You’ve experienced it before…the dreaded letter from a patient’s insurance company: We need more information, there is not enough evidence of need, please send us a diagnostic film (after you have initially sent one!). Several things are critical when submitting dental claims on behalf of your patient:
- Most patients are unaware that employers set the boundaries and limitations on their employee’s dental benefit plan
- Initially writing a good “obnoxiously detailed” narrative is imperative to resolving your patient’s claim early
- Diagnostic films are two-dimensional and don’t necessarily tell the whole story. A detailed narrative and/or attaching a photo should always accompany the claim
This article will deal with the challenges dental practices face when attempting to gain dental benefit payment on behalf of their patients. Whether you accept assignment of payment or are completely “insurance free”, it is important to supply enough information for the patient to receive benefits on their claims.
First and foremost, fill out the claim form correctly. Just because you supplied the insurance company with a diagnostic film doesn’t guarantee they will acknowledge receiving the attachment unless you mark the box on the claim form that you supplied the film. The same thing applies for the diagnostic photo. The most recent ADA claim form has a place to check notifying the insurance company that this information has been sent. When a narrative is attached to the claim form, mark directly on the form that you included a detailed narrative. Draw attention to your claim by highlighting any pertinent information. Most often, when a claim has a narrative attached, it must be referred to a live person for review therefore reducing the risk of requesting more information.
There is a wonderful tool available to dental practices now that allows the financial coordinator to send supporting information electronically. An electronic claims attachment service can allow you to send your attachments electronically. Note, not all insurance companies are accepting electronic attachments. However, there are enough insurance companies that will accept electronic attachments which can help to de-stress your environment greatly. Just remember to make full use of the tools available to you and you will have greater success!
Below is a sample narrative which can be uniquely detailed to each patient’s dental condition warranting the need for treatment.
Narrative Sample for insurance claim
Dear Dental Consultant:
A ___________________ has been prescribed for restoration of tooth #____ because:
|_____1.||The _______________________________cusp(s) has/have been destroyed by caries or fracture and require restoration.|
|_____2.||The _______________________________cusp(s) has/have been undermined by caries and/or previous restorations.|
|_____3.||The tooth has a symptomatic crack or fracture on the ________________________________surface(s).|
|_____4.||The tooth has had endodontic treatment.|
|_____5.||There is recurrent decay under the present___________________.|
Note: Prosthesis/or restoration is/is not an initial placement.
Date of prior placement ____________________________.
Extraction date ___________________________________.
A Bitewing ______ , or periapical(s) _______ x-ray(s) is /are enclosed.
One stumbling block which dental practices face is creating a narrative claim form that is too generic. The insurance industry calls this “not patient specific”. So, a word of caution…always be sure to design your narrative form in a way which allows the patient’s unique condition to be conveyed on the form.
Make sure that the treatment rendered matches what is listed on the claim form. If a dental benefit plan has an “alternate benefit” clause on the contract, there can be an opportunity to ask for an alternate benefit. For example; a fixed bridge is recommended but, the dental benefit plan has a “missing tooth clause”, which means if the tooth was missing prior to the effective date of coverage then the fixed bridge would not be a covered benefit. An alternate benefit equal to individual crowns on the abutment teeth can be requested. Please remember, it is imperative to bill for the procedure(s) that were actually performed. Therefore, bill for a fixed bridge utilizing the fixed bridge codes and in the detailed narrative, request an alternate benefit for individual crowns on the abutment teeth. A benefit for the pontic will most likely not be available if the tooth was missing prior to the effective date of coverage regardless of the available benefit for individual crown. Never promise the patient that their insurance company will cover an alternate benefit. Let your patient know that you will give it your “best attempt”. Patients want to know you cared enough to try.
Always be prepared to involve your patient in the process. They are your “squeaky wheel” and can always go to their employer to have the decision on their claim reversed and considered for benefit. Have your patient use the information available to them to make them your best weapon in resolving claims issues.
Lois Banta is CEO, President and Founder of Banta Consulting, Inc., a company that specializes in all aspects of dental practice management. Lois has over 35 years of dental experience and consults and speaks nationally and internationally. She is also the owner of The Speaking Consulting Network. To contact Lois for a personal consultation or to invite Lois to speak to your organization; Office-816/847-2055, Address: 33010 NE Pink Hill Rd, Grain Valley, MO 64029, Email: firstname.lastname@example.org or check out her website: www.bantaconsulting.com.
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Last modified: April 1, 2014