Claims can be tricky, but our insurance team is highly trained to catch things that look off and/ or need more attention from them. Below you will find some examples of how a claim will be formed all the way through how they are paid. These are not everything that the team will see from insurance companies, as they can be quite difficult, but this is the common path.
Insurance Benefits Check
Claims are a big part of the process. There are many steps and we rely heavily on our team for it. When a patient comes into the office for the first time, our office offers a complimentary limited benefits check. Our insurance team does these initial checks (DEBC) for patient’s and then when they come back, they get a re-check (REBC) to make sure the coverage is still active, nothing has changed and everything is good to go when we create a claim.
Insurance Claim Creation and Sending
After the patient comes for some type of production appointment (almost anything that has an associated fee, except for cosmetic procedures), the business team treatment coordinators will create a claim for that appointment. When the claim is created, the claim is then added to a list for the insurance team to check over. Some examples that they do is see if any supportive documentation is needed for the claim. For example, if we had completed a crown on a patient, the insurance company, 9.5 times out of 10, is going to request x-rays and intra-oral photos to prove how necessary the crown was to the patient’s oral health. Another example is if a patient came in for gum treatment, 9.5 times out of 10, is going to ask for bitewings and a perio chart supporting the need for that treatment too. Typically, all in network insurances can take claims can be sent through the portal.
How to find x-rays
These can get tricky to find on x-rays and photos because nothing is noted if you check the EZDent application, so our insurance team has the best eyes to find where treatment was completed.
How to find X-rays by MHS HRInsurance Claims and Appeals
After a claim have been submitted to the insurance and the insurance sends the claim back, they will leave a note and not pay for many reasons. Some examples include: 1) They are requesting even more information or evidence 2) They believe the procedure was not medically necessary 3) The patient is over their insurance maximum or they are outside of an age limitation 4) Incorrect codes/billing.
With this explanation of benefits (EOB), an appeal will be sent to all requests for more information, to prove medical necessity and/or to fix any coding errors. We send up to 3 per claim. These appeals are sent via mail, fax or email depending on the insurance company.
Insurance Paying Claims
When the insurance is satisfied with the claim details, information and codes, they will pay us (sometimes the patient depending on the plan). The insurance team will then put in the explanation of benefits (EOB) in the claim as well as the form of payment. The insurance pays two ways, electronically (EFT/ERA) or physical check from the mail. If it was sent to MHS, our business team will scan them electronically so our remote team can input the information.
