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National Dental Billing Services


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What narrative expedites dental insurance payment for indirect procedures?

Posted on October 8, 2015 at 6:45 PM

Q: What narrative expedites dental insurance payment for indirect procedures?

A: There are 10 main indications (medical necessity) for indirect restoration placement:

1. vertical incomplete fracture of a cusp

2. complete fracture of a cusp

3. missing cusp

4. restoration is greater than 1/3 of the occlusal tooth isthmus

5. inadequate contact promotes periodontal disease

6 inability to achieve an adequate contact with direct restoration

7. new restoration will undermine cusps

8. abfracture lesion undermines a cusp

9. previous root canal

At diagnosis in hygiene or emergency exam, the Doctor has to provide a diagnosis which is one of the above and treatment plan a procedure to fix the problem. We recommend that the team drafts a document which includes those items to make it easy for the team to check off what the narrative for the procedure is, until it becomes second nature. On the day of service, this sheet can be pulled out and mailed to the insurance company with an x-ray and intra-oral picture (or the narrative can be typed right on the claim before its submitted electronically with an attachment of an x-ray and intra-oral picture) and you should see a payment in 3 weeks. By the way, if on the day of service you only send a claim without supporting documentation for indirect restorations, you can add another 6-8 weeks before this claim resolves. This is because first the insurance will receive the claim and has to process it (this takes up to 4 weeks), then you will send in documents (1 week), then insurance has to process these documents (2 weeks), then 2 weeks later they send a check.

Additional tip: when you are replacing an existing indirect restoration/and dentures you must ask how old that restorations is because usually there is a frequency clause in the dental plan and the restorations will not be covered within a specified period of time. Write the original placement date on the claim (don't wait for the insurance to ask!) For bridges, ask when the tooth was extracted that you are replacing and get in the habit of writing this information on the claim. Normally if the tooth was extracted prior to the patient having the dental insurance company you are billing, they will not cover the bridge.

Categories: dental insurance

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