By Marianne Harper

Have you been frustrated by claims that are denied by insurance carriers? How do you handle those denials? If you haven’t been very successful or you haven’t even tried to appeal denied claims, then you are missing the boat. Read on for the steps to make that boat ride smoother.

Claims can deny for many reasons as is evident by the multiple denial codes that carriers use. Some claims deny legitimately but there are times when a denial should not be accepted without a fight. Not examining your denied claims to determine if they are legitimate denials means that you are losing money either by patients not paying the full balance which can result in bad debt write offs or by delays in patients paying the balance in full. It is a fact that when a practice takes the time to effectively appeal a claim, denials can be overturned and the practice can be more profitable.

The following are the steps to successfully appeal a dental or cross coded medical insurance claim:

  • Stay timely – Don’t create a problem folder for denied or problem claims and let the claims sit untouched in that folder for too long. Insurance carriers have time limits set for appeals, so you must be careful not to wait too long. If a problem claim requires multiple contacts with the insurance carrier which results in a lengthy time period, be sure to document each contact by recording the date, time, name of the representative, and notes on what the representative told you. The carrier will have a record of these communications also, so they will not be able to use the time factor against you.
  • Read EOB’s carefully to look for problems. Not all claim problems are easily evident, especially when a partial payment is made. If you accept a partial payment as the final payment without looking for the reasons why the carrier only paid a partial payment, you will be missing the chance to obtain a higher benefit for the patient. Become a coding detective with your EOB’s.
  • You can use several different methods to file an appeal – by phone, on paper, or through the carrier’s website. You will need to investigate which is the best method for each.
  • State the facts – Review the documentation of the case and glean from it the pertinent details to
    state your case:

    • The necessity of the procedure – how it was either dentally or medically necessary.
    • Attach copies of attachments.
    • If the denial states that the procedure was non-covered, state why you believe that it
      should have been considered a covered procedure.
    • Problems with bundled services – With medical insurance carriers, they may not have
      recognized your modifier that showed that services should not have been bundled, so
      you will need to either call the carrier and have them look at their copy of the claim or
      include a copy of the claim that shows the modifier and indicate that they did not
      process the claim correctly and need to reprocess it.
  • Evaluate problem claims as to whether an appeal or a correction is required. Not all denials
    require appeals because some of the following situations might apply:

    • Patient data was entered incorrect – misspellings or incorrect subscriber ID number that
      resulted in a denial.
    • Date of service was incorrect.
    • Wrong codes were used – either diagnosis, CPT or CDT. Also, with medical claims, the
      diagnosis code(s) must always support the procedure code(s).
    • Incorrect rendering provider is listed on the claim.

If you determine that the problem lies with errors made by your staff, you will need to contact
the insurance carrier for their instructions on how to file a corrected claim.

Make a difference – take the extra steps – to make your claim filing system run efficiently, effectively
and profitably.


marianne harperContributor:


Marianne Harper is the owner of “The Art of Practice Management”, a dental practice management consulting company. Marianne’s specialty is training dentists and staff members in implementing dental-medical cross coding. Her other specialties areas are business office systems, business forms, and the implementation of systems to lower accounts receivable.


View Marianne’s full bio