As a former clinical claim reviewer, I can assure you, that reviewing dental claims is a challenging job! You have an ever-growing number of claims to review clinically, with the numbers going up to about 300 a day. My time in the claims industry leaves me with unique insight into the workings of this opaque business and I thought it’d be interesting to share what a typical day for a dental claim reviewer looks like.

Reviewing dental claims is a hands-on job, with peer-to-peer call requests round the clock, irrespective of time zones, and it’s the reviewer who has to work around everyone’s schedules.

One might think of this as a leisurely role to adopt on your way to retirement, but the turnaround time (TAT) requirements dictate how your day’s going to be, what you’ll be doing and when.

But not all dental claims need a human’s eye to review them. As a reviewer, typical types of claims requiring your insight are around crowns, periodontal scalings and root planings, orthodontic claims, fixed bridges, extractions (most common cases requiring human insight), soft tissue grafting, endodontic retreatments and pediatricof dentistry, with some osseous surgeries and implants. Claims not requiring a human’s input, mostly include diagnostic examinations and x-ray claims.

The hardest thing for a claims reviewer is realizing that not enough claims are made to validate whether the treatment recommendation for a given case was appropriate or not or whether an appropriate standard of care was delivered for the given case.

Instead, claims are mostly reviewed for “medical necessity” and “compliance” with reimbursement policies and provisions.  The clinical element to the review process is hence missing.

Another point to understand is that, even though insurance is great when it offsets treatment costs, it is by no means a guarantee of coverage or a validation of the necessity of treatment recommendations made.

Clinical Claim Review: How is it Done?

Let’s say that you, as a treatment provider,  treated your patient’s upper right molar tooth. On completion of a successful treatment, your front office submits a dental claim to your patient’s insurance company for reimbursement of the treatment rendered.

This might include a preoperative radiograph along with a narrative from the chart notes.  You then wait while the benefit allowance is determined. The claim is sent via the clearing house to the insurance provider for the payer to make the final benefit determination. They do so by reviewing the claim.

How are Claims Selected for Clinical Claim Review?

A claim can either undergo a clinical review with a human involved in evaluating the information, or the insurance company may just adhere to an automated payment policy.

The type of checks include:

• to intercept services which were previously billed and paid,

• instances where the services billed were exceeding frequency limitations

• any other administrative red flags.

In case where a reg flag is indicated, the service will be denied, and an explanation of benefits (EOB) will be sent to the patient and the treatment provider, communicating the cause of denial of payment, complete with a unique code that indicates the reason for rejection.

Claims that have a certain number of “flags” or outlier behaviour can be sent to a consultant to review the information and make a benefit recommendation. It can either be sent to a URA (Utilization Review Agent) which is a company contracted by insurance companies to review the claims) or sent internally, where the benefit determination reviewer is working under the insurance company’s own umbrella.

Can AI Help with Claims?

Clinical claims review can be subjective. There is variability amongst clinicians reviewing claims, even variability with the same consultant from day to day. Pieces of information can be missing, go missing, or be overlooked.

This is a time-intensive, and costly process, prone to error and mistake. Artificial intelligence and other technological advances are bringing consistency to the payer market with objective, quantified, and consistent claim analysis, but claims not meeting clinical criteria for acceptance still require review by a human to determine if there is a more appropriate code such as an alternate benefit allowance or if benefits still are not recommended and shall be denied.

What are Claim Reviewers Looking at?

The insurance provider receives the claim via the clearinghouse for the payer to make the final benefit determination. If the claim is selected for clinical claim review, it’s then reviewed in-house by the Payer’s clinical claims review consulting team, or forwarded on to a utilization agent to make a benefit recommendation in accordance with the client’s clinical review criteria.

The clinical review team looks to see if the specific services on the claim selected not only meet medical necessity but are also in alignment with the policies and provisions of the dental Payer (i.e. is there enough tooth structure missing, decayed or filled that it meets their criteria for benefit allowance?).

If the service meets any number of criteria, the service submitted for review is recommended for benefits, and these are then paid to the provider’s office. If the services are denied, it could be due to an incomplete submission or because the service submitted did not meet the criteria for benefit allowance. Each category of CDT (Current Dental Terminology) coding has different criteria which are reviewed and are largely similar across the Payer market.

What Strategies are Out There for Tricky Codes or Specific CDT Code Recommendations?

Documentation:

When documenting procedures such as crowns, core buildups, indirect restorations, and restorative foundations, it’s crucial to provide comprehensive details such as any lost cusps, the location and extent of decay (ensuring coverage of at least 40% of the occlusal tooth surface), symptomatic cracked teeth. Include specifics about the diagnostic tools utilized and the findings obtained during the assessment.

SRP Claims:

In cases involving Scaling and Root Planing (SRP), it’s essential to go beyond merely noting signs of inflammation. Payers typically require radiographic evidence of bone loss to support the necessity of treatment. Therefore, ensure that your documentation clearly identifies and highlights specific areas of radiographic bone loss. This not only strengthens the justification for the procedure but also meets payer requirements for reimbursement.

Extractions:

When submitting claims for tooth extractions, provide clear and detailed documentation regarding the procedure performed. Specify whether bone removal and/or tooth sectioning were necessary or if the tooth was simply elevated out. This distinction helps convey the complexity of the extraction procedure and ensures accurate reimbursement.

Professional TIP

Avoid simply copying chart notes into box 35 of the ADA claim form. Instead, attach a comprehensive narrative detailing the procedure specifics. Furthermore, consider electronically submitting claims with attached radiographic images rather than mailing them. This ensures that the details are conveyed securely and effectively, as images received through traditional mail processes may not be as reliably transmitted or interpreted.

Conclusion

So finally, it turns out that this seemingly docile domain of claims review is actually a pretty demanding career path which keeps you on your toes quite a lot. It’s something which requires keen attention to detail, thorough knowledge of one’s subject and a methodical way of functioning. As a practitioner who transitioned into this role, I found the variety of the claims which I reviewed to be fascinating and realised the importance of input from professionals who are experts in their fields.

The Global Dentists’ Pool

An interesting initiative by NamNR Pro – Global Dentists’ Pool is its Global Dentists’ Pool, which is a worldwide cohort of clinicians & Premium Dental Advisors, with proficiency in dental academic research, clinical research, Research & Development, marketing, claims review & medical writing to support DenTech companies in overcoming their day-to-day, and long-term challenges.

As a Pool Member, dentists have an opportunity to up-skill themselves in areas that allow them to participate in Dental Tech projects, whilst maintaining their clinical practices.

Whether you are a company looking for clinicians & advisors to support your product’s success, or a dentist looking to up-skill & benefit from alternate work opportunities, reach out to NamNR Pro at contactus@namnrpro.org, to learn how NamNR Pro can support you today.

“Via the Global Dentists’ Pool, DenTech teams receive timely professional advice from people in the field, motivated to help you do the best at your job”  – Dr Dominique Fufidio – Claims Reviewer, Coach, DDS & Engineer

Special Mentions

We would like to thank Dr Vaibhav Sahni, OMFS, Periodontology, for his contribution to the article as Peer reviewer and Editor.

Author information

Dr. Dominique Fufidio, DDS, FAGD, is an engineer and a dentist. She received her Bachelor of Science in Biomechanical Engineering from Syracuse University prior to her Doctor of Dental Surgery from SUNY Buffalo’s School of Dental Medicine and completed a post-doctoral program at Baylor University’s Texas A&M’s School of Dentistry before obtaining her Fellowship with the Academy of General Dentistry, a prestigious designation for a select number of dentists. Dr. Fufidio serves as the Director of Specialty Services for Apex Dental Partners, a Dental Support Organization based out of Dallas, TX. Dr. Fufidio is the Founder and main coach at Fufidio Consulting Group (FCG), where she has pioneered a unique coaching experience focused on teaching an understanding of the dental insurance claims review process and rationale behind the decisions on the EOB. Dr. Fufidio has established herself as a successful, fee-for-service, former private practice owner, top performing dental claim reviewer and Utilization Review Director for the largest Utilization Review Agent in the United States, and dental artificial intelligence co-creator.