Understanding appeals and how to create one in your DentalWriter software
Denials are not final decisions. In our experience, most denials which are appealed, are paid on after first appeal. Pre-Authorizations, Gap Exceptions, Claims, and Appeals may all be appealed.
APPEAL, APPEAL, APPEAL
Reasons PRE-AUTHS are denied include, but are not limited to:
- Patient doesn’t meet the criteria for treatment.
- No medical necessity was shown/provided.
- SEND SLEEP STUDY & LETTER OF MEDICAL NECESSITY FROM MD.
- SEND DW NARRATIVE WHICH SHOWS MEDICAL NECESSITY.
Reasons GAP EXCEPTIONS are denied include:
- There may be another provider within the given distance from patient who performs the same service (in-network).
- CHECK ON THAT PROVIDER. MAY BE A PROVIDER WHO DOES NOT PROVIDE SAME SERVICE.
Reasons CLAIMS are denied include, but are not limited to:
- Insurance Company does not have all necessary information.
- No Pre-Authorization was obtained.
- Incorrect coding on claim form.
- Typos, name or address numbers mixed up.
- Provider credentialing issues.
- Service not deemed medically necessary.
- DO BENEFIT CHECK, MAKE SURE POLICY IS CURRENT, AND SERVICES ARE COVERED.
- MAKE SURE YOU’VE SENT IN ALL REQUIRED DOCUMENTATION.
- DID YOU FILE PRE-AUTHORIZATION & INSURANCE COMPANY MADE MISTAKE? THEY ARE HUMAN, AND HUMAN BEINGS MAKE MISTAKES.
- CHECK ALL CODING AND TYPOS BEFORE SENDING IN CLAIMS – IF MISTAKES WERE MADE, CORRECT THEM.
- IF FIRST TIME BILLING TO THAT INSURANCE COMPANY, SEND IN W-9, SO YOUR OFFICE IS RECOGNIZED.
- LOOK UP POLICY ONLINE, MAKE SURE YOU ARE USING CORRECT CODES FOR SERVICE.
In the following claim, the Federal Tax ID is missing or invalid. All that is needed is for a new claim to be submitted with the correct Federal Tax ID filled in on the claim form. No appeal is necessary.
In this next example, medical necessity has not been shown for this pre-authorization request, They are asking for a sleep study, letter of medical necessity and CPAP intolerance form, as well as a letter from the dentist - a DentalWriter narrative report - addressing that the patient has adequate dentition for retention of the appliance, lower jaw movement room, and an absence of active TMJ or periodontal disease.
For the following claim, there are 4 remarks listed as reasons why this claim was paid this way. These services were performed by an out-of-network provider, and there was not a pre-authorization submitted with supporting documents which includes a Dental Writer narrative showing medical necessity. A Benefit Check, GAP exception (if possible), and a pre-authorization was required for these services from this provider. A phone call to the insurance, and a request for a back dated (retro) pre-authorization and GAP exception (if allowed) would be necessary at this point.
Respond to Denials
Take a deep breath and:
Respond in a timely manner. Most denials state response deadlines, read fine print. Also, check address where appeal is to be mailed or faxed. Denials usually include denial codes. Be sure to respond to each code or note. Keep in mind, not all denials require an appeal letter. Carefully check claim form for incorrect numbers, names, and codes. Corrections on the claim may be all that is necessary.
Use DentalWriter to help you write your APPEAL.
Select your patient, and click on Quick Letters tab in your DentalWriter software:
Once you click on QuickLetters, click to View all Templates:
Once the list is open, click Search by Keyword.
Type in APPEAL, and then click on SEARCH NOW:
There you will see a list of many APPEAL templates for you to customize and use for your Appeal to insurance. Create your letter and make any changes and additions to claim form and you are on your way.
Finally – If your appeal gets denied. Consider appealing again. We have letters for that, too!