I have had a crown denied several times - what do I do?

There are times when a crown is warranted by an insurance company and their consultants just won't see things your way. You've written narratives about the size of the existing amalgam restoration and the fact that there is recurrent decay around the margins, sent in intra-oral photos and x-rays to demonstrate necessity, but the consultants just won't budge.

Your options are partially a function of the state in which you practice. Whenever you receive a denial of benefits, the EOB should always list your appeal options. In some states, after you've exhausted all in-house appeals (including review by their peer review committee) you are entitled to request review by an unbiased third party agency (often at the cost of the insurance company). Other options are the Peer Review Committee of your state ADA component. Check with your state board and dental association for your particular options.

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Providing Additional Information to Consultants

One of our members who is a consultant for a large insurance carrier reports that she had a recent call from a doctor's office about continued rejection of crowns.

"I always include a narrative if a person can't see the need for a crown on the x-rays" they reported.

The consultant had copies of several claims in front of her.

"I don't see a narrative on any of these," she said.

"Well I know I sent it in. I always write it on the x-ray envelope."

The moral of the story: if it isn't on the claim, it probably won't be seen and even if it is, the validity of it is questionable. Narratives, explainations as to why a requested service's needs and the like must be on the actual claim form if you want them to count.

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How should I file claims for pulp tests?

Based on the CDT codeset and the way most insurance companies view the procedure, pulp testing 1 or 2 teeth in question and testing the same teeth on the opposite of the arch for comparison counts as only one pulp test. The code should not be used for each tooth tested in a visit.

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National Practioner Identifier

Beginning on May 23, 2007, any provider who submits or has any portion of their claims, submitted electronically must use a NPI (National Practioner Identifier). This is 10 digit number selected by the govermnent. Applications to obtain an NPI will begin on May 23, 2005.

More information can be obtained by going to ada.org.

For additional information on practice management and dealing with dental insurance in your office, EMAIL US BY CLICKING HERE

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How do You Stay Fit In The Office?

We're taking a poll as to how practitioners stay in shape and still maintain their hectic (emotionally and physically) schedules.

Do you take a nap?

How do you deal with stress?

Let us know.

Your exercise might be another's salvation.

For additional information on practice management and dealing with dental insurance in your office, EMAIL US BY CLICKING HERE

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My laminates are being denied - Help!

Whenever I submit a claim for porcelein laminates, the claim gets denied. How can I prevent this?

Dr G, Pa

Most dental plans have cosmetic exclusions so if that is the reason you're placing laminates, they will continue to be denied. It's contractual.

If the teeth need structural support, then your documentation is not convincing the company's dental consultants that they are needed. Since a fair number of laminates are placed for cosmetics, you must provide solid proof that these restorations are needed.

If large restorations are present with recurrent decay (large fillings without decay are usually not sufficient reasons for replacement) make sure your x-rays reflect that.

If the necessity is not evident in the radiographs, then a photograph can help. (Discolored fillings without decay are also not a reason for replacement).

If you've replaced the restoration in that tooth several times and it's time to step up to a more comprehensive one, include a copy of the patient's charts documenting your more conservative attempts.

And if all else fails, include a narrative along with the film and photo. But remember that a narrative alone will usually not convince a consultant of necessity.

Remember that craze lines will not usually justify restoration replacement in the eyes of most consultants.

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