Denials are not Written in Stone

Do you know how to interpret the sometimes cryptic codes and messages medical insurance payers provide on statements? Although it can be daunting at first, cracking these codes is detective work at its best and is a skill set that we’re all proud of…especially when we can help patients get lifesaving treatment and have their medical benefits kick in!

The main goal is to avoid denials although some denials are out of our control when the insurer enters incorrect information. There are, however, many things that you can do to reduce the rate of errors and increase your reimbursements including being as knowledgeable as you can about the codes, processes, records needed, and medical insurer updated policies.

Many denials can be avoided

Success truly depends on what you do upfront!  It’s easier to bombard the insurance company with records showing medical necessity than to deal with an appeal.  While insurance companies may not reveal all of their secrets, they are required to spell out the documentation needed to process Dental Sleep Medicine (DSM) and Temporomandibular Joint Disorder (TMD) claims.  And once you know what’s needed, your clinical notes should be generated in a format that documents the medical necessity of the services.

Taking the time to place an insurance benefit phone call to inquire about what’s needed is important, too. For oral appliances for sleep apnea this typically includes the excessive daytime sleepiness score (Epworth Sleepiness Scale at 10 or higher), a physician Rx, notes from your patient examination outlining subjective symptoms, objective exam findings, your assessment and plan (SOAP format) and a copy of the sleep study.

Some questions to ask during the insurance verification call:

  • Does the claim need to be preauthorized? If so, may we FAX the clinicals?
  • Do we need to provide a CPAP intolerance affidavit signed by the patient (including if the patient declined PAP therapy)?
  • Is a “PDAC” Medicare cleared appliance needed? Some insurers are observing PDAC guidelines which refers to the Pricing, Data Analysis and Coding contractor who publishes the list of cleared appliances.
  • What is the reference number for this call?
  • When applicable; Is combination therapy covered (increasingly more insurers are covering both the oral appliance and PAP)

Denials are not written in stone

There are several different reasons as to why claims or pre-authorizations are denied, but whatever the reason, a denial is not written in stone! More than half of denied claims are overturned with one appeal. Appeals can be started with a specific form, in some cases, by phone and/or by a Peer-to Peer conversation with the medical director.

In the world of medical commercial insurance, there is no standardized “error code library,” so take the time to study the Explanation of Benefits statement (EOB) in order to respond specifically to each “error or denial code”. It does take some skill to investigate each denial reason, but it’s our job to do the detective work and reap the rewards of a job well done.

Demographics. Demographics. Demographics.

Demographics are the details on a patient’s insurance card and also provider detail such as Tax ID and NPI numbers. Demographics can be a problem area and should be checked and rechecked.

When registering the patient ask these questions:

  • Is your name the same as on your insurance card?  For instance, do you go by Jon or Jonathan?
  • Do you have original Medicare (the red, white and blue card) or a Medicare HMO?
  • Is your coverage active? (often the employer changes the insurance and you may be handed the older insurance card)
  • Is your address current?
  • Can I please see the back of your card? (so you can scour the card for group numbers and the insurance contact information).

Provider demographics – Information essentials


NPI, Tax ID, and taxonomy! All important for medical billing because the insurance carrier needs to know your specific credentials in order to provide reimbursement. If you’re already receiving medical insurance reimbursement, the cardinal rule is to avoid making any changes in your identifiers without contacting the insurance company first.  This is to ensure that you continue to be a known provider with that insurer. When in doubt, contact the insurer to inquire about your identifiers on file. Recently, some insurance companies started requiring a Type 2, organizational National Provider Identifier (NPI) for oral appliance reimbursement.  And some insurers now require a number called a taxonomy code, typically placed in the billing information section of the claim.  A taxonomy code defines your type of organization, such as dentist. This is the web site doctors go to register for their NPI 1 OR NPI 2. The provider will also get a taxonomy code here as well: https://nppes.cms.hhs.gov/NPPES/Welcome.do.

Timely follow up

Billing administrators get to know how to interpret the sometimes cryptic codes and messages the insurance payers provide on the EOB. The sooner you determine the reason for the delay and follow up on a claim, the more likely it is to be paid. In healthcare claims processing, time is an enemy to getting reimbursed. Most insurance payers have timely filing limits, so identifying problems and resolving them promptly is crucial.  Most insurance representatives will try their best to help you connect with the right department for appeals. And again, always ask for a reference number for any phone contact.

Patients can also make waves

If other avenues fail, a letter from a patient may catch the attention of an insurance manager. Patients are more proactive and knowledgeable about their healthcare than ever before. If a patient takes the time to call or write a letter to an insurance company manager or executive, then the insurance company may take notice, especially when you have provided the patient with copies of the documentation that you had provided.

Many denied claims, just through good communication and by providing more information, can beresolved. And keep in mind: Your patients need your help. It’s worth the effort!

Rose Nierman, RDH, is the Founder and CEO of Nierman Practice Management, an educational and software company (DentalWriter™ and CrossCode™ Software) for Medical Billing for Dentists, TMD and Dental Sleep Medicine advanced treatment, and co-founder of the SCOPE Institute, a non-profit educational organization dedicated to the advancement of sleep apnea, craniofacial pain treatment, and medical billing within dentistry. Rose and her team of clinical and medical billing experts can be reached at Rose@Dentalwriter.com or at 1-800-879-6468.

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