4 things your dental insurance claim needs for reimbursement (2023)

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Dental claims get denied for a myriad of reasons. Sometimes claims don’t pay because of a mistake, or because the insurance has made a change to patients’ policies you weren’t aware of.

Whatever the case, dental teams need to know what a clean claim looks like. When we say clean claim, we mean a claim that uses the correct form, has correct coding, patient data, provider information, and necessary attachments, and has been checked to be free of errors, mistakes, or omissions.

It can feel really frustrating when your claims are repeatedly denied. As a dental billing company, our professional billers at Dental ClaimSupport always have some kind of checklist for completing a clean insurance claim.

It’s important to do everything you can to avoid denials in order to protect the financial health of your practice, and its standing as a great place to work and perform dental care.

The longer the claim goes unpaid by insurance, the less likely it is to ever be paid. And no dental team wants that.

Whether you are working with a dental billing company or not, it’s crucial to know what a complete and accurate insurance claim is, so the practice receives the correct reimbursement.

This article walks you through a standard checklist of items that should always be included in every dental insurance claim you submit. By keeping this checklist in mind, you will see fewer claim denials, and increase your insurance collections.

1. Correct claim form filing: medical or dental

Whether the procedure is considered medical or dental will determine which form you'll use to officially request payment. Determining when you’re going to file a dental claim versus a medical claim can be a huge hang-up for dental teams. It’s hard to know when the right time for each claim is, and if you get it wrong, there could be delays on when the dental practice gets paid.

There are 3 types of procedures that will require a medical claim form (CMS 1500) as opposed to a dental claim (ADA Dental Claim Form):

  1. Oral surgery
  2. Trauma (broken jaw, tooth, or teeth)
  3. Pathology

Deep dive into these procedures and when to file a medical claim versus a dental claim in our Learning Center.

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When in doubt, ask the insurance company where to file the claim

Here’s the good news: you can always call and ask.

This is a common source of confusion, so when in doubt just call the medical and dental insurance companies to confirm which to send to. If you don't make a call and you just submit dental when it should be medical, you will receive an explanation of benefits back that will clarify: “Medical is primary, please submit to medical and start the process over.”

Medical insurance oftentimes has a timely filing limit of 3-6 months, instead of the year-long timely filing limits in many dental plans. So you will want to track medical claims especially carefully to avoid denials due to time limits.

Filing the right type of claim for the procedures performed is key to creating claims that pay.

2. Accurate dental patient information

First things first: you have to get certain information from the patient. This is all in the hands of whoever is initially speaking to the patient when they call to make an appointment.

Specific information is needed from patients and should be verified a second time when they come for their appointment

When the patient calls you to make a dental appointment, you’ll get their full name, birthdate, address, and then all of their insurance information. Their personal information is just as important as their insurance information, so it’s imperative to verify it’s correct.

It seems straightforward, but you’d be surprised how many claims are denied due to inaccurate patient information. Maybe their address has changed or even their name.

Not only do these numbers need to be correct (address and date of birth), you need to also have their name spelled correctly. Yep, these small mistakes can cause a claim to be denied. When in doubt, ask the patient to spell it out.

Then, when the patient comes in for their actual appointment, you can check that information again by looking at their driver’s license and insurance card. Another pro tip: Scan these cards and save them to the patient's account as a failsafe.

3. Accurate billing entity/provider information

Another reason claims are sometimes denied is because of inaccurate insurance information. When receiving the patient’s insurance AND personal information, the following information needs to be correct:

  1. Name of insurance provider
  2. Insurance company address
  3. Member ID number
  4. Member DOB
  • Patient DOB, if different than the Member
  • Name of employer
  • Group ID number
  • Telephone number of insurance (if you do not have a login for the web portal)
  • Having this information will allow you to check patient eligibility and obtain a full breakdown of their benefits.

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    Are you diligent about insurance verification?

    After you obtain this information, you need to confirm the patient’s coverage is currently active, what procedures are and are not covered, and the percentage of the costs covered for procedures. This is called insurance verification and needs to be a regular step in your billing process.

    This can be done in your insurance verification software, or you can call the insurance company yourself to verify all of this information.

    If your team enters all of the patient’s information into your dental software accurately and verifies the patient’s benefits, there should be no problem in sending an accurate claim that will be paid by insurance promptly.

    You will also know how much you can expect to receive from the insurance payer. If you know this amount, that means you’ll also know your patient’s out-of-pocket expenses, which should be collected before they leave the office after their procedure.

    Making sure all of the insurance information is accurate is key is getting insurance claims paid.

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    4. Appropriate attachments and documentation

    Different procedures require different attachments and documentation. Attachments are proof the services performed on the patient were necessary. Oftentimes, just saying in the notes why a procedure was needed is not enough.

    Sometimes claim details are neglected because the dental team gets caught up in the routine of the day and simply forget to attach certain x-rays or intraoral photos. It’s a good practice to always “over-explain” yourself and provide as much information as possible on an insurance claim.

    Stay up-to-date on what procedure codes require which type of attachment

    As we mentioned, different CDT procedure codes require different types of attachments. This could be various types of x-rays or intraoral photos. As you probably know, CDT codes change and update every year, so it’s possible their required attachment could change as well.

    It’s important that the dental team keeps up with this kind of information to avoid claim denials.

    Always consider taking intraoral photos of the original condition prior to treatment. Even if the specific code asks for an x-ray, intraoral photos document your clinical findings and show what the naked eye sees. Showing the original condition is essential in case you need to send in an appeal.

    Don’t let insurance companies dictate your claim revenue

    Insurance billing can be intimidating because so much of your livelihood comes from revenue that’s in the hands of insurance companies. Take control of your income by learning everything you can about what a claim needs in order to be reimbursed in a timely manner. Don’t get bogged down by avoidable missteps and missing documentation.

    Have a checklist by you at all times to ensure you’re including everything you need in your insurance claim to get the money you have earned.

    Because new ways to deny claims emerge every day, it’s also handy to have expert support to keep your claims revenue flowing easily. You can always turn to Dental ClaimSupport. We can help you with claim submission, appeals, and help your team improve the financial health of your dental practice.

    To continue learning what a clean claim looks like, and does not look like, read our article, “6 common myths about submitting dental insurance claims” in our Learning Center.

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