And certain procedures, such as periodontal scaling and root planing (SRP), tend to have a scaling and root planing, crowns, dentures and root canal therapy. Sample Letters For Your Important Situations. Send your appeal letter to the specified department of the carrier and it must be in the form the carrier requires, Include the word “appeal” in the title and the text of the document and in any cover letter that accompanies the appeal document, D4341 periodontal scaling and root planing – four or more teeth per quadrant, D4342 periodontal scaling and root planing – one to three teeth per quadrant, D2950 core buildup, including any pins when required. Such as: “Patient presents with periodontal disease including BOP, exudate, (if present) mobility, and generalized 4-6 mm periodontal probing depths.” If the root surface is rough it is much easier for bacteria and calculus to attach on it. Follow specific instructions provided by the particular carrier including the submission of the appeal in writing within the time allowed by the carrier. Most insurance companies provide their customers with a booklet that details the coverage in their particular plan. Front Desk Help Center Informative tips to simplify claim procedures and processes . Page | 2 Narrative description in the document should include the clinical condition of the oral cavity, description of the procedure performed, reasons why extra time or material was needed, how new technology enabled the procedure to be delivered as well as any specific information required under a participating provider agreement. submit two different treatment plans, or an initial phase of treatment, (such as scaling and root planing, followed by osseous surgery), the treatment plans should indicate this on the submitted claim form. Also include your policy, group and claim numbers in your appeal letter. Outsource Strategies International. D4341 periodontal scaling and root planing – four or more teeth per quadrant D4342 periodontal scaling and root planing – one to three teeth per quadrant Dental claims can be denied, delayed or alternate benefited for a myriad of reasons. Dentists are also confused about the policies of bundling these procedures and the total fee for the procedures. Website Design by MedResponsive, Nebulizer Treatments – Clinical Documentation and Medical Coding, Outsourcing Dental Insurance Verification, Chiropractic Telehealth – Implications and Billing Considerations, ICD-10 Codes to Report Toxic Effect of Tobacco and Nicotine, Documenting Food Allergies during December – Know the ICD-10 Codes, Insurance Preauthorizations – A Major Challenge for Gastroenterology Practices, National Handwashing Awareness Week, December 1-7, 2020, Medical/ Healthcare Search Engine Optimization, Include additional documentation that provides the carrier a clearer idea of why the treatment is recommended, Provide the dentist consultant as much information as possible, as they will only be checking the dental claim form. Other Tips to Prevent and Resolve Such Claim Errors. continued on page 40 We had a claim for root planing denied (by MetLife). According to your coverage details, a root scaling is a covered procedure when gingivitis is present and there is evidence of loss of soft tissue surrounding the teeth. What does this mean? Insurance companies look to make sure your patient meets a certain criteria when the company considers a claim for scaling and root planing. Periodontal scaling and root planing, per quadrant involves instrumentation of the crown and Secondly, ask the dentist’s office staff to give you copies of your records, including any x-rays and reports that support your claim that the procedure should have been covered. Limited benefits for periodontal maintenance. Cosmetic appeal – Scaling and root planing helps to remove tartar and plaque from the teeth and below the gum line. Before submitting a claim for scaling and root planing, check the company's guidelines on their website or in the provider's office reference guide. For SRP claims, try including documentation of radiographic evidence of bone loss, periodontal charting and a narrative description of procedures. Periodontal Scaling and Root Planing Policy United Concordia’s policy for claims submission of periodontal scaling and root planing (PSRP) (D4341, D4342) requires submission of diagnostic materials from all general dentists and non‐ periodontal specialists, regardless of the patient’s age. The purpose of this procedure is … HIPAA recommends using the version of the CDT Code in effect on the date of service, no matter when the claim is submitted. Narrative should contain the condition that the patient presented at the time of clinical examination. E-mail: info@managedoutsource.com, Home | About us | Contact us | Blog | News | Sitemap | Reviews | Disclaimer You should have received this as a letter from your local planning authority. Patient eligibility verification is a key factor in preventing claim denials. When submitting scaling and root planing for more than two quadrants within a single visit, a best practice would be to send documentation, including full-mouth periodontal charting, FMX, periodontal diagnosis and the treatment plan. In the event your dental insurance company refuses to pay for a procedure that you believe to be covered under your plan… You also want to make sure that you are well within your rights to request a second look at the denied charges. A dental insurance appeal letter format should include the verbiage in your coverage booklet that makes you believe the procedure should be covered. All Rights Reserved. You can’t use this service to appeal a high hedges decision or a tree preservation consent order decision. The patient had 5mm Letters: Scaling, root planing. Secondly, I made a copy of the page out of my dental insurance handbook which clearly shows the circumstances under which a root scaling is covered. MetLife Denied Root Planing Claims are denied for many reasons. Determine the date of service Provide a clear narrative The records clearly show that gingivitis is present in my gums and there has been some soft tissue loss around my teeth. It also provides for isolated scaling and root planing where indicated. Before you write this letter, make sure you read your policy and know your rights. APPEALING A DENIED CLAIM OR SERVICE Furthermore, superficial stains present on the teeth will be removed in the process of the scaling and root planning. While some payers have limited this procedure to be paid as a benefit only within 2 to 12 months of SRP, other payers have qualified periodontal maintenance by denying benefits for this procedure unless two or more quadrants have received prior therapy. It is better to perform complete scaling and root planing on a smaller area rather than to scale a larger area superficially, with the result that further scaling will be required at a later date. Dental Insurance Appeal Letter. Scaling and root planing are common nonsurgical techniques that may prevent the need for more serious procedures. After the procedure, when the dentist’s office filed the patient’s insurance, the insurance company denied the procedure and refused to pay for it. In the Feb. 5, ADA News article " ADA Resources Can Help Dentists With Scaling, Root Planing Claims Process ," author David Burger notes that periodontal scaling and root planing have the … 3. In many dental practices, patients are simply told that they have a \"gum problem\" and they need to have \"quadrants of scaling and root-planing to remove the calculus from below the gum line.\" Patients are told that the treatment will \"require three-to-six appointments and the cost will be around $900. Overuse or even abuse of scaling and root planing may be the reason for the high number of denials. Notice that the definition is clear in stating that this procedure is to be instituted for the life of the dentition. Use the right CDT codes without errors This procedure was performed on the 15th of July this year. Here’s what to expect if your dentist or dental hygienist recommends these techniques: You won’t feel it. Use the correct, current code set to identify the diagnosis, services rendered, and procedures performed. Keep the periodontal chart for your record; however, submittal is not required. Outsourcing dental insurance verification tasks helps hospital staff to focus on their core task and practices can also save time and money. Often claims get rejected due to missing patient details, errors in submitted codes, lack of verifying patient’s dental eligibility and more.In case of any claim denial or rejection, dental practices must make sure to check the claim first and evaluate the correction to be made. The deadline for appealing a planning decision is 12 weeks from the date of the decision notice. D4342 – periodontal scaling and root planing – one to three teeth per quadrant. This addition to DIQ's downloadable dental forms will help your practice collect what's owed to you for scaling and root planing. While appealing for periodontal maintenance claim denials, include details on radiographs, periodontal charting and a description of the treatment. A major contributing factor for low SPT compliance that I routinely observe is the \"unilateral\" enrollment of the patient in periodontal treatment. One way to diagnose periodontal disease is by taking dental x-rays. The denial states that the procedure was not medically necessary. This addition to DIQ's downloadable dental forms will help your practice collect what's owed to you for scaling and root planing. If you can find it in black and white in their policy, then you have a great c… Insurance carriers failing to release specific payment guidelines or processing policies for specific procedure codes is a major factor that creates confusion in actual benefits. Dental insurance companies are a thorn in the side of providers, and they are adept at creating frustrations by delaying and denying justifiable claims. You should mail the letter by certified mail and request a return receipt; this is the only way to know it arrived. • Maintain the originals of all radiographs, photos, and notes you send to the Medi-Cal Dental Program for your own records. Those consequences include further loss of soft tissue surrounding the teeth and eventually loss of teeth. Periodontal scaling and root planing involves the removal of calculus, bacterial plaque, bacterial toxins, diseased cementum (the outer covering of the root surface), and diseased tissue from the inner lining of the crevice surrounding the teeth. This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. This procedure follows scaling and root planing procedures (D4341/D4342), gingival flap surgery (D4240/D4241), or osseous surgery (D4260/D4261). Coverage on periodontal scaling and root planing (SRP). Following is a sample of an appeal letter to medical insurance company in the case of a denial based on medical necessity. I write with hope you can help me regarding the above referenced dental claim for my root scaling. I was assured by my dentist this was a relatively common and insurable procedure and that he had received pre-authorization from the insurance company. It is important to read your booklet carefully so that you understand what kinds of procedures are covered and, more importantly, which procedures are not covered. Log on to the message boards of Dentaltown.com today to participate in this discussion and thousands more. The second option may appeal to both patient and provider because it appears that more is accomplished in less time, but the appearance can be both deceiving and counterproductive. • All periodontal procedures require submission of radiographs. D4341 periodontal scaling and root planing – four or more teeth per quadrant Such companies will provide the services of skilled AAPC-certified coders and expert billing specialists who can ensure that your practice has only fewer accounts receivable and unresolved dental claims. Scaling and root planing is a procedure that treats the infected area by meticulously cleaning the tarter and bacteria from the teeth and their roots. MEDICAL BILLING | MEDICAL CODING | VERIFICATIONS. It is very important to contact the insurance company to determine the correct address, department and person to whom appeals should be sent. In the event your dental insurance company refuses to pay for a procedure that you believe to be covered under your plan, you can write a dental insurance appeal letter. Each company has various things they cover and those they will not. Tooth scaling is the procedure of scraping away the bacterial plaque and dental calculus (tartar) from the surfaces of the tooth, especially from the root surfaces below the gum line.. Root planing is the procedure of smoothing the root surfaces. For this procedure, dentists must make their patients aware that all procedures are not covered by some plans, for extended periods of time. Both patients and dentists must be clear that while SRP may be necessary, the plan will only provide benefit when its particular clinical indicators are present. 1. Frequencies for denial are more with certain procedures such as periodontal scaling and root planing (SRP) than other procedures or requests. Core buildup procedure performed prior to restoring a tooth with a crown is often reported to be denied for its lack of benefits. I have also included a letter from my dentist explaining why, in her expert opinion, the root scaling procedure was medically necessary and what the consequences would be of not performing the procedure. You’ll also need to submit any other documents that directly support your appeal, for example your grounds for appeal. In this case, a patient needed a root scaling due to gingivitis and loss of some soft tissue around the teeth. 2. I will discuss D4341—scaling and root planing four or more teeth, per quad, and D4342—scaling and root planing one to three teeth, per quad. The author cites that periodontal scaling and root planing tends to have the highest frequency of dental insurance claims denial. As insurance policies and plans change constantly at the insured level as well as for the insurer, it is important for the provider to verify eligibility each and every time services are provided. For new patients, all insurance information including patient’s name and date of birth, name of the primary insured, social security number of primary insured, insurance carrier, ID number, preauthorization and group number should be collected and verified before their visit. 2) Radiographic evidence of noticeable loss of bone support. I am writing to appeal the denial of my claim number 789 for my root scaling procedure that was performed on September 3, 2013. If you need to go out of network to get the services you need, explain yourself well and enclose any documentation necessary. If there is a coding error, prepare and submit a corrected claim. The whole purpose of the letter is to ask for reconsideration. My x-rays and other records from my dentist are attached. ADA recommends including radiographic evidence of the need for a buildup, while appealing for this procedure. Carriers have different policies or limitations for this procedure. Fax: 972-466-5385 Making patients understand the limitations of their plan prior to treatment may help dentists avoid problems. If there is no error in the claim, prepare an appeal. Dealing with insurance companies and claim denials is a frustrating task for all dental offices. You’ll receive a local anaesthetic to numb the area. Bacteria release sulfur waste products. Sample Medical Insurance Appeal Letters Sample Letter 1. Copyright © 2020. Four quads of scaling and root planing and periodontal maintenance were on order for her, and she willingly complied. Scaling and Root Planing Narrative should contain the condition that the patient presented at the time of clinical examination. However, some state laws and third party carrier processing policies and contract provisions specify the completion date as the date of service. While assigning a single code for a procedure that requires multiple appointments, ADA encourages third party payers to use the date of impression as the date of service. To write this type of letter, you need to be mindful that you are dealing with a business, and it should be a formal style letter. Based on the patient's clinical presentation, I placed PerioChip® in each of the pockets listed below: Tooth # Site Treated (MB B DB ML L DL) Probed Pocket Depth Total Treated Areas by Tooth initiated included scaling and root planing and oral hygiene instruction. Example: Yes, I would like to receive emails from Outsource Strategies International. I hope this letter finds you well. First of all, Karen Jones, who works for my dentist, Dr. Sherry Grant, contacted the insurance company and received a pre-authorization for the procedure. Frequencies for denial are more with certain procedures such as periodontal scaling and root planing (SRP) than other procedures or requests. D4346 – scaling in the presence of generalized moderate or severe gingival inflammation – full … Fresher breath – A very common signs of periodontal disease is halitosis (bad breath). The dentist’s office personnel contacted the patient’s insurance company and got the procedure pre-authorized. D4341– periodontal scaling and root planing – four or more teeth per quadrant. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of le… March 19, 2018. “Tenacious calculus rings and generous amounts of granulation tissue...” Those were some of the dictated notes my hygienist wrote when she scaled the patient. D4342 (scaling and root planing) or D4260 & D4261 (osseous surgery) if D4263, (First Site in Quadrant), D4266, D4267 Current dated pre D4264 (Each Additional Site in the Current dated pre-operative periodontal charting Identify each site/tooth -operative radiographs Note: A single code for multiple sites is not valid. Read this interesting discussion of a periodontal case denied. Most insurance companies provide their customers with a booklet that details the coverage in their particular plan. ADA’s Recommendations on How to Appeal a Dental Claim, A proper appeal involves sending the carrier a written request to reconsider the claim, Four Major Dental Claim Rejections and How to Respond. D4341-Periodontal Scaling and Root-Planing, per quadrant, is described as involving "instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. That document, including the pre-authorization number 3579 is attached. This procedure performed following periodontal therapy and at varying intervals is frequently denied because many carriers have limited benefits for this procedure. Please consider my appeal and pay for my root scaling procedure as it is included in my plan and the procedure was pre-authorized and medically necessary. Scaling and Root Planing. The patient did some research and wrote this dental insurance appeal letter sample. A request for periodontal scaling must meet the following criteria: CDT Codes: D4341 D4342 • At least one of the following must be present: 1) Radiographic evidence of root surface calculus. X-ray images assist in making the tarter build up under the gums more visible. In cases where the claim has not been properly adjudicated, you can appeal the benefit decision. Detecting Periodontal Disease. Planning appeal time limits. (You can unsubscribe anytime), 8596 E. 101st Street, Suite H You need to know what portion of the policy this denial violates. Periodontal scaling and root planing involves the removal of calculus, bacterial plaque, bacterial toxins, diseased cementum (the outer covering of the root surface), and diseased tissue from the inner lining of the crevice surrounding the teeth. Dental billing services provided by experienced medical billing companies can help dental practices meet their medical billing and claim submission requirements. However, it is important to recognize that a large body of scientific evidence has concluded that scaling and root planing is an appropriate and effective … United Concordia Dental is committed to making the claim submission process easier for your dental practice and the patients you treat. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in … It is important to read your booklet carefully so that you understand what kinds of procedures are covered and, more importantly, which procedures are not covered. Tulsa, OK 74133, Main: (800) 670 2809 Review the denied claims to check whether the procedure codes reported are correct. Dental Insurance Appeal Letter Sample Note: Make sure to state why you believe they made the wrong decisions. 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