How to Appeal Dental Claims

In the dental insurance claim world, it is incredibly important to follow the particular insurance company’s steps for submitting a dental claim request (if the procedure goes beyond the normal teeth-cleaning standard, prior approval may be necessary). Let’s say, unfortunately, that the insurance claim gets denied.

Under dental insurance appeal law, you’re entitled to the right to appeal the insurance company’s decision, which can help protect your patients from unfair rejections. The process is usually lengthy and paved with frustration, but if your claim is good enough, then there’s a good chance that the patient can receive the coverage they were promised. (However, it’s important to note that this is truly a case-by-case basis, and “dental insurance providers do have their own reasons for rejecting claims.”)

Appealing Dental Claims

 

1. Research the reason the claim was denied.

This usually comes on the denial letter itself or you can ask the insurance company for further clarification. (Sometimes the denial may simply stem from clerical errors, like wrong coding or typos.)

 

2. Adjust the claim accordingly.

Build a solid case in favor of your claim. Gather all the appropriate evidence and present it in a clearly understandable way.

 

3. Resubmit appeal.

This should be done in a timely fashion, and each insurance company has its own set of guidelines and steps. Once the insurance company receives the appeal, they must act within a certain number of days. In some states, if the insurance company fails to act before this time period ends, the claim must be paid. However, under dental insurance appeal laws, two appeals can be made per denied claim. The second appeal will be considered a civil case. After a 60-day waiting period, or cooling-off period, you have three to five years to pursue the second appeal (although this time period depends on the state).

 

Things to Consider

 

    •  As mentioned above, following the proper procedures of the specific dental insurance company is paramount, as different companies will have different rules for appeals. Consulting their website or looking at the explanation of benefits (EOB) will provide some information.

 

    •  Use a formal letter to appeal. This means typing up more details about what happened, clinical facts about the procedure, and providing all the necessary information about your dental practice as well as the patient’s information. (It’s also recommended to print on formal letterhead.)

 

    •  Re-examine the x-rays that were sent with the claim. Make sure they’re of good quality, and if there are more than can be sent, then send them as well. If the x-ray doesn’t seem like understandable evidence, include a “labeled intra-oral photo with arrows pointing to the evidence.”

 

Although you might have to read in between the lines to figure out how to fix the claim and make a good appeal, don’t give the insurance company the responsibility of reading in between the lines of your claim and supporting evidence.

To learn about the common reasons for delays and denials, check out our previous blog post!

 

We know the most common dental billing issues that plague most offices and our billing experts are passionate about helping you avoid the headaches of dental insurance billing particularly when it comes to appealing dental claims. Our dental billing outsourcing services increase your production, maximize your profitability, and we handle any appeals to save you the headaches.

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