected due to a simple, avoidable error. During the initial submission of a claim, it is important to focus on sending the claim as clean as possible. This means including the following: 

• Complete and accurate insurance information (active insurance policy, payer number, and claim mailing address)
• Accurate procedure code(s)
• Attachments needed to support the claim as required by the payer
• Correct patient and subscriber demographics (address, DOB, alternate ID)

Rejected claims require submitting the accurate information. Once the insurance company receives the correct information, the claim can then be processed for payment. 

Disallowed Service

Every insurance policy is different. One policy may cover a procedure that another policy does not allow. For example, some insurance policies may not allow coverage for major services. This can be determined by gaining a thorough verification of what the policy covers before rendering a service. This can remove the surprise of a disallowed service. 

Denied Claim

If a claim is denied due to lack of documentation, you may resolve the denial by returning the existing claim with the requested information. A claim could also be denied due to missing a specific criteria. For example, a policy with a waiting period would cause basic and/or major services to have a delay in allowed coverage for a specific amount of time. Once the time frame ends, the insurance can consider the services at their allowed percentage. 

There are also situations where claims are falsely denied. This type of denial requires research to determine any inaccuracies. 

Denied claims can often undergo the process of an appeal for reconsideration enabling further payment. This brings us to the common question, “How many times should I appeal a claim?”

How many times should I appeal a claim?

The short answer: it depends. Most insurance companies limit the number of claim appeals. This is important to keep in mind when pursuing a denied claim. If a denied claim is appealable, you could likely have it reconsidered within the first appeal; although other claims may require multiple appeals. Let’s walk through a few steps to consider when appealing a claim. 

Steps to consider when appealing a denied claim

1. Understand the claim denial. You can do this by reading the explanation of benefits. If you have further questions, you can contact the insurance company concerning the denial before creating an appeal. 
2. Write a letter of appeal to the insurance company. This should include an explanation of why you disagree with the denial. A narrative confirming why the rendered service was necessary should also accompany your appeal. 
3. Gather all supporting documentation that explains what and why. The what is the completed service(s) being denied and the why explains the necessity. This may include items like clinical notes, diagnosis, reports, intra oral photos, charting and x-rays. 
4. Include any required dispute documents along with the appeal. In order to consider the appeal, some insurance companies require a specific dispute form. You can confirm the need for this type of document by reaching out to the insurance company. 
5. Send the appeal to the proper appeal location. This is often different from the claims submission location. Some insurance companies will accept an appeal by fax, while others may only accept appeals by mail. 
6. It is also good practice to include the request for a peer to peer review within your appeal letter if the denial is being upheld. This would provide the request for an insurance representative to contact the doctor directly during the appeal review. 

When filing an appeal, it is important to provide everything to prove why the service was necessary. It is also important to answer all questions as the appeal is being reviewed. Such clarity can enable the reconsideration of the service(s) in question, removing the need for an additional appeal.

Conclusion 

As you can see, the process of following up and pursuing denied claims can be quite involved. Does the reality of filing an appeal seem unreachable? The platform specialists at eAssist Dental Solutions can take that stack off of the desk, get all of the information needed to appeal the claim, and follow it through to payment. Our platform is here to help with all of the tedious dental administrative tasks that are bogging down your dental office. Taking these tedious dental billing processes and streamlining them behind the scenes creates more time for your in-office team to focus on patient care, treatment planning, scheduling, marketing, and so much more. Email LearnMore@eassist, call 1-844-327-7478, or click here for a quick consultation!