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Dental Insurance Claims Processing: Navigating Complex Challenges

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While medical insurance claims processing requires specific expertise, dental insurance claims processing is significantly more complex and involves multiple stakeholders, including payers, providers, and members. Dental claims processing requires payers to have a deep understanding of oral health procedures, dental diagnoses, treatment plans, and clinical notes, as well as coordinate with dental providers to follow specific policies and procedures, including the standard for dental claims processing, the Code on Dental Procedures and Nomenclature.

For payers, understanding members’ dental health and keeping them satisfied with their dental plan starts with the ability to process dental claims accurately and efficiently. There are several factors payers need to understand when navigating the complexity of dental claims:

Dental Procedure Codes

Dental claims rely on a specific set of Current Dental Terminology (CDT) codes. Dental procedures and treatments vary from routine care to preventive services to complex oral surgeries, and each comes with its own set of codes and billing procedures. To accurately process claims, ensure fair reimbursement for members and dental providers, and reduce administrative costs, payers must have an in-depth understanding of these codes.

Predetermination Claims Processing

Dental plans often require preauthorization for procedures like orthodontics, oral surgeries, or procedures that exceed a certain financial threshold, for example greater than $500. Predeterminations, also called pretreatment estimates, are valuable for dentists and patients to aid in treatment planning and financing. In these cases, the dentist submits a claim for proposed services prior to treatment. The payer then estimates the amount the plan will pay and the amount noted for member responsibility. Payers must carefully review treatment plans, including dental records and X-rays, to ensure the proposed procedures are both necessary and follow the plan’s guidelines.

Coordination of Benefits

Coordination of benefits is critical when patients have dual coverage, requiring thorough attention to detail and increased coordination to prevent over or underpayment issues. Careful communication and coordination between medical and dental insurance providers are necessary to ensure the portions of the claims are allocated accordingly between the primary and secondary payer.

Frequency and Timing of Services

Dental insurance plans often specify the frequency and timing of oral health care services. For example, a plan may include annual maximums, exclusions for certain treatments deemed cosmetic, or limitations like covering two cleanings per year, provided the procedures are spaced six months apart. Payers need to be able to track the frequency, timing, and limitations to process claims accurately.

Dental Terminology and Documentation

Dental claims processing requires specialized knowledge and expertise that requires training and understanding of dental terminology and documentation. Payers need expertise in interpreting dental records, navigating treatment plans, comprehending clinical notes, and capturing the correct coverage rates for various procedures to eliminate claim denials or incorrect payments.

Bundling and Downcoding

Understanding bundling and downcoding is critical to the coding and billing of dental procedures. Payers implement these practices to control costs and ensure appropriate treatments and use of resources.

Bundling is grouping multiple dental procedures under a single code, typically when those procedures are done together. Downcoding is assigning a lower-level code to a dental procedure than what was initially submitted by the dental provider. This determination is made to align with the perceived level of complexity or care required for that procedure. It typically provides a lower reimbursement for the service, helping to manage costs.

Downgrading or Alternate Benefits

Another factor in dental claims processing is the least expensive alternative treatment provisions, where the payer may limit reimbursement to the least expensive clinically acceptable alternative treatment, designed to encourage the use of more cost-effective approaches. This often happens when multiple clinically acceptable procedures that provide satisfactory outcomes are available and are called downgrading or alternate benefits. Patients must pay the difference if they choose a more expensive option.

Rollover Maximum Benefits

Rollover Maximum is often available in the dental market and requires payers to manage member claims over multiple years. The benefit allows patients to roll over a portion of their unused spending in the current benefit year to increase their maximum benefit limit next year and beyond. This allows members flexibility in planning and paying for their dental care by allowing them to save part of their unused benefit dollars from a healthy year and use them for larger, more expensive procedures in the future, such as bridges, crowns, and root canals.

Evolving Regulations and Coding Systems

As healthcare is ever-evolving, regulations and requirements continue to evolve as well. Dental payers need to stay on top of updates to coding, compliance requirements, and billing guidelines and ensure they have claims processing systems that are accurate and current.

What to Look for in a Dental Claims Processing System

Payers and dental providers need a system that is easy to configure and considers the distinct needs of dental claims processing. Many outdated core administrative processing systems are not up to the task.

In addition to the Current Dental Terminology (CDT) procedure codes, the system needs to:

  • Capture a mix of data points associated with each procedure, including tooth number and surface configuration
  • Handle bundling and downcoding
  • Process large numbers of claims
  • Account for and provide predetermination to provide members with estimated costs
  • Manage a wide range of dental plans with different rules and requirements
  • Manage the insurance provider’s rules and anticipate a longer-term care plan that reduces costs, such as in the case when a payer’s rules indicate that a dentist avoid filling a cavity now, if in two years the member will need a crown.

Payers use the Code on Dental Procedures and Nomenclature as the standard for dental claims processing, and they need a system that maintains the current version of CDT and adjusts claims when they don’t follow the current standard. For example, the system needs to recognize and adjust claims that are component services within a main procedure, as is the case in bundling, and it also needs to address downcoding requirements and the least expensive alternative treatment provisions.

HealthRules® Payer & Dental Claims Processing

HealthRules Payer is a highly configurable core administrative processing system from HealthEdge that offers a unique rule set. It features the fundamentals of dental claims, including the tooth chart reference and the ability to bill per tooth per service. The rule set and validation policies can be configured to require specification of tooth, tooth surface, and quadrant to limit benefits and pricing, ensuring cost-effective treatments. It also includes an orthodontia scheduler that recognizes if the claim has a banding code to adjudicate and provides adjustments to defined scheduled payments.

The HealthRules Payer Benefit Predictor manages predeterminations, providing payers an easy way to submit member dental benefit inquiries. The system also integrates with secondary editor systems through many APIs, integrating with member and provider portals and other downstream systems. It manages bundling claims like x-ray billing, handles downcoding and least expensive alternative provisions, administers rollover benefits, and can bill self-funded accounts for claims expenses. In addition, predeterminations and cost estimates are easy to process, and the overall system is easy to use.

According to one HealthEdge customer, “The HealthEdge team is fantastic to work with. They are true partners in our digital transformation. With the HealthRules Payer core administration system, we’ve been able to configure the system to meet our claims processing needs. The configurability is particularly critical in dental insurance claims processing. HealthRules Payer helps us manage it all, including bundling and downcoding, so that we can lower costs and provide the best member experience.”

Processing dental claims certainly presents a unique set of challenges. To effectively streamline the process and reduce costs, payers need specialized knowledge and expertise and a core dental claims processing system on which they can rely. With the HealthRules Payer product suite, payers can handle complicated requirements, improve efficiency while accelerating throughput, reduce administrative costs through automation, and understand members’ dental health.

Accelerate your digital transformation and learn more about HealthEdge Dental Plan Administration Solutions, including HealthRules Payer, HealthEdge Source, GuidingCare® and Wellframe® Digital Care Management.