If I want to appeal a denied dental insurance claim, should I close the claim?
You’re an insurance coordinator or office manager moving through the dental billing process. You’re a little green when it comes to knowing the process front to back, and you’re not sure who to turn to with specific questions on insurance claims.
Hey, we’ve been there! The dental billing process is complicated and intricate, but unfortunately, your dental practice depends on you knowing this process. Dental ClaimSupport is here to help answer those uber-specific questions. We DO know the ins and outs of the dental billing process, and we’re here to share the knowledge.
In this article, we will share why you should not close out and recreate a dental insurance claim, even if it’s denied by the insurance company.
Why would a dental insurance claim be denied?
If a claim is denied, insurance is saying, “No, we’re not going to pay you the insurance’s share of the procedure.” Super annoying, right? Well, there’s usually a reason for this. To start, you need to figure out why your claim was denied in the first place.
Insurance claims can be denied for a myriad of reasons such as missing or inaccurate information on the claim. This could mean the CDT code, the birth date of the patient, the name of the patient, the procedure, missing required attachments - these things MUST be accurate in order to get your claim paid. It’s crucial to get these pieces of information correct the first time to prevent claim denials that lead to payment delays.
However, it’s important to note that some claims can be denied, accurately, as "no pays" (i.e. denied due to age limitation, frequency, or waiting period). These are just common limitations and exclusions in any insurance policy. So in these cases, an appeal isn't always necessary if the insurance correctly processed the claim.
BUT for claims denied incorrectly, or if certain procedures within a claim denied or were paid incorrectly by insurance, you need to appeal them... Below are some examples where appeals may be necessary.
Here is a list of certain denials that may need appeals:
- Alternate benefits
- Timely filing
- Medical necessity
- Any other incorrect denials
If you have decided that a procedure needs to be appealed, there is a correct way of going about it. You do not want to delete claims and recreate them in these cases. We’ll get into the “why” below.
What can happen if I close out a denied dental insurance claim and recreate it?
Once you figure out the reason the claim is being denied, you have truly two options:
- You can close the claim and bill the patient.
- You can leave the claim open and appeal it.
Spoiler: if possible, we recommend the second option in order to fight for your patient! If your goal is to appeal the claim, you should not close it.
Closing the claim and recreating it prevents your dental software from tracking the original date the claim was sent, and ultimately removes it from the appropriate aging category on your insurance aging report. Starting from scratch with the claim can result in the claim getting lost in the shuffle. Once an original claim is closed and recreated, it’s removed from your over 30 report.
This means when this report is generated, you won’t see the original denied claim there, and it’s easily forgotten until it has aged another 30 days from the recreated date. In simple terms: if you close the claim then recreate it, it starts the true aged time of the original claim over in your software.
When this happens and aged claims fall through the cracks, it’s going to take longer for insurance to pay you, the claim may even hit timely filing.
Delayed payments can result in a low collections percentage, AKA your dental office is not bringing in as much money.
Instead, ALWAYS strategically appeal the original, denied dental insurance claim
The process of appealing a claim can depend on the reason for the denial.
Like we mentioned, a claim can be denied due to missing information, such as a supporting document or image like an X-ray or a perio chart. So you would simply resubmit it with the correct information as an appeal.
Learn 5 Simple Tips on How to Win Insurance Appeals in our Learning Center!
Another reason a claim can be denied is because insurance will say the patient's coverage is no longer active. When this happens, people tend to close the claim right away and bill the patient. Some patients will tell you their employer has recently provided updated insurance information regarding a policy change. This means they have new information for you, or that they need to contact their HR department.
For this reason, a phone call to a patient prior to closing the claim is best. Leaving the claim open until you can either confirm that the patient no longer has active coverage and needs to be billed, OR that they do have updated policy information for you, will ensure the claim does not fall through the cracks.
Once you are given the updated information, you can close and bill the patient as needed, OR in this case, you would delete the original claim, update the policy information in your software and recreate the claim with the correct information. This is the only scenario that truly starts the age of the claim over again, as it is being billed correctly to a new insurance company.
The best way to avoid the situation we just discussed is through diligent insurance verification. Before patients arrive in the office for appointments, acquire your patient’s insurance information and verify that it is active. This way you can communicate anything out of the ordinary to the patient beforehand, and they’re less likely to have surprise bills. Always ask them every time they come in if anything has changed with their dental insurance!
Learn more about Dental Insurance Verification in our Learning Center!
Know the dental billing process like the back of your hand
It’s hard to remember the “right” way to do every part of the dental billing process. And everyone has their own way of doing things, but closing out or deleting an unpaid claim only helps your dental practice lose money. Do the extra work and get that claim appealed as quickly as you can.
To learn more tips on how to improve your dental billing process, check out our recently published book, Ultimate Guide to Dental Billing and Reporting.
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