Carol Tekavec, RDH
Numerous ADA dental-procedure codes require an explanation or "report" when filing claims for patients. In addition, many codes provide a definition that is not considered complete by insurance carriers without supplemental documentation and attachments to the claim. Providing documentation for the treatment that patients need is typically viewed by dentists as an intrusion into the doctor-patient relationship. Why should a dentist be required to explain anything to an insurance carrier?
Plan administrators
Insurance companies provide plan administration and claims payment for employers who purchase plans for the benefit of their employees with plan administration and claims payment. The employer agrees to a specific contract that includes what benefits will be provided and their costs, as well as provisions for the insurance carrier to monitor the plan. The employer wants to be sure that only the benefits that have been agreed upon are paid. This is particularly true for employers with administrative services only (ASO) contracts. The employer is not only paying premiums, but is at financial risk for claims.
For this reason, carriers must administer the terms of the contracts to fulfill their obligation to their bosses - your patients` employers. If supporting documentation is mandatory to pay a claim, that documentation must be provided. Even in cases where a dentist does not work with or accept payment directly from carriers, supporting information and/or narratives may be required for the patient to be able to file the claim.
Composing narratives
Writing narratives does not have to be difficult. The insurance carrier is looking for supporting information to determine whether a procedure is covered under the patient`s contract. Despite the fact that each contract is different, many contracts share basic payment parameters that can help a dentist truthfully focus his or her narrative on items that will be covered. (If a procedure is not covered under the terms of a contract, no payment will be approved, regardless of whether the patient requires the procedure or not and despite detailed and reasonable narratives.)
Some rules
(1) Narratives should be patient-specific, not checked off from a list of possible choices on a page of "canned" narratives.
(2) Carrier contracts typically cover two "cleanings" of any type per year. This includes root-planings (D-4341), perio maintenance (D-4910), and standard adult prophys (D-1110). Even if patients require more frequent procedures, narratives explaining the need for treatment will not result in better coverage.
(3) Many dental-plan contracts specifically exclude coverage for replacement of tooth structure lost through attrition (teeth worn down by friction, as in chewing and biting pressure), abrasion (teeth worn away from scraping or rubbing, such as toothbrush abrasion), and abfraction (tooth structure worn away as a result of traumatic occlusal forces). Some carriers also list the word "erosion" (wearing away or gradual destruction of tooth surfaces from acidic mouth fluids or oral habits) as an exclusion. The use of these words in a narrative will usually cause a claim to be denied. Coverage usually will be approved for decayed surfaces, decayed margins of existing restorations (if the existing restoration is more than three years old), open margins, and fractured teeth.
(4) Describe the functional, not the aesthetic, problems that need correction when writing narratives. Do not list problems such as "discolored existing restoration," because restorations or replacements related to appearance typically are not covered.
(5) Substitute completed and photocopied chart forms for written narratives whenever possible. A form documenting periodontal-probing depths, bleeding points, furcation involvement, recession, and mobility can take the place of a lengthy narrative and speed insurance processing. Simply attach the form to the claim or scan it into the e-claim software.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.
