How to Manage Denied Claims and Appeals?

Claim denials are a huge reason for payment delays and revenue losses for dental practices. Most of the practices don’t rework or resubmit the denied claims and end up writing off reimbursements, which can be easily collected.

Are you experiencing the same thing?

If yes, we’re here to guide and assist. 

By investing in the best dental billing services, you can work with experts who manage claim denials professionally. They review denial reasons and submit strong appeals that prevent your revenue loss and help you receive fair reimbursements.

If you’re wondering how that works, let’s discuss the complete process and best strategies to manage denied claims and appeals and recover the dues that your practice deserves.

Why Do Insurance Companies Deny Dental Claims?

Before checking the process, it’s important to know the reasons why payers deny dental insurance claims. Understanding these reasons is your first step towards denial management. 

It prevents future errors in dental billing and coding, and helps billing teams correct errors and submit proper appeals for resubmission.

So, let’s discuss common denial reasons. These include:

Coding Errors

Billers use wrong CDT codes for dental procedures or the codes that payers don’t accept. For example, payers may not reimburse for some individual checkup and diagnosis codes, and bundle these into a single treatment code.

Plus, using outdated codes from previous years can also result in claim denials. Now, if you take the American Dental Association’s 2026 CDT update as an example, the code D1352 for preventive resin restoration is deleted, and if billers continue to use this code, claims are prone to denials.

Missing Information

When billers don’t add all the required details in a claim form or make spelling mistakes, payers deny claims. If the information isn’t accurate, and each detail, whether it’s a single digit or alphabet, doesn’t exactly match the patient details in the payer’s database, the claim isn’t accepted.

Patient demographics like name, date of birth, social security number, or other details are ignored, or provider details aren’t mentioned in the form.

Lack of Medical Necessity

For some dental procedures, insurers require documentation that proves that the treatment is necessary for the patient’s health. It may include clinical notes, intraoral photos, narratives, periodontal charts, and radiographs.

If billers fail to attach any of the documents required by payers and cannot provide medical necessity for the treatment, insurers may deny the claim.

Timely Filing Issues

Insurance companies set their deadlines for submitting claims. Each payer has their own criteria. Some may require practices to submit claims within 30 days of the date of dental service. And some payer policy rules extend the deadline to a complete year.

If billers forget to submit the claim within the deadline, payers deny it, and the practice is left with two choices: either charge patients for the costs or bear the loss.

No Proper Coordination of Benefits

If a dental patient is subscribed to two insurance plans, the dental coordination of benefits (COB) helps determine the primary and secondary claim. In that case, billers have to submit claims for primary insurance first, and once the primary claim is reimbursed, they submit a claim for secondary insurance.

When billers confuse primary and secondary and don’t bill primary claims first according to the COB, they experience claim denials.

Patient Coverage Issues

If a patient’s treatment exceeds the limitations in the coverage plan and billers submit claims for that treatment, payers don’t reimburse and deny the claim.

Example: If a patient is allowed two cleanings per year, but gets a third cleaning during that year, it exceeds the plan’s frequency limitation. Due to that, the insurer doesn’t reimburse for it and denies the claim submitted for the third cleaning.

Similarly, there is a scenario of a waiting period. In it, you’ve treated a patient with an ongoing waiting period. It results in claim denials as payers don’t reimburse for treatments during the waiting period. The timeframe can be three to six months, depending on the coverage plan.

Pre-Authorization Requirements

Most insurer manuals publish a complete list of the dental procedures that require their prior approval before submission. These are mostly complex or expensive dental treatments, so billers must get payer approval before submitting claims.

If billers submit a claim for a certain procedure without requesting prior approval and fulfilling the payer’s pre-authorization requirements, payers deny the claim.

Duplicate Claims

If billers submit the same claim twice for a dental procedure, the payer denies the duplicate claim. This error mostly occurs due to billing system issues or a lack of coordination between billers if they’re submitting manual claims.

What are Common Denial Codes?

When a claim is denied by the payer, you receive the Explanation of Benefits (EOB) statement from them and can read it to identify the reason.

EOB statements don’t directly mention the reason, but add a denial or adjustment code, through which billers find out why the claim is denied. EOBs have columns for Remark Code, where they mention these denial codes as identifiers.

It’s important that your billers know the exact codes to manage denied claims and appeals, so they can effectively read the EOB, find the reasons, and send appeals accordingly.

These codes are known as the Claim Adjustment Reason Codes (CARC) for EOBs and Remittance Advice Remark Codes (RARC) for electronic remittance advice (ERA), an electronic version of EOB generated by the billing software for the practice.

Following is a list of some common denial codes:

Payers may define their own Health Care Policy Codes (HCPC) and interpret their meanings of the CARC and RARC codes. For that, you can check your payer’s policies to see their remark codes and use them to identify codes in EOBs or ERAs.

How to Recover Revenue from Denied Claims and Appeals?

Now, let’s review denied claims and appeals management in this step-by-step process.

Step 1: Review the Claim Denial Immediately

The best approach to appealing a denied claim is to act fast. Once you submit your claims, track them regularly, so you’re aware of the status, and you can proceed accordingly.

When you receive the EOB from an insurer or ERA in your software with a claim denial, it’s time to review it. Check the denial code and reason. It may be a hard denial, which the insurer doesn’t pay, or a soft denial, which needs correction and resubmission.

Make sure the process is fast because payers have set their deadlines to submit appeals after claim denials. In most cases, these are 30 days, but they can be different for each payer.

Step 2: Check Your Payer’s Appeal Policies

Each insurance company has its own policies and timelines for the appeals process. Your billing team must comply with these regulations to write appeals that win.

So, check your insurers’ policies, like required documents and deadlines to submit appeals.

Step 3: Categorize the Denial Type

Each claim denial requires separate follow-up. Some require simple corrections while others need comprehensive changes.

Categorize each denial type and manage denial accordingly:

• Technical Denials: These are the easy wins. Incorrect patient ID numbers, wrong dates of service, or simple coding mistakes fall into this category. Fix the error and resubmit.
• Clinical Denials: These require proving medical necessity. Attach documents like clinical notes, x-rays, photos, and reference peer-reviewed journals to prove that treatment is necessary for the patient.
• Authorization Denials: These happen when you haven’t obtained pre-authorization from the payer. You’ll need to prove either that authorization isn’t required or you obtained it properly. In case you haven’t requested it properly, attach the required documents with the appeal letter to prove the procedure is medically necessary.

Step 4: Gather Supporting Documentation

You need to submit strong appeals to convince the payer to reimburse the claim. But, it isn’t possible if you haven’t provided solid evidence to justify its necessity.

So, when you’re submitting appeals, prepare complete documentation, which includes:

• Original claim
• EOB containing denial reason
• Detailed appeal letter with corrected fields in the claim form
• Supporting documents like radiographs, photos, or other diagnostic proofs

With complete details, insurers are more likely to accept appeals and reimburse the payment.

Step 5: Write a Compelling Appeal Letter

Craft a professional appeal letter that persuades the payer to reimburse the amount. Do the following to write an appeal that wins:

• Follow payer compliance: Each payer has their own criteria to accept appeals. Review their policies and start writing letters in a way that payers approve and fulfill their requirements.
• Identify the denied claim: Include patient name, date of service, claim number and the procedure denied
• Mention appeal reason: Clearly describe denial reason (e.g. lack of medical necessity, wrong coding, incomplete documentation, etc.) and any denial codes from your EOB or ERA.
• Explain treatment purpose: Briefly describe the patient’s dental condition with the affected tooth number and evidence like x-rays, periodontal charts, and images to prove why treatment is necessary.
• Cite supporting evidence: Reference peer-reviewed journals, ADA guidelines, or other reliable sources that support the necessity of treatment.
• Request reconsideration: Request the payer to reconsider the denial and reimburse the claim. Use a professional tone in your appeal and mention the terms your payer easily understands. Avoid using technical words.
• Attach documentation: Include all supporting records, imaging, lab results, pre-authorization requests, and records of previous chats with payer representatives.
• Provide contact information: Include the provider’s name, contact details, and a direct phone number or email address for follow-up.

Step 6: Submit and Track Your Appeal

Send your appeal to the payer by sending it via email to the payer or using their payer portal, if it’s available. Save the screenshots, save the appeal number, and pursue payer representatives consistently to make sure that you receive your reimbursements faster.

Step 7: Post Payments to the Accounts

Once the payer has reimbursed the claim, post the payment to the correct patient ledger. If you’ve activated payment posting automation in your software, it automatically posts the payment in the account.

How and When to Escalate Your Appeals?

Even if you’ve submitted the correct appeal to justify the procedure, the payer may still deny your appeal and send an appeal letter to explain why it’s incorrect.

After putting in the effort, seeing appeals getting denied is frustrating. But don’t give up here!

Escalate these appeals to recover your due payments. Do the following:

Submit Second-Level Appeals

Submit a second-level appeal where you need to attach more documents that support the procedure and write a letter to request an independent review of the appeal. The following entities review the appeals for each payer:

• Qualified independent contractor for Medicare (Part A and B)
• Independent review entity for Medicaid and Medicare Advantage (Part C)
• Senior dental consultant or a claim reviewer for commercial payers

So, when you’re writing the request letter for second-level appeal, address the concerned reviewer.

Get External Reviews

If your internal appeal processes haven’t succeeded, contact an independent reviewer organization (IRO) or a dental consultant, who isn’t a part of the insurance company. These firms or professionals aren’t directly related to the dental claim, and don’t benefit from it.

Some states offer the option for external reviews and you can avail it if your state offers it. Otherwise, consult with other independent reviewers.

Make sure that your reviewers are professionals and know dentistry in detail, so they can help review if the treatments justify claims and appeals.

Explore Legal Options

If payers aren’t accepting your proper appeals and denying your correct claims, explore legal options.

The first option is to file a complaint with your state insurance commissioner, who regulates insurance laws in that state. Insurers don’t want to get into legal troubles, so they resolve claims quickly to avoid these issues.

The other option is to consult with legal experts, who assist you in managing your denied claims and appeals.

Tips to Manage Denied Claims and Appeals Effectively

These tips are helpful in managing denied claims and appeals effectively.

Submit Clean Claims

This one might sound obvious to you, but it’s important. There is no need to manage denials if you submit clean claims in the first place.

For that, use real-time eligibility verification to know all the coverage details. And then fulfill claim forms by attaching documents required by payers, filling complete details, and using correct CDT codes. Perform a final check via claim scrubbing to detect errors and compliance issues. Fix them and submit claims that get faster approvals.

These processes make your dental billing smooth, minimizing much of your staff’s effort required in managing denied claims and appeals.

Build Strong Payer Relations

If you’ve strong relationships with representatives at the insurance companies, your task becomes easier. These payer representatives guide you about payer policies and assist you in preparing appeals that comply and can get approved.

They also support you on a personal level by providing you real-time progress on your claim status and submitting appeals. They also keep you updated about the appeal progress.

Automate Denial Management

Use the latest technology to make tasks quicker, easier, and more efficient. You can do that by deploying a dental billing software, which easily integrates with your payer portals and manages all your tasks related to dental claims.

The billing software monitors your claims once you submit them and automates the follow-up process. It reviews the EOB statements by payers, identifies the denial reason, and prepares a complete and professional appeal template for you according to your payer requirements. You can modify the appeal letter by making edits and submit it through the software.

You can save these templates for later use.

The software makes it easier to track the appeal progress. If appeals are successfully reimbursed, it automatically posts payments into the right patient ledgers. And if appeals are denied, it instantly proceeds with escalation.

Monitor Your Performance

When you’re using a billing software, it’s easy to set and track key performance indicators (KPI) that define your success in denial management. You can also check performance metrics which help track your daily activity.

The following key metrics are important to track and measure the success of denial management:

• Claim Denial Rate: This metric helps track the efficiency of your claim submissions.
• Appeal Success Rate: This helps track if your appeals are strong enough to convince payers.
• Days to Appeal Submission: It helps measure how fast you’re at appealing for denied claims.
• Revenue Recovery Rate: It shows how much amount you’ve actually recovered from appeals.
• Denial Overturn Time: This metric helps track how fast insurers overturn and reimburse after your appeals.

When you review these metrics, you understand how efficient your dental billing and denial management processes are. You know if you’re heading towards success or there are certain areas that need improvement.

You can start improving your processes, so your appeal management is effective.

Outsource Denial Management

Denial management is a huge task. In fact, it’s way more complicated than submitting the initial claim.

First, you’ve to track claims regularly. Then you’ve to read the EOBs carefully. If claims are denied, you have to identify the denial codes. And then review payer policies, prepare appeal requests, and write appeal letters that comply with these rules. After that, you have to track progress to see if payers are reconsidering your request. If payers deny it, escalation is again a hectic process.

It’s a very careful process and you can’t afford any mistakes in this task. Wrong appeals mean that chances of recovering revenue have become less.

The solution is to hire experts who can manage denied claims and appeals. But, that means paying huge salaries and increasing overhead.

The good news is that you can get denial management services at the same expert level at a lesser price. For that, you need to partner with professional billing companies like TransDental, which manage your claim denials and submit appeals. They know what payers want and follow the exact processes, making your appeal management smoother and recoveries faster.

And the best thing about outsourcing is that your staff is relieved of the hectic processes. They can focus on other practice tasks, like caring for patients and offering them quality treatment and care.

Conclusion

Managing denied claims and appeals is an opportunity to recover revenue, but most practices ignore it. It requires a lot of effort and careful planning, but if you succeed in it, you can protect much of your revenue.

So, automate your claim denial management to track claim progress regularly, read EOBs and identify denial reasons, prepare appeal templates to save time, review payer policies, and submit strong appeals that ensure reimbursements are quicker and your dollars are secured.

Frequently Asked Questions (FAQs)