I receive hundreds of inquiries from dental practices about how to appeal denied claims. Recently, an office manager sent me a copy of an explanation of benefits (EOB) and a note from the dental plan addressed to the patient (name of patient and identifying information omitted) that stated:
“Your plan covers a crown, onlay, or veneer on a tooth with a favorable prognosis when needed to restore decayed and/or currently missing tooth structure caused by a complete fracture that cannot be restored with a routine filling and/or to treat a symptomatic tooth that has been clinically diagnosed with cracked tooth syndrome. Our reviewing dentist has determined that the documentation we received doesn’t support the presence of decayed or missing tooth structure that cannot be restored with a routine filling or documentation of symptomology or testing consistent with a clinical diagnosis of cracked tooth syndrome. You may request an appeal against this decision. Work with your dental office to include additional previously unsubmitted diagnostic materials such as intraoral photographs and x-rays, treatment records, and chart notes that might support a different decision.”
Crowns and other high-end restoratives are the bread and butter for most general dentists. These single crown codes, D2710–D2799, are often denied by plan payers. When denied, it can send shock waves through the cash flow system that needs payment to cover overhead expenses. According to professional billing companies, to mount an appeal for a denied claim can take six weeks to six months to resolve. It’s common to have to appeal two or three times before getting a resolution. With proper documentation that meets the plan requirements, most claims can be overturned on the first appeal. Once the claim goes to a second appeal, a professional biller on your team or another source can make a huge difference in cash flow.
Stepping through the claims process
Pay the claim on the first submission. Good prevention is to give the plan what it needs to pay the claim on the first submission. Obtain the individual plan’s list of requirements to bill from the plan website or the patient. If you follow the plan’s directions and still get a denial, you have to dig deeper.
Read your contract and the denial carefully. To understand why the plan denied the claim and what it needs to adjudicate, you must read the denial carefully. There are many reasons for claim denials, and some are difficult to understand. You must be part detective to figure it out. The claims examiner selects from a list of denial reasons the one that best suits the situation; however, it may not be a complete reason. Sometimes claims are denied for processing policy limitations in the contract. You must carefully read the contract that you signed and agreed to.
Demonstrate medical necessity. In the situation with the denied crown claim, it could be due to a lack of demonstration of medical necessity. Insufficient medical necessity is the least structured of any reason for a claim, and it provides the most significant opportunity for treatment denials. Insufficient medical necessity is subjective and can often be overturned during appeals.
Appealing a denied insurance claim
- Follow the instructions of each plan to appeal a denied claim.
- Don’t use a template you created unless it matches the plan’s directives.
- Send a written request to reconsider the claim. A proper appeal involves sending the plan a request to reconsider the denial—in writing. A phone call is not acceptable.
- Provide additional documentation to give the plan examiner a clearer picture of why you recommended the treatment. The dentist consultant representing the plan may only be looking at a dental claim form, so you will want to give the consultant as much information as possible so they will agree with your treatment plan and approve the appropriate benefits for your patient.
Documents that assist in the claims denial process
The following documents may assist you in getting attention for denied claims:
- Radiographs showing the entire crown and the apex
- Photographs labeled with the tooth and surfaces treated
- Charting notes
- A narrative description providing as much information as possible
The goal is to have the dentist consultant understand the rationale for your recommended treatment plan. When appealing a claim, it is essential to follow the specific instructions in the insurance plan, including submitting the appeal in writing within the allowable time frame.
Send the appeal to the specified plan department, which must be in the form the plan requires. Prominently include the word “appeal” in the title, the document’s text, and any cover letter accompanying the appeal document. If you don’t have a copy of the relevant documents needed, the plan should provide them to you.
If you have further questions, call the plan at the toll-free number on the patient’s identification card. Some dental plans outsource original claims review and appeals. For these plans, appeal claims to the consulting firm.
Types of reviews
These are several types of reviews you may encounter:
Informal review: Submittals for informal reviews must be in writing, and there are no specific forms to submit. There is no fee, and an informal review is not considered a formal appeal.
Internal appeal: Submittals must use an internal appeal form, and there is no fee for the internal appeal.
External appeal: Submittals must use an external appeal form. For additional information, don’t hesitate to contact the plan directly.
Checklist for appealing a claim
- Ensure that you use the current CDT codes. Did you use a deleted code? Is there revised code language?
- Carefully describe procedures using proper narration directly from the clinical notes. The dentist may be consulted for information if there are no clinical notes.
- Verify and include supporting evidence of the intended procedure: radiographs, scans, periodontal charting, intraoral photos, specialist reports, lab results.
- Confirm the date(s) of service and note whether the service is complete.
- Understand insurance policies and plan differences to see if there are limitations on the plan.
- Know the terms of your provider agreement and the insurer’s provider manual.
- Be aware of the lack of procedure benefits (limitations) or a contract wait time before procedures are paid.
- Ensure timely filing of your claims; some plans have only a three-month filing window.
- Inform patients of the potentially limited benefits of a written treatment plan.
- Record all information required by the insurance provider.
- Consider outsourcing your dental office’s billing procedures if you have denials and a backlog of unpaid claims.
Pay attention to these codes
Some codes trigger more denials on average than others. If you are providing the following services and using these codes, be prepared to document carefully and thoroughly:
- D4210
- D4211
- D4212
- D4241
- D2750
- D2950
Preventing claim denials is the best way to keep a steady and reliable cash flow and ensure financial solvency in your dental practice.
Editor's note: This artcle appeared in the March 2024 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.
Estela Vargas, CRDH, founder and CEO of Remote Sourcing, brings a visionary fusion of clinical expertise and creative leadership to the ever-challenging business of dentistry. As a writer and dynamic speaker, her surgical dental hygienist and practice builder background makes her an essential voice for positive change. Estela’s mastery of dental claim coding and follow-through has forged the success of her business and brought peace of mind to her clients.
