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Dental Accounts Manager Manual

Tips For Successful Dental Insurance Claim Submission

These tips were gathered from discussions with dentists who work for insurance companies, dental consultants, and offices that have successfully implemented protocol to maximize their dental insurance claims success.

X-rays

  • Do not send original x-rays. Always send duplicates or copies.
    • If you want x-rays returned, you must include a stamped self-addressed envelope.
  • Send x-ray documentation for these procedures:
    • Crowns; fixed bridges
    • Build-ups
    • Posts
    • Implant supported crowns and prosthetics
    • Scaling/root planing
    • Periodontal surgery (gingival flap procedure, osseous surgery, crown lengthening, bone grafts)
    • Surgical extractions
  • Send appropriate pre-op and/or post-op x-rays.
    • Send pre-op for restorative, endodontic, periodontal, and surgical procedures.
    • For build-ups, posts, and when periapical pathology was present in the pre-op x-ray, send a post-op x-ray documenting root canal treatment.
    • For teeth with a questionable prognosis, send a post-op x-ray documenting successful results.
    • For custom indirectly fabricated posts, send a post-op x-ray documenting that it is indeed a custom post and not a prefabricated post.
    • Pre-op means prior to any operative procedure, i.e. before crown prep, before filling removal, before endo access, etc.
  • Send quality, clear, diagnostic x-rays.
    • Look at the x-rays that your office staff is sending out...you might be surprised by the (lack of) quality!
    • Make sure the entire tooth in question is visible on the x-ray.
    • Make sure the exposure matches the original; not too dark, not too light.
    • Make sure the contrast is adequate, and details of tooth, restorations, bone, and pathology are clear.
  • Choose appropriate x-ray views.
    • Periapicals and bitewings are usually more diagnostic than panoramic x-ray for many conditions.
    • Panoramic x-ray might show an entire tooth to be extracted that cannot be imaged with periapicals.
  • Do not send too few x-rays.
    • The reason we take more than one x-ray is because different x-rays show different things. So include them.
    • If submitting for a perio procedure, don't just send one periapical. Also send bitewings if available. Or if a full mouth series is available, send it. If a pano is also available, send it also.
    • Sometimes a bitewing shows the crown of a tooth but not the root. The periapical shows entire root, but cuts off the crown. If this is the case, then send both.
  • Do not over-manipulate digital x-rays.
  • Submit x-rays that are at least the same size as originals.
    • Do not send photos that are smaller than an actual x-ray.
    • Bigger is not necessarily better; do not send photos that are too large. One x-ray filling up an entire page might seem like a good idea, but is actually an overkill, and can slow down processing. Large printed x-rays often are grainy, and are more difficult to read.
  • Print x-rays on photo paper using a photo printer.
  • Label x-ray with left/right, patient name, x-ray date.
  • Add arrows and notes on the x-ray to call attention to details you want seen.
    • However, do not write annotations in a way that covers over other important information.

Periodontal Chart

  • Send perio chart for these procedures:
    • Scaling/root planing
    • Periodontal surgeries (gingival flap procedure, osseous surgery, crown lengthening, bone grafts, gingival grafts)
  • Perio chart should include, at a minimum, pocket depth measurements for all teeth in the area of the procedure, and indicate missing teeth.
  • A date of exam should be on each chart, or each set of measurements.
  • Also helpful are gingival margin level, furcation involvement, mobility, bleeding points, attached gingiva width.
  • Use good penmanship. Make sure the numbers are easily readable to someone else.
  • If you are treating periodontal disease, include your diagnosis on the perio chart. Remember, scaling and root planing is a treatment of disease, and must have an actual documented diagnosis of the specific disease.

Clinical Photographs

  • If tooth condition is not completely documented by the x-ray, then send a photograph. It is not unusual for an initial claim to be denied but allowed upon appeal when photo is sent because necessity is seen on the photograph but not the x-ray.
  • Make sure photo clearly shows the tooth or condition in question, and adds supporting information for the submitted procedure.
  • Label photo with tooth number, left/right, patient name, photo date.
  • If photo is reversed because of mirror use, then mention this.
  • Add arrows and notes on the photo to call attention to details you want seen.
    • However, do not write annotations in a way that covers over other important information.
  • For crowns or veneers on anterior teeth, photos are helpful to show that the procedure is not solely for cosmetic purposes.
  • For periodontal grafting, photos can document recession and lack of attached gingiva that x-ray does not show.
  • Photos can show cracks and fractures that do not show in x-ray.
  • Photos can show large buccolingual width of existing fillings that aren't obvious in x-ray.
  • Photos taken sequentially during the restorative process can be helpful.
    • Pre-op
    • Tooth with only old restoration removed
    • Tooth with caries removed
    • Tooth with final preparation
    • Tooth with new restoration

Narratives

  • Be concise.
  • Be specific.
    • Writing "open margin" means open margin. It does not mean recurrent decay. If there is decay, state that also.
    • "Open contact" means open contact, but does not state what, if any, problems are being caused by that open contact.
  • Describe objective clinical findings. Limit your subjective opinions.
  • If narrative does not fit on the claim form, write it on a separate page, and note this on the claim in the narrative section.
  • Note any information that is not obvious in rest of claim documentation.
  • Include actual diagnosis for the submitted procedure.
  • Do not include extraneous or unnecessary information, such as:
    • "Please process for payment"
    • "To treat periodontal disease, it is necessary to perform scaling and root planing".
    • "Periodontal treatment is necessary to improve overall health of mouth and improve environment for teeth".
  • If using abbreviations, make sure they are commonly used and understood by others.
  • Use correct grammar, punctuation, and spelling to make the narrative more readable.
  • Do not use threatening language or phrases.
    • It will have absolutely no positive affect on your claim processing speed or approval outcome.
    • There is no need to remind the insurance company of rules, regulations, guidelines, and laws that cover them. They are extremely aware of this already; probably much more so than the person submitting the claim.
    • Quoting legal cases has no positive influence on a claim, and can actually call credibility into question since many quoted cases are actually not applicable to dental insurance claims.
    • Examples:
      • "Please note that the insurance commissioner will be contacted if the claim is not paid within 30 days of the claims creation".
      • "Unless this claim is paid or denied within 30 days we will file a formal complaint with the insurance commissioner".
  • Do not use generic narratives.
    • The more the narratives are customized for this patient, the more credibility and influence it has.
    • Using a pre-made template or form is good as long as it is filled out in a way that is clearly specific for the submitted claim, and customized for each specific procedure or tooth.
  • Do not throw in the kitchen sink.
    • Including every possible finding that might get a procedure covered can call the credibility into question.
  • Be truthful.
    • Include anything that you have actually documented in the patient's records...but do not include anything that is not documented in the patient's records.

Other Attachments

  • A copy of actual clinical notes can be helpful in documentation.
    • Examination findings, and accompanying diagnoses.
    • Diagnostic process that was used to actually diagnose Cracked Tooth Syndrome.
    • Level of surgical involvement for extractions.
  • Pathology reports can help document biopsies, cysts, tumors.
  • Reports from specialists.

Claim Form

  • Use the latest, most up-to-date ADA claim form.
  • Use the most current CDT codes.
  • Fill in all pertinent sections on the claim form.
  • For crowns, bridges, and other fixed or removable prosthesis, accurately note whether it is a replacement or not.
    • If it is not an initial placement, note when the existing one was placed (prior placement).
    • Prior placement refers to crowns, bridges, inlays, onlays, veneers, removable appliances. It is not referring to prior placement of fillings.
  • Note missing teeth in the Missing Teeth Information section.
  • Enter the correct entity in the Billing Dentist section, and correct dentist in Treating Dentist section.
  • Specialists can denote their specialty in the Provider Specialty Code section.
  • Some codes require Area of Oral Cavity, and others require a Tooth Number. This depends on the CDT code, and insurance company guidelines.
  • If a patient discount is given and is not already calculated into the fee on the claim form, the discount amount must be clearly reflected on the claim, either as a separate line item or in the Remarks. Otherwise a fraudulent claim is being submitted.

Miscellaneous Tips

  • If you will be doing more scaling/root planing or osseous surgery in other quadrants later, but not submitting for all of them on the claim, go ahead and include x-rays and perio chart of all four quadrants anyways. If you do this, some consultants will automatically pre-process all four quads and store it in the computer, which will save processing time on the future submission.
  • Use the correct terminology. For example, do not write "prognosis" if it is actually a "diagnosis." Do not refer to a restoration as an "onlay" if it is actually an "inlay."
  • Become intimately familiar with the CDT codes and the descriptors. Re-read them regularly to refresh your memory about the descriptor for codes you might not use very frequently. Make sure the entire office staff is familiar with them, including the doctors.
  • If you get a request for information after submitting a claim, then send the requested information...plus more. This means the claim is being evaluated by a human rather than processed by the computer. Make sure you include information clearly documenting what you did, and more importantly, the necessity for why you did it. If it is not immediately evident in the x-ray, explain it in a narrative and/or send photos.
  • Do not request a phone call in hopes that it will increase payment likelihood unless you actually have information that needs to be discussed. Insurance companies are not more likely to pay a claim just to avoid the bother of making a phone call. Any phone call request will delay the claim processing.
  • Maintain good patient records.
    • Document exam findings and any specific exam actions (such as how a cracked tooth was diagnosed, pulp tests and specific results, Diagnodent use and readings).
    • Document any x-rays taken, that they were actually read, and which dentist interpreted them.
    • Document all pathology.
    • Document decay findings specifically for each tooth, how it was detected, and surfaces where it was found.
    • Document treatment plans.
    • Document referrals, and reason for referral.
    • Document patient discussions.
    • Document actual treatments in detail.

Appeals

  • If resubmitting a claim on appeal, send additional documentation of some kind. Don't just resubmit the claim in hopes it will be reviewed differently the next time.
    • Additional narrative explaining your claim submission.
    • Additional or better x-rays.
    • Additional or better photographs.
    • Additional or better chart notes.
    • Additional or better pathology report.
  • Write "Appeal" on the resubmitted claim.
  • If claim is being resubmitted with corrected information, write "Corrected Claim" on it, and call attention to the corrected information.
  • Call attention to the new information being submitted.

Things To Remember

  • If payment is denied for a procedure, this does not always mean you cannot do it. It simply means that it is not a benefit in the insurance plan that the patient's employer purchased for them.
  • Submit quality x-rays. If you cannot see the condition in question on the submitted x-ray, then nobody at the insurance company can either.
  • Do not commit insurance fraud. This can be very costly in terms of legal costs, reimbursements, and dental board sanctions. Fraud can take many subtle forms, such as:
    • Submitting date of service that is different from the actual date you did the procedure on the patient.
    • Submitting a fee that is different from the fee you actually intend to collect from the patient (unless you have a contract with the insurance company).
    • Not collecting copay amounts.
    • Submitting a CDT procedure code that is not the most accurate one for the procedure actually done.
    • Resubmitting denied services as other services.
    • Submitting procedures that were not actually done.
    • Submitting a procedure for an area different than that actually done.
    • Submitting fillings that are on more tooth surfaces than were actually filled.
    • Submitting perio chart that shows deeper perio pockets than patient actually has.
    • Misrepresenting cosmetic procedures as having other necessity.
  • Insurance companies usually can request copies of records to investigate the validity of any filed claim (this concept is true for any insurance claim, not just dental insurance claims). Keep in mind the philosophy of legal experts...If it isn't documented in the chart, then it didn't happen and doesn't exist. What the dentist says actually carries little importance compared to what the patient record says. This is especially true for dentists who have been placed on targeted review by an insurance company.

See also:

 
Written by Jacob Hodara

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