Insurance administration has become much more challenging for dental teams over the past
few years. There are some basic steps for successful claim submission to ensure timely and
legitimate reimbursement. This article will provide you with some of the top administrative
errors to avoid.
Failure to submit a clean claim: A clean claim is a claim that is free of errors. The basics of a
clean claim include the following:
Correct Claim form is used: The current dental claim for is the 2012 ADA Dental
Claim Form. If you are still using the 2006 version, update your software to the
2012 version. The current claim form to be submitted to medical payers is the
CMS 1500 (02-12). Payers began requiring these current forms on April 1, 2014.
Complete and accurate patient information: This includes the patient and
subscriber demographic information. Confirm all demographic information on
file at each visit is accurate. Go beyond asking the patient if there have been any
changes, confirm the information. Oftentimes, patients do not realize they have
not been in for a dental visit since they moved 5 months ago, etc. and will
answer no to the general question, “Have there been any changes since your last
visit?”. If the patient or subscriber information reported on the claim does not
match the information on file with the payer then the claim is subject to
rejection, which delays payment.
Complete and accurate insurance plan information: Always ensure a copy of
the insurance card is in the patient record. If the wrong plan information is
included on the claim, the claim will be rejected and/or denied. Confirm the
insurance information listed in the patient record is accurate prior to submitting
the claim and verify coverage with the payer. Verification of coverage may be
obtained via a phone call utilizing the automated system of the payer, payer
website, speaking with a representative, or utilizing a third party company for
Correct current procedure and diagnoses codes: Coding guidelines state that
the code used to report procedures must be the code that most accurately
describes the procedure performed and selected from the current CDT, CPT, or
ICD-10-CM code set. Only codes that are fully supported by the clinical
documentation should be reported. It is imperative to maintain current coding
resources. Code sets are updated on an annual basis and a practice should invest
in the current resources and review changes with the entire team to ensure
Complete and accurate provider information: The doctor who provided the
treatment and/or supervised the hygiene services is listed as the treating doctor
on the claim with his/her individual NPI type 1 number and license number in
the appropriate box/field on the claim form. The location of the treatment is
also included in the same area. Note the treatment location may be different
than the billing entity address.
Failure to document the medical necessity for radiographic images and recording the clinical
findings of those images: Radiographic images should be ordered specifically by the doctor and
should only be taken when medically necessary, based on the individual patient’s needs.
Furthermore, the image must be interpreted by the doctor, and the clinical record should note
the doctor’s findings of the radiographic evaluation or lack thereof. It is not uncommon for a
payer to request the clinical note when a periapical(s) radiograph is taken during a hygiene
recare visit and some payers may request the actual image. The payer is verifying that the
medical necessity documented supports the need for the radiograph.
Billing for nondiagnostic quality radiographic images: Nondiagnostic radiographic images are
considered worthless and should not be submitted to the payer for reimbursement. If
submitted and later determined by the payer to be of nondiagnostic quality, the payer can, and
will, request a refund of any benefit paid. For example, a periapical is taken to diagnose the
need for a crown at any emergency visit. The payer reimburses for the periapical. The
periapical is then attached to the claim for the crown as supporting documentation; however,
the periapical is cone cut and does not show the apex of the tooth receiving the crown. The
payer considers this periapical of nondiagnostic quality and history shows the plan reimbursed
for the periapical on a previous claim and not only requests a refund for the periapical but can
deny the crown.
Invest in proper current coding and administrative resources to ensure compliance. Train your
team and document training. Identify errors and develop protocols to reduce errors. Current
resources and an educated team are key elements to maintaining insurance administration
compliance. Order Dr. Blair’s Administration with Confidence Guide from Henry Schein Dental
to stay current.
Dr. Charles Blair is dentistry’s leading authority on insurance coding strategies, fee positioning
and strategic planning. A widely-read and highly respected author and publisher, he currently
offers several publications, Coding with Confidence, Administration with Confidence, Medical
Dental Cross Coding with Confidence, Insurance Solutions Newsletter, and