Once your dentist submits a dental insurance claim, it goes through an adjudication process which includes verifying its details, assessing treatment provided and checking insurance coverage.
Dental claims processing doesn’t need to be an overwhelming experience – you don’t need to wait forever before starting!
Processing Time
As soon as a claim is submitted to an insurance company, it will first be assessed for completeness – this involves checking insurance policy number, deductibles, co-insurance levels, fees associated with treatments as well as factors impacting coverage – then fees are compared against their “allowable fees” (Usual, Customary and Reasonable- UCR) for that procedure – either below or above which an approval or denial decision will be rendered and an Explanation of Benefits statement with payment information issued as necessary.
Dental insurance claims sometimes require additional documentation in order to be processed or validated, including X-Rays, charts or narratives. When such attachments are necessary it’s a good idea to submit it with the initial claim submission as this reduces back and forth and potential delays.
Insurance companies will examine the codes used to describe dental treatments, and compare them with similar claims submitted to them. If claims that are improperly coded are submitted for review by insurance companies, they will either be rejected outright or resubmitted with correct codes; any resubmitted claims take longer due to additional reviews by them.
An experienced dental biller can ensure timely and accurate claims submission, minimizing resubmissions or rejection payments. They can also advise the dentist regarding changes to insurance policies or regulations which might impact claim processing or processing timeframes.
Use of an electronic dental claims system can greatly decrease processing times for claims. Many dental offices now employ digital EDI solutions for this process, reducing manual data entry while improving accuracy. Furthermore, the system will scan for discrepancies and notify billing teams as necessary.
Utilizing an automated EDI solution speeds up claim processing significantly and typically receives confirmation within 24 hours from their insurance carrier, giving dental offices more time to focus on seeing patients instead of claims administration.
Verification Time
Prior to receiving reimbursement from their insurance provider, the dental office must first conduct an insurance verification check. This step can significantly decrease collection challenges in practice by preventing patients from receiving services they aren’t covered for and enabling accurate claim submission.
Verification involves gathering key patient information such as their group ID and member ID numbers, employer contact info, procedures performed and services offered, etc. Once this data has been entered into software for tracking claims submitted it allows easily matching to those services in record. Furthermore, this process allows dental offices to verify details like deductibles, copayments/coinsurance percentages/annual maximums or any exclusions and limits that might exist for claims being submitted against dental practices.
In cases where the verification process is unsuccessful, a dental office should contact their insurance provider in order to clarify coverage or address any identified issues. When this occurs, dental offices must document all communication as well as any action items or resolutions provided; then relay this information back to their patients so that they are aware of what’s going on and can take steps toward solving any potential problems that arise.
Once a claim is submitted to an insurance company, they will review it to make sure all information has been filled out accurately and that all documents have been attached. They may then request more information or issue a final verdict on it. If a claim is denied, dental practices can appeal the decision by providing additional documentation, clinical notes or x-rays that prove the procedure was medically necessary – an often time-consuming process but important if timely reimbursements are to be received.
Apex EDI’s dental billing solution offers automated processes to streamline data entry and ensure accuracy, making the processing of claims simpler than ever before. Plus, Apex EDI offers tools to speed up submission times of insurance claims faster than ever! To learn more about how Apex EDI’s software can streamline claims submission, schedule a demo today!
Payment Time
Once your dentist submits their insurance claim, it must go through adjudication. This step involves the insurance company verifying claim details to ensure accuracy and validity, as well as whether rendered services align with your dental plan coverage. Following verification, the insurer settles your claim by disbursing funds directly to your dentist; once paid out, an EOB (Explanation of Benefits) document containing information about this payment will also be provided as proof.
Many states have prompt payment laws requiring insurance companies to process a claim in a specified timeframe, with most states mandating payment within 30 days after submission. To ensure timely payments of claims it is imperative that all necessary documentation is included with each claim, such as medical records, patient statements of account, receipts, X-rays and dental treatment notes.
Along with providing all of the necessary documentation for a claim, it’s also crucial that follow up is conducted when necessary with an insurance company. This is especially relevant if payment has not yet been processed due to missing documents or errors within a claim submission; additionally, an insurer may require further documentation from dental offices in order to validate claims submitted.
Insurance verification is an integral component of insurance submitting, helping reduce billing headaches and paperwork burden. Making extra efforts toward insurance verification could pay dividends by expediting claims payments faster and increasing revenue streams. This step may save time, stress and effort while increasing revenue streams.
Automatic eligibility verification software can help expedite the claims processing process and minimize denied and rejected insurance claims. Furthermore, using this tool can also allow you to track and monitor each insurance claim’s processing status so as to ensure timely processing. Furthermore, if an insurance claim has not been processed within the timeframe dictated by your state prompt payment law you can file an appeal and pursue this avenue further.
Denial Time
Too often, dental insurance claims are denied by insurance companies for various reasons, making it essential that your office remains on top of this issue. One way is hiring an experienced insurance coordinator who focuses solely on managing all aspects of claim processing for your practice; or outsourcing this responsibility to a dental billing service which ensures claims are filed correctly from start to finish.
Staying abreast of deadlines for filing claims is also key, with most dental insurance plans having specific filing deadlines that must be adhered to for timely processing and payment. Implementing a system to notify staff about these dates and prevent missed filings is especially useful for busy dental practices.
One of the primary factors for an insurance provider to reject a claim is inadequate or incomplete documentation. Accurate and comprehensive documentation is key in minimizing rejection rates; such as providing detailed narratives with intraoral pictures and x-rays.
Claim rejections often occur because claims don’t follow insurance plan guidelines, including submitting an accurate claim form with accurate information and signature, as well as sending out an Explanation of Benefits with all required forms completed and sent directly to patients. Staying abreast of these changes can be challenging, yet your team should do everything in its power to understand and adhere to them to reduce denials.
Denied claims can significantly decrease revenue and administrative workload, as well as negatively affect patient experience at your dental practice. Therefore, it’s critical that you develop a strategy for appealing any denied or downgraded claims, in order to collect what patients owe and expedite payments quickly – something your dental billing team can easily do by having an effective template in place that they can use when appealing a claim with the insurer.
