8 THE ADA PRACTICAL GUIDE TO EXPERT BUSINESS STRATEGIES Denied Claims When a claim is denied, additional information is requested, or additional documentation is required by the carrier. The office should make note of the adverse result and determine the cause. The answer as to why a claim was delayed or denied most often lies in proper documentation and code reporting, or specifics of the plan’s contract language. Carriers are looking to contain costs and provide value to employers, plain and simple. The carriers do this by providing insurance products designed to lower the costs for their customers (employers or individual purchasers of a dental insurance plan). The cost reductions are made by limiting coverage, establishing waiting periods and deductibles, and increasing co-payments. Keep in mind that the plan may not provide reimbursement for appropriate care provided or the coverage may be limited or “remapped” to a less expensive procedure to save money. The fact is, if the carrier pays more than the contract allows or covers something that should not be covered as established by the contract, the carrier is in violation of the terms of the contract and can be sanctioned. The practice must continue to monitor and note the limitations and restrictions of the many dental plans and thereby maintain up-to-date information referencing each plan’s coverage. Patients should be informed of these cost-based restrictions so they have the option to choose alternative treatment. Reference Materials and Team Training Are Essential The Current Dental Terminology Codes (the CDT Codes) are the bible when it comes to reporting dental codes. Every dental practice should own a current CDT reference, and that reference should be updated every year. The CDT is subject to change, with codes being added, revised or deleted every year by the ADA Council on Dental Benefits and Practice’s Code Maintenance Committee. Those changes become effective on January 1 of the following year. Today, CDT references are available as paper, electronic, or cloud-based products and contain the information every practice must have to work properly, effectively and efficiently with the dental insurance industry. Dr. Jim Richeson, the past chairperson of the Code Maintenance Committee of the American Dental Association, stated, “A code set that provides specificity is needed to allow dentists to code ‘for what they do.’ This has always been the position of the ADA that dentists must accurately code for the procedure that is performed, not for any other reason, including maximizing claims adjudication. It is only possible to fulfill that mandate if the code set provides the means to accurately and specifically code for what a dentist does. Having an accurate code for each procedure performed does not mean that there will be a third- party payer benefit provided for the procedure.”1 Every dental practice should own a current CDT reference, and that reference should be updated every year. The CDT is subject to change, with codes being added, revised or deleted every year by the ADA Council on Dental Benefits and Practice’s Code Maintenance Committee. 1 Soderlund, Kelly. “ADA creates new committee, process to maintain CDT Code.” ADA News. January 16, 2012. ADA.org/news/6670.aspx. Last accessed on September 12, 2013.