Tips

• Why are some claims denied from the same company that approved the same work on another patient?

1. They deny claims based on the parameters of a patient’s contract.  Every company negotiates a different contract for services that will be covered under the plan.  Each company may have over 30 different types of coverage according to the amount of money the company contributes to plan.  They do not cover because of medical need.

• Can a patient obtain a list of codes allowed under the contract?
• The law states that a patient should be able to write to plan for information including the codes covered, however insurance companies feel this is a trade secret and do not give them out.  Let your patient know that the ERIA was put in place to protect employee pensions and company self funded plans and must be given to participants of the plans when requested in writing.

How do I handle an eob that states my fees are higher than the UCR fee the insurance company pays on?

At this point if that happens and your patient questions why they are paying up to your fee, you can send this to the state insurance commission in your state.  If you are not participating and insurance company cannot state that your fees are higher than their UCR fee.  Send a letter to ADA since they and other dentists have had suits against companies in suites.