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Your Guide to Dental Insurance Claims Processing

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Dental insurance can be challenging to navigate as it involves complex processes and strict rules. Dental clinics typically have dental billers whose primary role is to receive payments from patients and contact health insurance companies to process claims. For accurate and timely reimbursement from insurance companies, dental billers must be able to verify patient insurance coverage and submit all the relevant documentation on time.

This comprehensive guide explores the essential requirements and concerns relating to dental insurance claims processing, including topics like insurance coverage verification, prior authorization, and supporting documentation. Let’s dive in!

Verifying Dental Patient’s Insurance Coverage

Verifying a patient’s insurance coverage is a vital step in processing dental insurance claims. It ensures:

  • Accurate claim submission
  • Helps patients understand their dental insurance plan and financial responsibilities
  • Ensures dental clinic is paid for the service they provide  
  • It helps avoid delays in payments
  • It helps prevent claim denials

Verification of patient insurance coverage starts with collecting insurance details such as their insurance company name, insurance policy number, and group number. After collecting the insurance details, a dental practice contacts the patient’s insurance company to confirm the coverage details, the patient’s eligibility, or pre-existing condition clauses.

Prior Authorizations

The pre-authorization process allows dental clinics to determine a patient’s coverage. In pre-authorization, dental billers contact an insurance company to enquire about a patient reimbursement amount and, if qualified, the co-pay amount. When patients learn about their co-pay amount, they can create an effective payment plan. Insurance claims are sometimes denied due to the patient’s refusal or inability to make the required co-payments.  

While sending the pre-authorization request, dental billers must include detailed documentation like perio charts, X-rays, treatment plans, and other supporting documents. This is essential, especially for complex treatments or high-cost services.

Comprehensive Treatment Documentation

Accurate treatment documentation plays a great role in the success of numerous dental insurance claims. The documents increase the validity of the claim and enhance quick processing. Besides those mentioned above, other key treatment documents that should be attached and recorded to a claim include diagnosis codes (CDT codes), treatment notes, and radiographs.

Utilization of Electronic Claim Submission

Electronic claim submission is a system in which dental clinics utilize electronic claim forms and dedicated software to submit dental insurance claims to insurance companies. Electronic claim forms are created using recognized formats like the ADA Dental Claim Form. These forms contain all the relevant patient information required when processing a dental insurance claim. The most commonly used software is the Dental Practice Management Software which has a user-friendly interface and thus streamlines the whole process.

Electronic claim submission embraces advanced technology, real-time validation, and standardized coding procedures, resulting in faster processing and efficient claims submissions. In addition, transmitting claim forms electronically can result in significant cost savings for both dental practices and their patients. Also, dental clinics can receive timely Electronic Remittance Advice (ERA) from insurance companies while using this system. Traditional paper-based methods have been associated with erroneous, expensive, and slow claim submissions.

Clean Claim Submission

A submission with errors will most likely be rejected or will take an extended period before processing. Clean claim submission is characterized by properly coded procedures, accurate patient demographic, attached relevant treatment documents, and timely submissions.

Dental billers should know the specific details required for specific claims and send them with the initial claim submission. This increases the chances of the claim submission being accepted through the first time.

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Properly Coded Procedures

Utilizing the most current medical code prevents delayed reimbursements and claim denials. While filing a claim form, dental billers use a standardized coding system, mainly the Current Dental Terminology (CDT) codes published by the American Dental Association (ADA) every two years. Insurance companies require medical billers to assign each dental service or procedure to the correct dental code.

Some of the reasons why using properly coded procedures results in quick reimbursements are:

  • Ensures accurate claim submission
  • Promotes consistent billing
  • Ensures compliance with specific policies and guidelines from an insurance company
  • Streamlines the whole process
  • Enables clear communication between dental practices and insurance companies
  • Patients easily understand the dental service being catered for

It is essential for dental billers to take note of the bundling and unbundling rules. These rules govern whether specific dental procedures should be billed together as a single code (bundling) or separately as a single code (unbundling). However, insurance companies have different policies, and thus the bundling and unbundling rules may vary.

Understand the Coordination of Benefits

At times, a patient may benefit from numerous dental plans. In such a case, insurance companies will coordinate the benefits to ensure no duplications of benefits. Typically, if a patient has coverage with multiple insurance plans, the primary coverage pays the patient’s claims first. If the primary plan reaches its limits and benefits, the secondary plan clears the remaining eligible expenses according to its limits and coverage.   

Dental billers play a significant role in determining the insurance companies to assign primary or secondary insurance coverage and their coverage limits. It is no secret that settling accounts for patients with numerous coverage plans is not a walk in the park for dental billers. With this, dental offices need to be aware of the COB rules and work closely with insurance companies and payers to enhance the seamless coordination of benefits. State laws and regulations may, in some cases, govern the coordination of benefit plans.

Claims Adjudication

In claims adjudication, an insurance company reviews a claim submission and determines the payable amount if all the details are accurate. In addition, the insurance company will send an Explanation of Benefits (EOB) which indicates the verified procedures and the patient’s co-payments. An insurance company may deny a claim or reduce the amount paid to the provider, especially if the submission was inaccurate or the billed service didn’t correspond with the procedure codes.

After the reimbursement, dental billers are responsible for billing the patient the co-payments. It is essential for dental billers to develop effective collection strategies to ensure that a patient clears the remaining balances.

Utilize Apex EDI Software to Seamlessly Process Dental Insurance Claims

One way to ensure dental insurance claim reimbursement is by submitting accurate claims. Adopting digital technology while processing insurance claims helps minimize errors and inaccuracies related to manual data entry. Apex EDI’s Software contains tools that simplify the claims delivery process. With an easy-to-use interface, dental billers can process dental insurance claims with just a few clicks. Our software also provides real-time eligibility information and claim status reporting, which helps identify errors in a claim before it is submitted. To learn more about how Apex EDI can help you with your dental billing, schedule a personalized demo now.



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