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Handling Appeals Effectively
Marianne Harper

Have you been frustrated by claims that are denied by insurance carriers? How do you handle those denials? If you haven't been very successful or you haven't even tried to appeal denied claims, then you are missing the boat. Read on for the steps to make that boat ride smoother.

Claims can deny for many reasons as is evident by the multiple denial codes that carriers use. Some claims deny legitimately but there are times when a denial should not be accepted without a fight. Not examining your denied claims to determine if they are legitimate denials means that you are losing money either by patients not paying the full balance which can result in bad debt write offs or by delays in patients paying the balance in full. It is a fact that when a practice takes the time to effectively appeal a claim, denials can be overturned and the practice can be more profitable.

The following are the steps to successfully appeal a dental or cross coded medical insurance claim:
Stay timely – Don't create a problem folder for denied or problem claims and let the claims sit untouched in that folder for too long. Insurance carriers have time limits set for appeals, so you must be careful not to wait too long. If a problem claim requires multiple contacts with the insurance carrier which results in a lengthy time period, be sure to document each contact by recording the date, time, name of the representative, and notes on what the representative told you. The carrier will have a record of these communications also, so they will not be able to use the time factor against you.
Read EOB's carefully to look for problems. Not all claim problems are easily evident, especially when a partial payment is made. If you accept a partial payment as the final payment without looking for the reasons why the carrier only paid a partial payment, you will be missing the chance to obtain a higher benefit for the patient. Become a coding detective with your EOB's.
You can use several different methods to file an appeal – by phone, on paper, or through the carrier's website. You will need to investigate which is the best method for each.
State the facts – Review the documentation of the case and glean from it the pertinent details to state your case:
The necessity of the procedure - how it was either dentally or medically necessary.
Attach copies of attachments.
If the denial states that the procedure was non-covered, state why you believe that it should have been considered a covered procedure.
Problems with bundled services – With medical insurance carriers, they may not have recognized your modifier that showed that services should not have been bundled, so you will need to either call the carrier and have them look at their copy of the claim or include a copy of the claim that shows the modifier and indicate that they did not process the claim correctly and need to reprocess it.
Evaluate problem claims as to whether an appeal or a correction is required. Not all denials require appeals because some of the following situations might apply:
Incorrect patient data entry – Misspelling names or errors in subscriber ID numbers.
Date of service was incorrect.
Wrong codes were used – either diagnosis, CPT or CDT. Also, with medical claims, the diagnosis code(s) must always support the procedure code(s).
Incorrect rendering provider is listed on the claim.
  If you determine that the problem lies with errors made by your staff, you will need to contact the insurance carrier for their instructions on how to file a corrected claim.
Make a difference – take the extra steps – to make your claim filing system run efficiently, effectively and profitably.

Bhaskar's Formula
Colleen Rutledge, RDH

I recently presented a course on ultrasonics and the last segment discussed pre–procedural rinses and irrigation. Pre-procedural rinsing/irrigating is important because it greatly reduces the bacterial count in oral cavity and thereby aerosol created by ultrasonics. Among the medicaments discussed was chlorhexadine gluconate, essential oils, subgingival tetracycline and povidone iodine. The interest and questions from the audience centered on tetracycline subgingival paste, commonly known as "Bhaskar's Formula".

Bhaskar's Formula was created by Dr. S.N. Bhaskar, a California periodontist / national speaker. Anyone who has ever attended his courses leaves well-informed and totally entertained! Dr. Bhaskar made a "paste", with 2 - 3 days substantivity, from 250 mg tetracycline mixed in a gel medium. A homogenous paste is formed by mixing the ingredients with a flexible spatula on a glass slab or oil resistant pad and placed in a BD 3 ml 22G 1 ½ precision glide syringe. It can be refrigerated for up to 3 weeks. One syringe can treat the entire oral cavity.

For the exact formula and clinical photos showing how it is used, email me at:

Save 10% on our "Do-It-Yourself" Dental Hygiene Department Consulting Kit until May 15th, 2013. Visit and use code APRILMEZ at checkout.
  Insurance Alert
Dental – According to Michael Uretz, a contributing writer for, the topic of EHRs (electronic health records) and EDRs (electronic dental records) will become more prominent and important this year. He reports that the EHR mandate, the United States' meaningful use program, is what is fueling the rapid adoption of EHRs in medical practices. He states that the mandate is not applicable to dental practices at this point but it has gotten the interest of many in the dental field who see the eventual migration to electronic patient records. This statement should speak to those dental practices that are still filing paper claims. The time is approaching when all claims will need to be electronic so why not take the challenge and move to electronic claims? It's easier than you might think and creates a much more efficient and effective insurance system. Contact your practice management software company to learn how to make the change.
Medical – When cross coding, make sure that you are using modifiers when necessary. Modifiers are part of the CPT code set and insurance carriers use these codes to evaluate whether a normal benefit is applicable to a procedure because a treatment was altered by a specific circumstance. Examples of such circumstances are:
-25 – If you need to report that an exam was separate from an x-ray on the same date of service and should each be paid individually
-26 – If you only provide the professional component of a procedure (e.g. the evaluation only of a scan)
-52 – You provide a TMD appliance that was fabricated by an outside lab
  Time Line
Update Time is Past Due – Medical Codes and Dental Codes for 2013
And your updated medical coding manual contains the new CDT codes also
CPT Code (medical procedure code set) will update as of January 1, 2013. Purchasers of "CrossWalking – A Guide Through the CrossWalk of Dental to Medical Coding" and/or the "Quick Look Up Cross Code List" – you should have received an email that provides information on the way to order the update. Medical insurance carriers will not accept outdated codes and will deny claims for that reason. I am offering a less expensive update to the paper manual this year in an electronic format. So take advantage of the savings and keep your codes up to date.
CDT Code UpdatePast Due – The ADA has announced that CDT codes will update on January 1st of every year. If you haven't already purchased your 2013 code set, now is the time. I recommend Dr. Charles Blair's "Coding with Confidence." It is the best source for all the detail that you need to understand the CDT codes. In addition, consider a subscription to "Insurance Solutions Newsletter." Not only will you receive a newsletter packed full of great coding information but the subscription also includes a coding support service. You can't go wrong with that kind of help. To order either or both of these, please click here.
May 1, 2013 – Medicare PECOS Phase II Activation – Dentists and others who are eligible to order and refer items or services for Medicare beneficiaries need to establish their Medicare enrollment record through either a paper form CMS 8550 or online through Medicare's PECOS site. Due to the impending date, the online method is the best. Without this enrollment, denials will occur. Dentists must make sure that they have enrolled in order to be sure that the Medicare claims submitted by pathology labs will be paid. In addition, providers who refer Medicare patients to a dentist must be enrolled or the Medicare claim submitted by the dentist will deny. This enrollment is not for claim submission but to ensure that the ordering and referring provider is a part of Medicare's enrollment record.
September 23, 2013 – HIPAA Omnibus Final Rule – The updates to this rule were published on January 25, 2013. The compliance date is September 23, 2013.
October 1, 2014 – The new date for ICD-10 implementation.

Favorite Quotes:
"Efficiency is doing things right; effectiveness is doing the right things."
Peter Drucker

Tips – For our Patients:
Tis the season! No, I'm not crazy, I know that it's not December. However, it is allergy season and it seems as though a lot of us are fighting allergies. A suggestion provided on the Dr. Oz blog ( is the following:
"To soothe itchy eyes, use a peppermint tea bag as a warm compress for washing your eyes. Steep the tea bag in hot water for 30 seconds, let it cool to warm and place it gently over your eyelids. Leave on for 5 to 10 minutes. Mint in general is considered to have allergy-reducing properties, so a cup of mint tea might help, too!"

Points of Interest:
Abraham Lincoln was elected to Congress in 1846.
John F. Kennedy was elected to Congress in 1946.
Abraham Lincoln was elected President in 1860.
John F. Kennedy was elected President in 1960.
Both were particularly concerned with civil rights.
Both wives lost a child while living in the White House.
Both Presidents were shot on a Friday.
Both Presidents were shot in the head.
Now it gets really weird.
Lincoln's secretary was named Kennedy.
Kennedy's Secretary was named Lincoln.
Both were assassinated by Southerners.
Both were succeeded by Southerners named Johnson.
Andrew Johnson, who succeeded Lincoln, was born in 1808.
Lyndon Johnson, who succeeded Kennedy, was born in 1908.
John Wilkes Booth, who assassinated Lincoln, was born in 1839.
Lee Harvey Oswald, who assassinated Kennedy, was born in 1939.
Both assassins were known by their three names.
Both names are composed of fifteen letters.
Now hang on to your seat.
Lincoln was shot at the theater named "Ford."
Kennedy was shot in a car called "Lincoln" made by "Ford."
Booth and Oswald were assassinated before their trials.
And here's the "kicker":
A week before Lincoln was shot, he was in Monroe, Maryland.
A week before Kennedy was shot, he was with Marilyn Monroe.
Lincoln was shot in a theater and the assassin ran to a warehouse...
Kennedy was shot from a warehouse and the assassin ran to a theater...

Timeline Photos • Jan 10 at 11:18pm

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