Dental Insurance Claims Processing 101

Dental claims processing entails all aspects of giving care to patients, starting from the moment a patient is registered until the explanation of benefits (EOB) and payments are completed. Dental insurance claims are submitted via paper and electronically.  

Electronic transactions are where clearinghouses such as the Smart Data Stream Clearinghouse come in. 

Clearinghouses give dental practices the tools and access necessary to submit, receive and request information from different payers. A quality clearinghouse is one that successfully provides a seamless data exchange between dental care providers and insurance payers. 

Dental claims are complex, but understanding the workflow can help businesses identify areas to reduce cost and speed up turnaround time.

Steps in Dental Insurance Claims Processing 

The first step in the dental claims process is to ensure that the patient has been seen and received care. After a patient has visited a dental provider, claims go through several steps before patients receive their final bill: 

1. Billing. Insurance is sent a bill for charges of service, not including any charges paid via co-pay upon check-in.
2. Adjudication. A certified claims processor will review the claim, ensuring accuracy and comparing it against the insurance plan to validate that services rendered were or were not covered by insurance.
3. Reconciliation. If services received were covered by benefits, the insurance company will pay the claim based on allotted coverages. They may pay the entire claim in full depending on their plan, otherwise, the remaining balance will be billed to the patient.
4. Validation. Amounts will be validated and applied to deductible and max-out-of-pocket totals as they apply to an insurance plan. Those will be updated immediately.
5. EOB. An explanation of benefits is sent to the patient, which outlines a detailed list of services received, how much was covered by insurance, how much the provider paid, and what remains to be billed.
6. Final Billing. A final bill will be sent to the patient for payment, if applicable.
7. Payment. Before paying the claim, the patient should compare the EOB and final bill and ensure everything is accurate and billed correctly. Sometimes balances don’t align because of a mismatched procedure code or other clerical error. Claims can be updated and fixed without penalty.

The dental claims process, similar to medical claims, entails many steps beyond giving care and billing patients. Dental insurance claims processing can be completed manually in-house or outsourced to a third party. Partnering with a BPO vendor can speed up claims workflows and increase the accuracy of billing because of automated processes that are continually enhanced through processing large volumes of claims. 

The 2020 CAQH Index studied the current state of claims processing in medical and dental industries, noting the top spending in dental claims comes from eligibility and benefit verification, alongside remittance advice. 

Transitioning eligibility and benefit verification to an electronic process yields a potential cost savings of $8.75 per transaction according to the Index. When multiplying these savings by the number of claims a dental practice processes in any given day, the potential for savings from outsourcing adds up quickly.

What is a Dental Insurance Claims Clearinghouse?

 A dental claims clearinghouse is essentially the middleman between the dental providers and the insurance payers. Clearinghouses bring momentum to dental claims processing because of automated processes that ensure faster turnaround time. Efficient clearinghouse operations will reduce both paper submissions and call center traffic, providing dental practices with the information and services they need to process claims quickly and accurately.

A clearinghouse electronically checks dental claims for transaction compliance errors to ensure accuracy before being processed by the payer. Once these claims are “proofread” and “cleaned”, the claims and any associated dental or medical records and attachments are sent electronically to all appropriate organizations. Electronic workflows for dental claims have become increasingly common in the industry, surpassing manual transactions in 2020 and representing 46% of total transactions. 

Benefits of Partnering With a Clearinghouse for Dental Insurance Claims Processing

Processing dental claims is incredibly complex and tedious. 

The primary benefit of partnering with a clearinghouse is simple: you are partnering with an industry expert who knows claims processing inside and out to help optimize your workflow. A clearinghouse expertly communicates between providers and payers, while understanding which forms require special attention. 

Electronic processes make quality assurance part of the standard procedure to increase auto-adjudication, accuracy and reduce re-work later in the workflow. Quality control for clearinghouses is a key task that involves scrubbing the data on claims to ensure sensitive health information is both accurate and secure. 

Machine learning has proven useful to the industry in recent years because of its ability to process large volumes of collateral with 99.5% accuracy. 

However, machine learning can only go so far, having to rely on consistent and reliable forms or processes in order to be impactful. If forms change too rapidly for machine learning to keep up with, clearinghouses provide manual support to lift the burden of processing claims off of dental practices. 

How Does Electronic Data Capture Play Out in Dental Claims Processing?

Auto-adjudication and electronic data capture pays or denies insurance and public benefits claims quickly without the need to review each claim manually. 

Auto-adjudication uses business logic to scan for errors then match key details to make the decision of approval, denial, or a change to the claim automatically. This results in decreased turnaround time for lab results, claims processing, receiving a diagnosis, transferring records, and more.

While electronic data capturing is efficient, some processes benefit from remaining manual. Many proprietary forms remain manual due to low volume and because they often change on a yearly basis. This consistent change and low volume mean that it may not be cost- or time-effective, to develop optical character recognition software for such niche processes. On occasion, some record transfers for referrals and second opinions must still be requested and collected by the patients themselves and are hand-carried to the second opinion appointment.

How to Vet Dental Insurance Claims Clearinghouses

When searching to contract with a clearinghouse for dental claims, there are a few things to keep an eye out for, like certification and how user-friendly they are. The more a clearinghouse checks off on this list, the higher quality they are:

1. HIPAA certified, which ensures a clearinghouse understands the importance of being HIPAA compliant.
2. While HIPAA sets regulations, being HITRUST certified shows that a company is highly secure.
3. Providing technical expertise and having immediate customer support.
4. A quick response time on acknowledgments.
5. The ability to receive 835s and view in a human-readable format.
6. A user-friendly portal and easy-to-use website.
7. The ability to accept electronic attachments

While each one of these factors is important, it’s vital to align your business with a clearinghouse that achieves all of them.

What Dental Insurance Claims Processing Services does SDS Offer?

Smart Data Solutions offers dental claims management services that include:

• Claims routing specific to your needs. We can configure routes based on member, provider, location, etc.
• Pre-adjudication clinical editing and bill review.
• E01 data exchange and CMS integration for clients offering Medicare supplemental plans.
• Expert data capture for claims, EOBs, x-rays, bills, and more. 

SDS and EOB Attachments

Coordination of Benefits and managing paper EOB attachments is a headache for many dental payers today. SDS has partnerships in the dental industry that help dental practices achieve significant time and cost savings related to managing coordination of benefits and ensuring accurate claims payment.

As part of our mailroom and paper claim conversion workflow and services, Smart Data Solutions takes in paper claims and accompanying EOB attachments, captures the appropriate data on both documents, and is able to send the correct data in the CAS/COB loops of the 837.

Efficient X-ray Attachments

Dental claims come with many different attachments, one of the most common being x-rays. With the dental hitching technology at Smart Data Solutions, we can make the dental attachment process more efficient while providing a structured intake process. 

Our proprietary solution for dental hitching is a simple three-step process:

1. Using our unique x-ray scanner, QuickShot, we capture the x-ray while simultaneously scanning the claim on our OPEX scanners
2. The scanner then automatically attaches the x-ray to the claim.
3. Both the claim and the x-ray attachment are uploaded together in the system as one.

As the industry continues to move toward electronic attachments, payers utilizing our paper data capture process, along with x-ray processing, will be a step ahead when it comes to streamlining their intake workflows. Not only do we allow payers to view the images on our QuickClaim portal, but we can also send your attachments electronically in a 275 format.

 Partnering with a facility like Smart Data Solutions to handle your dental insurance claims processing can bring enhanced security, fewer claim denials, and a faster turnaround time on billing processes. Many healthcare facilities utilize our services to streamline their workflows from beginning to end. Learn more about how Smart Data Solutions creates efficient claims processing workflows for dental practices by reading about our commitments in service level agreements.