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Dental Claims 101 - What You Need to Know

Dental claims are complex. But understanding the workflow involved can help dental practices identify areas to reduce costs and speed up turnaround time.

Dec 21, 2023 4 min read
Dental Claims 101 - What you need to know

Dental claims processing includes all processes involved in giving care to patients, right from the moment a patient is registered with a dental practice, up until the explanation of benefits (EOB) and payments are finished. There are two ways of submitting a dental insurance claim; one via paper and the other, electronically. Any inefficiencies in these insurance claim submissions end up being a source of additional cost to dental practices. This article will walk you through the dental insurance claims process and everything else you will need to know about dental claims.

After a patient has visited a dental service provider, claims have to go through multiple steps before the patients receive their final bill. The sequence noted below is what the entire process looks like:

Billing:

The insurance provider is sent a bill for charges for services rendered. This is not inclusive of any charges paid via co-pay upon check-in.

Adjudication:

A certified claims processor will then review the claim, ensuring accuracy and comparing it against the insurance plan to validate whether the services rendered were covered by the insurance or not.

Reconciliation:

If the services received were covered under the benefits, the insurance company will pay the claim based on the allotted coverages. They may pay the entire claim in full depending on the patient’s plan. Otherwise, the remaining balance will be billed to the patient.

Validation:

These amounts are then validated and applied to deductible and maximum out-of-pocket totals as they apply to an insurance plan. Those are updated immediately.

Explanation of Benefits: 

An explanation of benefits details the list of services received by the patient, how much was covered by insurance, how much the patient has to pay, and what remains to be billed. An EOB is sent to the patient post-treatment.

Final Billing:

A final bill will be sent to the patient for payment if there are any additional payments that need to be made from the patient’s side apart from the co-pay that was paid upon check-in.

Payment:

It is the patient’s sole responsibility to compare the EOB and final bill and ensure everything mentioned is accurate and billed correctly. Sometimes these numbers do not measure up because of a mismatched procedure code or other clerical error. Once detected, these mismatches can be fixed and claims can be updated without any penalty.

What are the necessities for filing a dental claim?

Given below is the standard set of information required for filing a dental claim. Each claim that you submit to payers needs to include the following:

  1. The Subscriber’s ID.
  2. The name of the patient, his/her date of birth, and relationship to the Subscriber.
  3. The name of the dentist or practice, Tax Identification Number or Social Security Number, National Provider Identifier (NPI), and phone number;
  4. The procedure code number as per the American Dental Association (CDT), the treatment date, tooth number, tooth surface(s), the doctor’s fees, and a narrative or description of services as deemed necessary;
  5. The Member’s signature for the release of information and/or assignment of benefits. The Dentist’s signature.

It is vital to do everything a practice can to avoid denials in order to protect the financial health of the practice, and its reputation as a preferred place to work and perform dental care procedures. Here are some measures that can be taken to avoid delays and denials while filing for dental claims:

  1. Map out your dental insurance claims process workflow in detail to streamline it.
  2. Identify the insufficiencies in your claims process, in order to fill in any gaps discovered.
  3. Reduce errors in data entry by double-checking the patient information.
  4. Choose electronic forms over traditional paper forms to collect patient information.
  5. Promote the use of templates to record clinical notes so as to ensure uniformity and clarity in data collection.
  6. Make sure claims are submitted including all the relevant imaging, else there is a risk of rejection.
  7. Carry out frequent evaluations of your process to ensure they are up to date.

Conclusion:

There is no doubt that managing dental insurance claims is a distressing task for a lot of dental practices. However, staying on top of the collection game needs to be top priority for all dental practices alike. The better a practice gets at submitting claims successfully, the sooner its accounts receivables get converted into cash, and the healthier the cash flow of that practice becomes. Since a good claims process in place can affect the profitability of a dental practice to such an extent, it is crucial that all collection issues be addressed at the earliest.

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Dec 21, 2023 4 min read

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