A fairly common perception is that insurers make it difficult for dentists to get claims paid on behalf of their patients. Nevertheless, payers have a responsibility to their clients, typically employer groups, to ensure that paid procedures are covered by the enrollee’s contract, and that this is supported by the submitted claim, along with accompanying information.
The following are suggestions from Delta Dental of Virginia’s Clinical and Network teams to help you get claims paid, and to avoid delays:
- Fill out the claim form completely and accurately.
- Use the subscriber ID instead of the social security number.
- Provide your NPI.
- Use the correct code for the procedure being submitted – avoid DX999 codes when there is a more specific code for the procedure.
- Submit what was performed without trying to second guess what might be covered.
- Take advantage of the pre-determination process for high cost procedures and when you are uncertain whether a procedure will be covered.
- Provide sufficient documentation that supports the submission (ex. X-rays, photos, charting and narratives).
- Be sure that X-rays are readable, of good quality and appropriate to the procedure being requested (ex. provide a full mouth series or panorex when submitting for a bridge).
- Use a narrative where it will support the submission and include information that may not be apparent in other documentation (see August’s Clinical Tip of the Month for recommendations on Narratives).
- Be aware of the patient’s overall eligibility (are they still employed, have they met their deductible etc.), as well as their eligibility for the intended procedure (ex. have frequency limits been exceeded) – again, take advantage of pre-determination when uncertain of coverage levels.
Avoid these common errors to ensure a complete and accurate claims submission. It will go a long way to receiving timely claims payments.
Michael D. Weitzner, DMD, MS
Dental Director, Delta Dental of Virginia
