A former claims processor explains what`s usually wrong with the claims forms submitted by dental offices - those little bitty clerical errors that hold up payment
Linda S. LaFlamme
In my employment at Delta Dental Plan as a cross-trained claims processor in operations, I have noted the clerical errors that are turning up again and again in the claims that are submitted. I would like to share this information with the dental provider to serve as a training aid for new employees. Understanding what information is critical in submitting a dental claim will make it easier for a dental practice to proofread claims that have been denied.
Competitive and progressive dental insurance plans such as Delta Dental of Massachusetts have a comprehensive understanding of what the needs are of a participating provider and can initiate and manage the reprocessing of claims with clerical errors or missing critical information. However, the burden of resubmitting denied claims usually rests on the provider`s shoulders. There are ways to ease that burden by simplifying the resubmission process.
Let`s walk through the information that is critical to the payment of claims. Now, we will get down to dignifying all those worthy places on the claim form. You might find it helpful to cluster the information into three different groups:
- Information relevant to the patient and his insurance.
- Information relevant to the provider.
- Information relevant to services performed.
If information in any of these three areas is wrong or missing, it can cause your claim to be denied. Of course, active coverage on the date of service must be verified before a denied claim is viable for payment.
> Information relevant to the patient and his insurance - Photocopies of patient ID cards kept in office files reflect the patient`s name, ID number and group number exactly as they are on the insurance company`s computer. First, we determine whether the name on the card is printed last name first or first name first. Not all names are familiar to everyone. When preparing the claim, to get an exact match with what information the insurer has, we refer to the patient`s ID card. We focus on verifying ID and group numbers because they are common causes of error due to mistyped or inverted numbers. In proofreading denied claims, another focal point is date-of-birth. Although they are not focal points, the other information is double-checked: the relationship to the insured, sex, condition of treatment (whether service is related to injury or accident), the need for X-rays. With prior authorization claims, X-rays and charts may be required so those items of information take on added importance.
> Information relevant to the provider - This section deals with information about the provider: name, address, phone, licenses number and Social Security number. A statement should be included that indicates service was performed in the office (01) or in the hospital.
> Information relevant to services performed - Don`t` let this give you a headache. Always verify your procedure codes. Amalgams and composites especially are tricky because each requires a tooth number and a code for each surface worked on. There is one set of codes for deciduous (child), and one set of codes for permanent (adult). Be sure to list the tooth number as a tooth letter in deciduous teeth. Remember that there are varying codes for the number of surfaces worked on. Never send in a four-surface code and list only three surfaces. It is a common error and it literally does not pay.
The tooth number section is the place to put relevant information such as quadrants on gum work, or maxillary (U) or mandibular (L) on dentures. The tooth number section is necessary information unless the procedure is an initial exam or a prophy. On root canals, it is safe to put the start and the finish dates, one claim. After you have verified that your descriptive work has all the information, the tooth number or quadrant, any surfaces (amalgams and composites) and the correct codes, check that each procedure has a date-of-service and a fee. Then total your claim. Make sure that you have all required signatures.
Denied claims for allowed procedures within the time restrictions on patients with active coverage on the date of service call for resubmission. When resubmission is necessary, send a copy of your original claim and a letter (see sample letter).
In the letter, you can list corrections and the reasons that the claim didn`t pay. Some examples:
- Original submitted without tooth number; tooth number is...
- Original submitted with surface(s) missing; all surfaces are...
- Original submitted with wrong procedure code; correct code is...
- Original submitted with wrong recipient ID number; correct number is...
- Original submitted quadrant given (gum and root work); quadrant should be UL, LL, UR, LR...
If, in proofreading our claim, we find that the error was on the insurance company`s part, our comment would be: original submitted correctly, active coverage verified for allowed procedure.
Linda S. LaFlamme was employed for nine years with Delta Dental Plan of Massachusetts. Currently she is a student pursuing a degree in psychology.