Accurate Dental Claim Submission: Reducing Denials for Faster Payments

Payers can deny claims at any time, even for minor mistakes. You miss just one spelling in the patient’s name or write just one incorrect digit in the provider’s NPI number, and your claim is denied.

You just don’t lose revenue and see a delay in payments. It also affects your cash flow, and your staff is overburdened with reviewing the EOB, writing an appeal, and submitting a claim all over again. It takes a lot of time!

But you can prevent that by implementing strategies and investing in professional dental billing services for accurate dental claim submission.

If you’re wondering how, we’ll guide you through the ways and processes in this informative blog.

What is a Clean Dental Claim Submission?

A clean claim is an insurance claim that is free of errors and complies with the payer policy rules for dental claim submission.

Payers mostly approve clean claims and reimburse payments for them quickly.

While each payer has its own requirements, the most common things to look out for in a clean claim are:

• Correct patient details like name, date of birth, and member ID
• Correct claim details like claim number and accurate CDT code
• Complete treatment details, like tooth and surface number
• Complete documents required by the payer, such as clinical notes, periodontal charts,  and radiographs
• Prior approval obtained for certain dental claims

You must verify each detail with the payer before submitting a claim. Contact the payer by calling the representative or cross-check details via the payer portal. 

And once you submit a claim, match the details in the dental claim form to detect errors. If the claim has errors, correct them. But if the claim is completely perfect, submit it with confidence.

What are the Common Errors in Dental Claim Submission?

The first thing is to find the top errors in dental claim submission and fix them.

Here, we’ll mention the common mistakes in billing that result in dental claim denials:

Billing for non-covered services

Payers don’t reimburse claims for certain dental services, which are either high-cost, complex, or not considered medically necessary. When you submit claims for the non-covered services, payers deny them.

Solution: Search for non-covered services. You can easily find the list of non-covered services in the payer manuals and in the patient’s coverage plan, which clearly explains what the payer covers.

Exceeding frequency limitations

Payers set limits on a patient’s coverage plan for dental treatments in a calendar year. They limit how many times they cover a treatment and the maximum amount they cover for each procedure.

If you submit claims while exceeding the limitations, payers deny the claim, and you must charge the patient for the remaining costs. If you can’t recover the amount, you’ll have to write it off.

Example: A patient’s coverage allows only two cleanings per year, and if the patient gets treated for the third cleaning within the year, the payer doesn’t pay for it. 

And if the patient’s plan covers $2000 and the treatment costs exceed the limit, the payer doesn’t reimburse, and you’ll have to charge the patient for the remaining balance.

Solution: Use real-time eligibility verification to know the limitations in a patient’s plan at the time of service. When you know how much the payer covers and what the patient pays, you can provide accurate written treatment estimates to the patient, so they can easily pay. With that, you can submit the right claim and get paid right from both ends.

Failing to obtain pre-authorization

Payers require practices to obtain pre-authorization for high-risk or costly treatments, like bone grafting, bridges, crowns, dentures, implants, inlays, onlays, and surgical extractions. 

Each insurance company or Medicaid state plan sets its own pre-authorization requirements, which practices must follow. They publish manuals listing dental procedures that require payer pre-authorization before dental claim submission.

If you don’t comply and submit claims without requesting approval, insurers deny the claim.

Solution: Check the payer manuals and verify with the insurer if the dental procedure requires pre-authorization before treating the patient. If the payer requires it, submit a pre-authorization request letter with solid evidence to justify that the patient needs the dental treatment. 

If the payer approves it, submit the claim, and if the payer doesn’t reimburse for it, inform the patient and charge them.

Missing or incorrect patient information

If you submit a dental claim with a misspelled patient name or a wrong member ID, the payer denies it. Even a single typing mistake isn’t acceptable.

Solution: Ensure the patient demographics and insurance data match the patient details in the coverage plan and payer portal.

This process begins when a patient schedules an appointment with your practice for a dental treatment. Your front desk team receives all the details from the patient and records them in the practice management software. 

The team should immediately verify these details by processing practice management integration with dental billing. The billing software automatically fetches details from the PMS and verifies them from the payer end.

Missing payer’s timely filing limit

Payers set deadlines to submit dental claims after performing a treatment. For example, if you have performed a root canal therapy, the payer requires you to submit claims within 30 days of the treatment.

If you don’t submit the dental claim within the deadline, the payer doesn’t pay for it.

Solution: The best practice is to submit a claim within 24-48 hours of the date of service and confirm if the payer has received the claim. Receive the claim tracking number from the payer and ask the representative to provide you with an expected time for reimbursement.

Mostly, payers reimburse dental claims quickly after receiving them.

But, if your payer doesn’t pay within the expected time, complete your documentation by keeping a record of your conversations with the payer representative and save the tracking number. It protects you when you’re managing denied claims and appeals, follow-ups, and escalations.

Missing tooth numbers and surface designations

The ADA dental claim form has available sections for tooth numbers and surface designations. If you don’t mention the treated tooth number/letter or tooth surface, the payer denies the claim. 

The claim is also denied if the tooth number/letter or surface on the form is incorrect or doesn’t match the treatment details.

Another instance is that the payer may reimburse a lower amount if you don’t clearly mention the surface. For example, if you bill a 3-surface composite but don’t list the surfaces, the payer may reimburse the amount for a 1-surface restoration.

Solution: Enter all the required fields in the claim form, especially the correct tooth number and surface. Make sure that the details are the same as on your clinical records.

It protects your claim from denial and underpayment, as the payer gets the complete details about the treatment, knowing about the damaged and treated tooth and its surface.

Providing incomplete documentation

Payers expect billers to provide all the documents required for dental claim submission. They mostly mention the required documents for each dental procedure in their manuals.

These documents are evidence that a treatment is necessary for the patient’s health and must not be missed. Payers review these documents to check a patient’s dental condition, diagnosis, and the need for treatment. If the documents validate the claim, payers likely reimburse it.

But if you fail to provide these documents, payers deny the claim.

Solution: Check payer manuals to see the documents required by the payer. You can also contact the payer representative in real-time to ask for these documents. And when you fill out a dental claim form, attach all the documents with it.

Mostly, the following documents are required in dental claims:

• Clinical notes or narratives
• Copy of patient’s insurance card
• Dental radiographs
• Intraoral photos
• Operative notes
• Periodontal charts
• Prior authorization approval by the payer

But the requirements can vary for each procedure.

Bonus tip: Attach the documents that justify the necessity for a treatment, even if the payer doesn’t require it. These documents strengthen your dental claim submission, as you can confidently prove to the payer that the treatment is valid, leaving no room for claim denial.

Submitting duplicate claims

Submitting a claim twice is a common billing error. Payers deny a dental claim if the patient, date of service, CDT codes, and provider are the same across both claims.

Plus, if your staff makes a mistake more than once, it can lead to legal complications. If you submit a dental claim twice, your account may be subject to inspection by the insurance company or even state authorities.

Solution: Automate your dental billing and coding with software that tracks a claim before submission. It automatically flags or blocks a claim with matching patient details, CDT codes, date of service, and provider information, before dental claim submission.

Using the wrong CDT codes

Payers use CDT codes to identify dental procedures. The ADA publishes CDT code updates each year, revising these codes. It modifies some existing codes, adds new ones, and deletes outdated codes.

Payers publish their own manuals. They provide a list of the dental procedures they reimburse and the CDT codes they accept. 

Example: Payers may bundle the CDT codes for diagnosis and check-up into a single treatment code. They also may not reimburse costly procedures or cosmetic dental procedures that may not be necessary for a patient on medical grounds.

If you don’t submit the CDT codes according to the latest updates and payer manuals, payers deny the claim.

Solution: Follow the ADA code updates and check the payer manuals to see the codes for which they reimburse.

You can also automate the process by integrating the payer manuals into your PMS or billing software, so it fetches the right code according to the latest updates and payer guidelines.

How to Prepare a Dental Claim Submission Workflow?

If you want to make your dental claims error-free and compliant, prepare a complete process that your dental billing staff must follow.

The following are the steps in a complete dental claim submission process:

Verifying Insurance Eligibility in Real-Time

The dental claim submission process begins with a patient’s eligibility and benefits verification. 

Front office staff must check the patient’s coverage plan and verify the insurance details in the payer portal to check if all these details are accurate and if the patient is eligible to receive a treatment under insurance.

The coverage plan also helps you check the benefits, including how many times a patient can get a certain treatment within the year, and how much the payer reimburses for that plan.

While each plan has its own requirements, commonly, payers cover:

• 80-100% preventive care (fluoride treatment, oral exams, routine cleanings, X-rays, etc.)
• 50-80% basic services (extractions, fillings, periodontal maintenance, etc.)
• 40-60% major services (bridges, crowns, dentures, implants, root canals, etc.)

The annual maximum that payers cover in most plans ranges between $1,000 and $2,000. They may also cover lifetime coverage on orthodontic dental treatments.

But the benefits and limitations vary by each plan. A payer may modify a patient’s coverage according to the patient’s dental condition and purchased plan.

Make sure that you verify details in real-time, as payer requirements and patient coverage can change at any time. If you do it upfront, things may not stay the same.

Collecting Accurate Patient Information

All the patient information must be complete and correct. Whether it’s their demographics, like name, DOB, and contact information, or insurance data like member ID, the patient details in your system should match what’s available in the payer’s system.

If the patient data in your system needs an update, contact the payer and confirm with it. Cross-check details to make sure that the patient data is accurate. It makes your dental claim submission clean.

Documenting All Treatment Details

Enter all the details of the treatment, including the relevant CDT code, tooth number, and surface designation, on the ADA dental claim form.

Make sure that all the details match the patient’s clinical record in the patient’s chart. The complete dental patient chart features everything, including:

• Medical and dental history: Details of the patient’s health conditions, medications, allergies, and past dental treatments to ensure safe and appropriate care
• Clinical examination records: Findings from exams, charting, and diagnoses to support the need for treatment
• Progress notes: Detailed documentation of procedures performed on each patient visit, including tooth numbers, surfaces, and clinical justification
• Diagnostic records: Intraoral photos, periodontal charts, and x-rays to prove a dental condition and support its treatment
• Treatment plan: Documentation of proposed treatment to the patient, with financial details of what insurance covers and what the patient pays
• Consent forms: A form that contains a list of treatment expenses and requires the patient’s signed approval for care

The payer reviews all these details to check if the treatment is valid and the practice has clearly explained all the details of the patient and obtained their consent for the treatment.

Documenting these details doesn’t just benefit you with a dental claim submission. It also:

• Protects your practice legally
• Complies with insurance requirements
• Helps other providers to see patients’ treatment history and issues, and propose relevant treatments

Attaching Supporting Documents

Attach all the documents that support your case for claim submission. These include:

• Diagnostic radiographs: Bitewing or periapical X-rays that show decay, bone levels, or pathology to justify the treatment
• Intraoral photos: Clinical real pictures of teeth and oral tissues, which are used to visually document damage, fractures, or restorative needs
• Periodontal charting: Detailed measurements of pocket depths, bleeding, and attachment loss to support treatment for procedures like SRP, flap surgery, and periodontal maintenance
• Clinical narrative: A written document that describes the patient’s dental condition with the treatment, explaining why a procedure is necessary.
• Prior authorization approval number: The reference number issued by the payer, which confirms that the payer approves coverage for the specific procedure.

Detecting Errors with Claim Scrubbing

Before submitting dental claims, you need to detect errors and correct them with claim scrubbing and error prevention.

It’s important to check if all the details are correct in your claim and comply with payer requirements.

There are two ways to do so: either you can electronically scrub claims via a billing software or manually check claims.

If you do it electronically, it saves time and automatically detects errors, whether these are typos, wrong CDT codes, or missing documents.

Claim scrubbing saves your staff’s valuable time by preventing the need to manage claim denials, pursue payers, and send appeals to recover payments.

Scrubbing rejects the claim, so you can correct all the mistakes and also fulfill all the payer requirements.

Submitting Claims to Payers

When your claim is fully compliant and free of errors, the software forwards it to a clearinghouse, which can be a built-in feature or a separate tool.

A clearinghouse converts the dental claim into 837D or any other electronic format approved by the payer. It sends the claim straight to the payer, so the payer receives and reimburses your claim quickly.

How to Make a Checklist for Dental Claim Submission?

Create a checklist for your dental billing staff, so they make sure that the claims are complete and error-free. It helps reduce denials, prevent duplications, and speed up reimbursement.

Here is a sample of a one-page checklist for dental claim submission:

What are the Best Practices for Dental Claim Submission?

Submit Electronic Claims

Electronic dental claim submission is the fastest way to get reimbursements. There is no need to send paper forms via mail, which takes time to reach the payer. 

The electronic claims go straight to the payer, reducing delays and eliminating lost paperwork. Payer instantly confirms that it has received the claim and provides you with a tracking number, so you can easily track its status in the payer portal.

If you submit claims via a dental billing software, it automatically removes errors by flagging missing tooth numbers, surfaces, or CDT codes before sending a claim. Without errors, there are fewer denials, faster payments, and a consistent cash flow for your dental revenue cycle.

Automate the Billing Process

Automating your dental claim submission saves time and reduces human error. Whether you integrate your PMS with a billing software, use an all-in-one software, or invest in high-tech solutions like dental RPA, the billing process becomes easier and quicker.

With automation, your system automatically pulls patient info, procedure codes, and insurance details, and verifies the information on the payer’s end to generate and submit clean claims.

It also relieves you of worrying about forgetting filing deadlines or resubmitting rejected claims manually. With automation, claims are submitted on time, and rejected claims are corrected, even though an expert review might be required for complex cases. With that, it’s easy to track a claim and follow up with the payer.

Outsource Claim Submission

If you outsource your claim submission to a billing company like TransDental, it reduces your overhead and streamlines the billing process. Experts handle dental coding, claim submission, and follow-ups, while automation speeds up billing tasks and removes errors. It frees up your staff to focus on patients instead of paperwork.

An expert billing company knows payer rules, can reduce denials, and make reimbursement faster. Outsourcing makes your revenue cycle smooth, so your:

• Staff work with dedication
• Patients receive the care they deserve
• Practice gets paid with hard-earned dollars

And they charge you much less than staff salaries. So, you get customized dental billing services and maximum profits at affordable rates.

Conclusion

To get paid smoothly, make sure that your dental billing services are smooth and reliable. With that, your dental insurance claims are clean and accurate. Denials happen, but you can reduce their volume and maximize your collections with the right strategy, team, tools, and processes. 

So, prepare a complete process with the checklist, automate the billing process, and work with billing experts for fast claim approvals and quick and complete reimbursements.

Frequently Asked Questions (FAQs)