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Inside Dentistry
January 2014
Volume 10, Issue 1

Navigating Reimbursement

Getting Paid in the Healthcare Reform Era

Jackie Syrop

If you ask any dentist, “What are your top concerns?” you will likely hear that denials of claims and problems with reimbursements are at the top of the list. It’s no surprise, because when claims have to be submitted many times or payment is denied, it can lead to problems paying staff and covering administrative expenses. Claims issues can frustrate patients, too, who may wonder if the dentist performed work that was not needed.

Inside Dentistry consulted several experts knowledgeable about claims, coding, attachments, and Medicare and Medicaid to gain insight into the claims process and provide advice to our readers about ways to streamline the process and avoid reimbursement missteps. We’ll also briefly look at what may be expected after January 2014 under the Affordable Care Act (ACA).

Problems to Solve

Dentists experience problems ranging from slow payments, lost attachments, requests for more information or clarification of information already submitted, and disputed claims based on the payer’s decision that the dental services provided were not necessary or that a different procedure should have been done. Dentists complain about what they view as “delaying tactics,” “bundling” (the systematic combining of distinct dental procedures by third-party payers, resulting in a reduced benefit for the patient/beneficiary), and “downcoding” (alteration by a third-party payer of Current Dental Terminology [CDT] codes for providers to those of lesser complexity, resulting in decreased reimbursement). Dentists often wonder why there is a system of procedure coding for distinct procedures when payers disregard them; for their part, payers counter by explaining that what dentists call “bundling” is actually the payer’s efforts to follow the guidelines established in the code.1

It’s easy to see that there is a difference of opinion. But how can dentists learn better ways to navigate these troubled waters? What are the best ways to avoid the pitfalls of the reimbursement process?

“Dentists have to embrace that they’re part of the problem and make changes in how they approach reimbursement,” counsels Tom Limoli, Jr, president of Limoli & Associates, an Arlington, Tennessee, dental consulting company. Furthermore, he says, dentists’ hostility toward insurance companies is misplaced. “They’re tilting at windmills. The insurance companies are not holding the funds. The claims are paid with employers’ funds that the insurers are managing,” he explains.

According to the National Association of Dental Plans (NADP), a Dallas-based organization that represents 92% of dental insurers (covering the 187 million Americans who have dental benefit plans), 96.7% of all dental claims are processed in less than 10 days. But even when insurers process claims quickly, it doesn’t ensure that dentists receive payments for their services swiftly. In addition, approximately 80% of commercial dental claims are auto-adjudicated—that is, processed with computerized decision logic linked with provisions of the employers’ group policy (personal communication with NADP Executive Director Evelyn Ireland, November 4, 2013). This makes it all the more important that claims be properly coded and submitted to payers with all the required components of the process, including the correct attachments, adequate notes and diagnostic explanations, and proper dates of service for both commercial insurance carriers and Medicare and Medicaid.

Claim Forms and Code Confusion

The claim form conveys what was done, when, and to whom, and acts as the bill to ensure that the dentist is paid. The problem is that payers find that common information needed for adjudication and coordination of benefits is often missing. It is also common for periodontal charting and radiographs to be missing from claims when they are required. Another issue for payers is that claims arrive with outdated CDT codes.

The CDT code was developed to identify and categorize dental procedures to third-party payers with the idea of facilitating the filing and processing of claims by using standardized definitions and nomenclature. The CDT code set is maintained by the American Dental Association (ADA), which periodically reviews and revises it to reflect dynamic changes in dental procedures. Revisions of the code are published and effective every 2 years, at the start of odd-numbered years. The most recent code revision effective on January 1, 2013, introduced 36 new codes, 37 revised codes, and 12 deleted codes.2 Any claim submitted on a standard dental claim form must use dental procedure code from the version of the code in effect on the date of service. CDT codes are also key for determining what attachments are needed to process dental claims.

Misunderstandings about coding are responsible for much of the confusion with reported reimbursement problems. But in reality, the rules of coding are simple, Limoli asserts. Accurate coding is key. “Use the code that best identifies the intended procedure that was (or will be) performed. If a specific code does not accurately describe the procedure, submit a brief narrative description or utilize a ‘_999’ code within the appropriate category of service.”

He emphasizes that there should be no distinction between the treatment, coding, and billing parameters for insured and uninsured patients. “One of the biggest problems is that dentists believe that just because there’s a procedure code for a procedure, that the procedure is payable under the terms of the patient’s plan,” Limoli emphasizes. He notes that each individual benefit contract has its own individual parameters of payment for dental procedures, so even though the ADA comes up with new procedure codes, it doesn’t mean the plans are going to pay for them.

For example, on January 1, 2014, a new code for a base under an indirect restoration went into effect. “But every plan I’ve looked into says they consider it part of doing a final restoration, and it’s not payable under the plan,” Limoli says. He points out that this particular procedure has never been paid for, as it’s always been part of doing the filling. Other procedures that as a rule are never covered by commercial dental insurance are cosmetic procedures, such as whitening, and implants.

Be careful about people who talk about a “coding strategy,” Limoli advises. “The only coding strategy is to code for what you did. There’s no strategy in that.” Even if you believe that it’s altruistic to manipulate and play with procedure codes based on what the office knows the plan pays for and doesn’t pay for, you’re not doing patients a service, he says. “The procedure code that identifies the procedure that was performed should never be selected by an administrative person in the practice,” Limoli cautions. “It has to be selected by the dentist or a member of the clinical team who has seen the procedure taking place.”

Confusion about coding for a compete radiographic series is also common because the code for an intraoral complete series, including bitewings, does not specify the number of intraoral films composing a full set of radiographs.1 Because radiographs are individualized, the number of films to adequately view what is defined in a complete series will vary from patient to patient. Therefore, payers may establish benefit guidelines that limit reimbursements for multiple intraoral films on the same date of service. These guidelines should be available to dentists and patients.

Avoiding Missteps

Contacting insurance companies.“Do not ever call an insurance company for benefit information!” advises Tom Limoli. When patients or office staff call the insurance company to determine whether the procedure is covered under a plan, specific payment guidelines (eg, clinical indicators that must be present before a payer will cover the procedure) are not provided or explained, leading to confusion. Instead, use the company’s website to get the summary for the patient’s plan directly. Obtaining benefit information this way guarantees you have no questions about whether the patient is covered, because what you print out has the patient’s name, what they have left in benefits, what the plan pays for, and in what amount. “It turns a 45-minute call into a 15-second transaction,” Limoli says.

Preauthorization. Patients and dentists must understand that preauthorization is not a guarantee of payment. Preauthorization is always tempered by the allowable benefits at the time of service, not at the time of preauthorization.3

Incomplete documentation. Docu­men­tation is key because it presents the important reason why a procedure was performed. “Anyone who tells you that you need to come up with a ‘magic’ narrative to tell the insurance company what they want to hear is leading you astray,” Limoli says. “The clinical narrative is exactly what your notes are.” Clinical notes are supported by photographs, radiographs, and a written description of what was seen.

Richard Celko, DMD, is the national dental director of utilization management at AVESIS Incorporated, a Phoenix-headquartered national hearing, vision, and dental (Medicaid only) plan that administers benefits for health plans and commercial accounts. He recommends that dentists submit the proper diagnostics, making sure that the radiographic images are labeled appropriately with right and left, and with correct dates on them. “Send in a pre- and postoperative image showing the apex tooth if endodontic treatment was done. You’d be surprised about how many people send us bitewings with a root canal,” he says. You want to send a diagnostic image showing the tooth in its entirety. If crowns are covered, you want to make sure the whole tooth is shown. Otherwise the payers’ consultant may not see crestal bone on bitewings and you can’t tell if there is a periodontal condition or not.

Dentists should dictate and transcribe notes, or do whatever they are most comfortable with to document every procedure. “Take more pictures,” Limoli advises. For example, if the dentist does a surgical extraction, he or she should submit the photos electronically with the claim, taking pictures with each step that shows bone involvement, justifying the need for surgical extraction.

Specific documentation is critical. Avoid the use of “auto notes,” or cut-and-paste documentation in patient charts. All too often dentists don’t regard auto notes as a problem until they find themselves in a liability or malpractice situation, Limoli warns. “Auto notes are the kiss of death.”

Incorrect information about actual benefits. Denials of claims for procedures—for example, for core build-ups—often occur because the patient’s plan lacks a benefit for this procedure, or the group policy requires specific documentation to support this procedure in addition to a crown. The dentist’s submitted documentation must meet the plan’s definition of a crown build-up, or it will be deemed part of the crown procedure. Thus only the crown will be reimbursed.3

Documentation is also important for procedures such as scaling/root planning, for which many dentists receive denials of coverage. The ADA recommends that dentists document full-mouth periodontal charting, full-mouth radiographic examination, periodontal diagnosis, and a treatment plan. The patients’ prior periodontal history is imperative when coding for periodontal maintenance.4

Communications gap. Patients often do not know the coverage details for their own dental plan and expect the office staff to be the experts. This communications gap means that the patient’s understanding of what their individual dental insurance covers is not always realistic when it comes to what is actually reimbursed.5 Therefore, to avoid misunderstandings, dentists must guide their patients so they can better understand their coverage ahead of time, and have realistic expectations about the level of benefits they have. The dentist must take the time to explain to patients in advance what treatment plan is proposed, and why it is clinically appropriate. Then a discussion of what the patient’s dental benefits cover and do not cover can occur, and together the patient and dentist can agree on how to proceed.

When there are several procedures available to address a patient’s dental needs, dentists should advise the patient that a least-expensive-alternative-treatment (LEAT) provision may affect their out-of-pocket costs.6

Electronic attachments. An electronic attachment is simply a copy of the clinical notes from that day’s treatment as well as any radiographs, photographs, perio charts, or information gathered during that day’s visit. That information should be transmitted electronically, along with the claim, to the insurance company. When this is done properly, the insurance company has no question about what was done and why, Limoli advises.

Services that provide secure electronic document exchange between providers and payers streamline the claims process. Electronic attachment services can handle private payers as well as Medicare and Medicaid.

One such electronic attachments service is provided by NEA of Norcross, Georgia. As David Fincher, vice president of dental sales at NEA, explains, the company’s secure, private, HIPAA-compliant unstructured health information exchange (uHIE™) is connected to many US dental providers—more than 40,000 provider locations accounting for approximately 60,000 US dentists are already connected to NEA’s uHIE. Through this connection, any type of human readable communication can be exchanged between payer and provider. One use of this uHIE is electronic claims attachments. Providers capture, store, and transmit the claim attachments using the NEA system.

The process starts with the payers providing NEA with the list of procedure codes that require attachments, and those are stored in NEA’s database. When providers send a claim electronically, NEA’s system tells them exactly which attachment is needed. “This saves a lot of time spent determining whether you need to send an attachment in the first place,” Fincher states. “Instead of just relying on memory to decide when an attachment is needed, or spending a tremendous amount of time looking up every manual or every website to see if a claim needs an attachment, the system allows the provider to simply receive a request from the payer that an attachment is needed.”

Compared with mailed claims attachments, the electronic attachment system can dramatically decrease the number of lost attachments and duplication of work and follow-up time. Staff members will find the reimbursement process is simpler to conduct and track. This will provide more time for the staff to concentrate on the patients.

Best of all, the electronic systems have faster turnaround times and faster payments.

NADP partnered with NEA to create a single online portal for dental offices to check payer attachment requirements. This portal (NEA FastLook) can be found at

In addition to receiving claims attachments, payers are using NEA’s uHIE to securely and instantly deliver an electronic request directly to a provider’s desktop, for about half the cost of a postage stamp, regardless of the number of pages contained in the request. NEA’s web-based system replaces the need to send documents physically. “We’ve created an electronic envelope for the content requested and then transmit the electronic envelope to the payer,” Fincher explains.

The exchange is bidirectional and works as a system consisting of requests from the payer and replies to the request in the form of a message and/or document (response) from the provider to the payer. All communication is initiated by the payer. The system saves all messages, providing a record of communications between the payer and provider. Confirmation of providers’ response and delivery are instantly made.

Not all providers need an electronic attachment service. Pediatric dentists, for example, have very few cases that require attachments. General dentists, oral surgeons, periodontists, and endodontists have the greatest number of attachments to transmit.

However, many practices that could benefit from the electronic attachment services are not using them, Limoli says. That may be because many dentists are not keeping adequate records.

Noncommercial Payers


Medicare does not cover dental care that is needed primarily for the health of the teeth, including routine checkups, cleanings, or fillings. Medicare also does not pay for dentures or implants. It may pay for extractions in preparation for a medical procedure or for a dental service required to protect general health, or if a dental procedure is needed for another health service that Medicare covers to be successful.

For example, Medicare will pay for dental services if a hospitalized patient receives an oral exam because of a planned kidney transplant or a heart valve replacement in a rural or federally qualified health clinic; for a disease involving the jaw requiring dental services such as radiation treatment; for removal of a facial tumor and reconstruction; for surgery to treat fractures of the jaw or face; or for jaw surgery requiring dental splint and wiring. Medicare may pay for these services, but it will not pay for any follow-up dental care after the underlying health condition has been treated.

Medicare Advantage Plans may offer extra coverage for dental procedures.


All 50 states participate in Medicaid and each has a state plan that outlines what the plan covers with respect to dental care (see Table 1 for more information about Medicaid expansion). States are required to provide dental benefits to children covered by Medicaid and the Children’s Health Insurance Program (CHIP). Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits called the EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Benefit.

However, individual states choose whether to provide dental services to adults on Medicaid. The past decade has seen a significant erosion of Medicaid adult dental benefits in most states, to the point where many are skeletal. Even once-robust state dental programs, such as existed in California, have cut all elective dentistry.

“Very few states cover adult dental care, with all the budget cutbacks and problems. If they previously covered adult dental at all, they basically took it away,” notes Lee Perry, DDS, retired Medicaid dental director at the New York State Department of Health (NYSDOH) in Albany, New York. New York is one of the few states that has maintained an adult dental program despite budget problems, he says. “I have to give kudos to the taxpayers of New York, Governor Cuomo, the legislature, NYSDOH Commissioner Shah, and Medicaid Director Helgerson. I believe that they understand and appreciate the need for good dental care, at all ages, in order to maintain a truly healthy population, and they should be commended for not slashing adult dental benefits in these difficult times.”

Dentists who treat Medicaid patients have basically the same claims reimbursement process as dentists with patients in commercial plans, according to Dr. Celko. Dentists treating Medicaid patients can see which procedures are covered in their state by reviewing the appropriate benefit grid. “While many benefits for adults have been cut, there are still quite a few states that cover adult benefits,” he notes.

In addition to the approaches already discussed for submitting claims to commercial carriers, there are recommendations specific to Medicaid claims. Again, it’s important to show as much diagnostic information as possible and to make sure that if there is something you want the payer to consider, that you write it in the remarks section of the claim form. This is especially important for replacements of existing dentures, advises Dr. Celko. “You want to make sure you provide this information because the patient’s history may not be in our system, or it was assumed from another carrier and it may have been replaced the previous year. We have no knowledge of that, so indicate it on the claim form.” Most state Medicaid plans have very strict guidelines for denture replacements. Pennsylvania, for example, has a once-in-a-lifetime limit on denture replacement.

Mark the date of prior prosthesis replacement—there’s a place on the claim form for that. Completely fill out the claim form and indicate if it was done in an office or hospital. Sometimes procedures are eligible for payment if they are done in a short procedure unit, ambulatory surgical center, or in-patient hospital.

It is important to explain what the medical necessity is for general anesthesia. “It should not be for patient comfort or because they’re anxious,” says Dr. Celko.

Electronic attachment systems are also used for Medicaid claims. You can upload claims and attachments through their portals and send them electronically, and it’s actually the preferred method, according to Dr. Celko, as it is easier to store these files.

Dentists treating Medicaid patients should always follow through on the diagnostics, Dr. Celko advises. “Many times we’ve seen that providers will do an exam and a cleaning and may not take radiographs, and if they do, are there any restorations that follow this? Are they performing treatment? You want to make sure that quality diagnostic radiographs are there, and if you’re treatment planning, you’re doing the work that shows on the radiographs,” he says. If restorations are needed, subsequent treatment shows that. “Not seeing a treatment plan, just restorations without x-rays or submissions for treatments like that, indicates a quality of care issue to me.”

Dr. Perry recommends that dentists treating Medicaid patients take advantage of vendor assistance. “All vendors that process Medicaid dental claims provide training sessions, hands-on programs, webinars, and service representatives to assist dentists who have claims.”

The Incurred Medical Expense (IME) regulation can help nursing facility residents who are enrolled in Medicaid pay for dental care. Medicaid residents with Social Security or other retirement income may be able pay for medically necessary dental care that is not covered by Medicaid using the IME. Each state has variations in the procedures for IMEs, so dentists using this program to bill for services need to work with the resident’s Medicaid caseworker to address these rules.7 IMEs apply only to services that are not covered under the state Medicaid program and any other third-party payer, and they apply only to medically necessary dental services.


The best way to avoid the pitfalls of the reimbursement process is to approach reimbursement realistically and strategically, using every tool available to streamline and the process, while understanding how to work within its confines so that you get paid as soon as possible. Table 2 provides additional information about what to expect now and in the future with the ACA.

Here are our top 10 pointers for reimbursement, assembled in a list based upon the advice and recommendations presented by the experts we interviewed.

1. Code for what you do, not what you are paid for.

2. Just because there is a procedure code for something does not mean that it is a paid benefit or covered service in a dental insurance plan.

3. Your treatment plan should be based on the patient’s clinical needs and not the covered procedures.

4. Some procedures have annual or lifetime limitations. Limitations and exclusions can vary between plans offered by the same company.

5. Check date-of-service requirements. Some state laws and third-party processing policies and contracts specify completion date as the date of service.

6. Guidance on which code to use is based on the published procedure code nomenclature and descriptions.

7. Contracts include limitations and exclusions. Know what you are signing.

8. Detailed documentation is critical. It is the key to justifying treatment that was provided. This means using radiographs, clinical notes and charting, and photographs.

9. Explain what you saw that made you decide what treatment was needed and appropriate. Is the information obvious on the x-ray? If it is not obvious to claims reviewers, send a narrative stating what cannot be seen on the x-ray.

10. Keep complete records, identify a comprehensive medical/dental history, accurately chart an initial exam, diagnosis, and sequence treatment plans.


1. Furlong A. ADA, NADP share views on bundling and downcoding. ADA News website. June 20, 2007. Accessed November 1, 2013.

2. Essling M. AAPD Coding and Insurance Workshop. Presented at: The California Society of Pediatric Dentistry Annual Meeting; April 28, 2013; Rancho Mirage, CA.

3. Furlong A. ADA, NADP share views on dentists’ concerns—Part 2. ADA News website. January 2007. Accessed November 1, 2013.

4. Furlong A. ADA, NADP share views on dentists’ concerns—Part 1. ADA News website. November 2006. Accessed November 1, 2013.

5. ADA/NADP share views on educating front office staff. ADA News website. October 2011. Accessed November 1, 2013.

6. ADA/NADP share views on the least expensive alternative treatment clause. ADA News website. September 2007. Accessed November 1, 2013.

7. American Dental Association, National Elder Care Advisory Committee, Council on Access, Prevention and Intraprofessional Relations. Incurred medical expenses: paying for dental care. A how-to guide. Accessed November 1, 2013.

Table 1

FAQs: ACA and Medicaid Expansion

What is the Medicaid expansion?

The Affordable Care Act (ACA) aimed to extend health insurance coverage to approximately 32 million uninsured Americans by expanding both private and public insurance programs—including an expansion of Medicaid to all non-Medicare eligible people younger than 65 years with incomes below 133% of the federal poverty guideline. The US Supreme Court upheld the Medicaid expansion but limited the ability of the US Department of Health and Human Services to enforce it. This allowed states to make Medicaid expansion optional. At press time, 26 states and the District of Columbia will expand Medicaid. Several states are undecided, 1 state is leaning toward expanding Medicaid, and 21 are leaning against the expansion.

How many children are expected to gain dental insurance through the ACA?

By 2018, the ACA is projected to add approximately 8.7 million children to the numbers of children currently covered by dental insurance. That number is split among those getting dental benefits through Medicaid (3.2 million), health insurance exchanges (3 million), and employer-sponsored insurance (2.5 million).

How many adults are expected to gain dental benefits through the ACA?

Even with the slim benefits for adult Medicaid dental patients, the ADA estimates that approximately 800,000 adults will gain dental benefits through the health insurance exchanges. The ADA estimates that about 17.7 million adults could gain some type of dental coverage through Medicaid expansion; however, because many states currently have only emergency or limited dental benefits for adults through Medicaid, only 4.5 million adults will gain more extensive dental benefits under the ACA.

Source: Affordable Care Act, dental benefits examined. ADA website. August 19, 2013. Accessed November 14, 2013.

Table 2

What to Expect with the ACA

When the Affordable Care Act (ACA) took full effect on January 1, 2014, dental coverage for children (defined as younger than 19 years)—but not adults—was included as part of the essential health benefit (EHB) package that must be offered in the individual and small group market, both inside and outside the exchanges. Here is what every practice needs to know:

• Small group is defined as 50 or fewer full-time employees for 2014; in 2016, small group will increase to 100 or fewer.

• EHB pediatric dental coverage is different inside and outside the exchanges.

• Outside the exchanges: All qualified health plans (QHPs) have to provide what the ACA mandated as EHBs with one exception. When consumers have already obtained pediatric dental benefits that meets the ACA coverage requirements, the health plan can exclude pediatric dental coverage.

• Inside the exchanges: QHPs can offer the EHB package of benefits without pediatric dental when stand-alone dental carriers offer pediatric dental on the exchanges. Consumers can buy a health plan without pediatric oral health services and will not be required to buy a separate dental policy covering pediatric dental services in most states.

• Adult dentistry is not mandated by the ACA.

• Only a few states—at press time, Connecticut and Washington—have not allowed dental carriers to offer separate dental coverage on the exchanges that could cover adults. Washington is offering dental coverage on the individual exchange but not on the Small Business Health Options Program (SHOP) exchange, through which individuals and small businesses with up to 50 employees can purchase qualified coverage.

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