Increase your chance for
rapid claims payment
Include narratives with claim
submissions
Lack of sufficient information
is the most common reason for a delayed or denied
dental claim.
Put yourself in the shoes of
the dental consultant reviewing your claim
Provide the narrative
and documentation that you yourself would need to
understand why a patient requires a particular treatment
or treatment regimen. Dental consultants cannot
directly observe a patient's condition, so your
narrative should address what cannot be seen on
an x-ray.
Example:
If you file a claim for
a crown without any narrative and submit an accompanying
x-ray, a dental consultant might be unable to
detect a fractured cusp that may have prompted
you to place the crown. That claim would likely
be returned with a request for more information,
or perhaps denied altogether. The same is true
of a crown provided for a tooth that appears on
x-rays to have a satisfactory amalgam restoration.
The rationale for the crown is only apparent when
you describe any recurrent decay that is only
evident through a clinical examination.
Anticipate questions related
to policy
In general, dental consultants
look for reasons to approve claims payment, not
to deny it. That's why it's advantageous to anticipate
what questions a particular claim might raise,
and provide the reason it should be paid, in advance
of the question ever arising.
Example:
If you replace a crown
that is less than five years old, anticipate the
obvious question and explain what event or circumstance
made replacement necessary.
No claim is denied for containing
too much information
One helpful tip is
the old axiom: "A picture is worth a thousand
words." Wherever practical, a photograph may
be more effective than words. Few dental carriers
will reimburse you for intraoral photographs, but
if it saves you time, sending in photos to support
your claim may be worthwhile.
Keep in mind that dental
consultants are usually practicing dentists themselves,
who share your depth of knowledge about dental
treatment and disease. Your narrative need not
be eloquent or grammatically perfect. Your knowledge
and expertise about dentistry will likely come
across clearly if you remember that your audience
is a dentist just like you.
Understand the difference between
what's covered and what's needed
Some necessary procedures
won't be payable, no matter what documentation is
submitted. In such cases, it's important to understand
that a recommended treatment may be perfectly appropriate
-- it's just not a payable claim under the terms
of the employer's contract.
Example:
If you provide treatment
for erosion, there's a good chance the claim cannot
be paid because erosion is a common exclusion
under most dental programs. The same principle
applies to treatments that address cosmetic needs
rather than dental disease. Basically, if erosion
or cosmetics is the reason for treatment, no amount
of explanation will allow the consultant to approve
the claim for payment. If such causes are not
the case, however, you can make that clearer by,
once again, anticipating these policy issues
in your narrative and offering your assessment
of the contributory factors (e.g., poor hygiene,
personal injury, etc.).
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