How to appeal a denial for covered services

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DrBicuspid.com has teamed with a former dental insurance executive to provide expertise to you and your staff for maximizing your patient's benefits. Twice a month, Doyle Williams, DDS, will give nuggets of advice to help your claims get approved.

Doyle Williams, DDS.Doyle Williams, DDS.

Early dental insurance contracts were very detailed and often listed each Code on Dental Procedures and Nomenclature (CDT) code that was covered or excluded. That has all changed over the past 20 years, to where the current contracts might just say that "periodontal" treatment is covered without any more explanation. Inside the contract, it refers to guidelines that the insurer may develop and modify in keeping with the standard of care in a community.

The ADA originally created procedure codes that lasted for many years without modification. Then it moved to adjusting the codes every five years, then every two, and now every year. Insurance contracts are usually multiyear with employers, so listing individual CDT codes would require modifying the contracts every year, which is costly to insurers and employers. To react to the annual changes, guidelines have replaced contractual limitations. Many insurers have not updated their guidelines for several years, so their claim to follow the community standard of care is often lacking.

‚ÄúDentists should appeal a denial for covered services with an explanation as to why their patient required the services, and they should copy the regulators in their state.‚ÄĚ

So what does this mean to the dental office? It means that many of the denials for procedures performed are done automatically by insurance carriers without a human review. Dentists should appeal a denial for covered services with an explanation as to why their patient required the services, and they should copy the regulators in their state (usually the Department of Insurance). By copying the regulators, a "contractual reason" will need to be given, and if the insurer relies solely on their guidelines clause in the contract, then they will need to engage in a clinical discussion with you.

Here is a list of some of the most common guidelines that are not part of your patient's contract.

  • Scaling and root planing denied under the age of 30
  • Replacement of fillings denied within 24 months
  • Endodontic retreatment within 24 months denied
  • Gingival grafting limited to two sites per quadrant
  • Surgical extractions denied for deciduous teeth
  • All ceramic bridges denied on posterior teeth

Doyle Williams, DDS, spent 24 years as an insurance executive.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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