Dealing with insurance companies can be painful. Even when everything is filled out correctly, a dental insurance claim could still be denied for a simple mistake. Something as minor as a missing address of a patient could throw a wrench in the entire claim process. Thankfully, most denials are due to 4, relatively easy to fix, reasons. It is easier to spot these mistakes once you know what to look for. To help your dental insurance claims go as smoothly as possible, be on the lookout for these potential issues:
- Non-Covered Services
It can be difficult for patients to understand the ins and outs of their dental insurance. The verbiage makes it challenging for someone not in the dental field to know how often services are covered. A dental claim can be denied due to limitations or for too frequent visits.
What can be done?
The best way to guard against this denial is to circumvent it before services are performed. The dental practice must verify insurance benefits to ensure the insurance policy covers the treatment.
- Missing or Incomplete Information
The insurance company could require additional information before agreeing to cover the treatment. They want to ensure that procedures are not performed frivolously. It is important to submit any and all documents supporting the claim in the first go around, otherwise, the claim could be denied.
When submitting a dental claim, a detailed narrative must also be submitted. Using a general narrative for multiple patients is unacceptable per insurance standards and will result in a denied claim.
What can be done?
This is a simple and easy-to-correct mistake. The dental office must gather the missing information to submit to the insurance company. Once the documents have been submitted and attached to the claim, the claim will be reprocessed. Although this is an easy denial to fix, it can still eat up man hours to find and submit the missing information. Ensure that all necessary documents are properly submitted the first time around to save on staff work.
- Criteria Not Met
If a dental insurance company believes that a patient did not meet the criteria for a procedure, they could deny the claim. The onus is on the dental office to prove that the patient met the criteria for the treatment and was covered by the insurance policy.
What can be done?
Insurance companies can be intentionally vague with the reason for a dental claim denial. Suppose a “criteria not met” denial comes across your desk. In that case, there must be a follow-up with the insurance company to determine what the criteria are and what other information they require. Using this information, documents can be gathered and attached to the claim for reprocessing.
- Core Build-Up (Code D2950) Denied
A build-up involves restoring a tooth that lacks the structure to hold a crown. Teeth that require a build-up procedure typically lack over 50% of their form. Often, an insurance company will balk at this code because they view it as inclusive to a crown procedure.
What can be done?
If a build-up procedure was conducted independently of the crown or bridge, the insurance company must be made aware of the crown or bridge seat date. Additional information may also be required, such as x-rays or proof of the tooth’s condition. As always, a detailed narrative will assist in pushing the dental claim through.
Additionally, Cigna uses at least two denial codes for D2950; PB & NT.
PB: Benefits are not provided for this service as it is considered to be a part of, and inclusive to, the primary service performed.
NT: Your plan does not provide benefits for this service.
If a build-up is denied with code NT, it can be treated as a non-covered service by billing the patient the UCR fee. If a build-up is denied with code PB, call Cigna to provide the seat date of the crown. That is usually all what’s required to overturn that denial.
Versa Solutions can help find a list of denied D2950 procedures in your software and overturn these denials. Ask us how!
Say Goodbye to Denials
If the dental insurance company denies a claim, it is usually for one of the above reasons. Although it can be frustrating dealing with vague denial reasons, submitting all the necessary paperwork the first time around can make the process easier for everyone involved. Use this information to your advantage to stop claim denials and receive the money that your dental office is rightly due.
We’ve spoken with many, many, MANY dental offices and found that most are only collecting 60-80% of the pay they should be receiving.
If you are in this camp, you work wayyy too hard and wayyyyy too many long hours to only take a fraction of what you’re owed.
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Want to take that 60-80% to 100% in a cost-effective, time-saving fashion?
Schedule a 15-minute call with us to find out if what we do would be a good fit for your office!