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ADA/NADP share views on a single claim form

Paper processing issues are among the most frequent claims problems the dental benefits industry reports to the ADA Council on Dental Benefit Programs.

The topic launches a series of ADA News articles about the dental benefits industry's "Top 10" concerns submitted to the ADA about dental claims processing. It follows articles published from 2006-08 examining the "Top 10" dental claims concerns that dentists reported. That series was developed in response to CDBP discussions with the National Association of Dental Plans and the payer industry to facilitate communication and eliminate claims problems for members and patients.

"In its leadership role, the ADA anticipates the needs of dentists to facilitate changes that are of maximum benefit and minimal inconvenience to a practice," says Dr. Bert Oettmeier, chair of the Council on Dental Benefit Programs.

With a goal of clarifying information necessary for the timely and consistent adjudication of claims, these articles will include perspectives from ADA members, National Association of Dental Plans members and the Council on Dental Benefit Programs about topics within three broad categories:

  • paper processing issues;
  • education of dental office staff;
  • myths and misunderstandings.

NADP member companies represent some 80 percent of the estimated 176 million Americans covered by dental benefit plans.

This first installment features the one of three topics falling under the category of paper processing issues, the single claim form. Subsequent articles will cover the remaining "Top 10" concerns, which include information technology, how fees for services are developed and diagnoses.

Visit www.ada.org/goto/top10concerns to read other installments in this series.

For more information about dental benefits issues, call the ADA toll-free or e-mail dentalbenefits@ada.org.

Single claim form

Dentist perspective

The American Dental Association agrees with the underlying theme of the National Association of Dental Plans' adjoining article—adoption and use of a single standard paper dental claim form by all sectors of the dental community. Such a single standard exists: it's the ADA Dental Claim Form.

In 1991 the ADA House of Delegates formally recognized the value of a standard claim form to dentists, third-party payers and other sectors of the dental community by adopting policy entitled ADA's Dental Claim Form. This policy, which continues in force today, states that the ADA urges universal use and acceptance of this form, as well as the Code on Dental Procedures and Nomenclature, for claim submission.

The ADA recommends that dentists use the most recent version of the ADA Dental Claim Form, while also acknowledging that use of the ADA claim form is voluntary. The form's current version is in widespread use. Member dentists inform ADA staff that many third-party payers providing coverage to patients require use of the current version of the ADA Dental Claim Form as a result of the payers' own business practices or through provisions in participating provider contracts. Some state Medicaid agencies also mandate use of the ADA's claim form for reporting services provided to covered individuals.

Linking the paper and electronic claim, and automated processing:
The paper ADA Dental Claim Form's data content served as the starting point for creation of an electronic dental claim format by ANSI ASC X12.

ANSI ASC X12 is the acronym that stands for American National Standards Institute Accredited Standards Committee X12. X12 is the specific accredited committee that develops electronic data interchange standards and related documents for various sectors of the business community, including health care. X12N is the subcommittee responsible for development of insurance EDI standards. Several X12 transactions have been named as Health Insurance Portability and Accountability Act of 1996 standards. X12 work led to the HIPAA standard electronic dental claim transaction—a federal requirement for all health care providers filing electronic transactions.

In 2001 the ADA House of Delegates recognized that HIPAA standards can also influence the ADA Dental Claim Form. ADA policy adopted that year stated that paper form data content should be coordinated with the HIPAA standard electronic dental claim transaction. Such content coordination is evident in the current version (2006 © American Dental Association), which incorporates changes that enable reporting of the national provider identifier, also required under the Health Insurance Portability and Accountability Act of 1996.

NADP's adjoining article also notes that use of a standard paper form brings a variety of preparation and processing efficiencies, with particular mention of automated data entry via Optical Character Recognition technology used by third-party payers. A red ink form that supports OCR has been and continues to be offered in the ADA Catalog (J404).

Updating the ADA Dental Claim Form:
The ADA Council on Dental Benefit Programs has ADA Bylaws responsibility for the ADA Dental Claim Form. This responsibility includes determining content and format, as well as when a new version of the form should be introduced. The council considers suggested changes from several sources including dentists, practice staff and individual council members as representatives of their district's dentists.

In addition, the council established the Dental Claim Form Advisory Committee to engage varied sectors of the dental community in discussion of possible changes to the ADA Dental Claim Form. As an advisory body, DeCFAC offers suggestions for form changes on its own, as well as commenting on changes suggested by others in the dental community. DeCFAC is comprised of representatives from the Council on Dental Benefit Programs and the Council on Dental Practice, representatives from third-party payer organizations, including NADP, and electronic data interchange agencies.

Education:
The ADA uses several different avenues to promote adoption and correct use of the ADA Dental Claim Form. A separate section of the CDT manual contains comprehensive claim form completion instructions. This feature, first seen in CDT-2005, provides field-by-field guidance on form completion for dentists, front-office staff and practice management system vendors using software that prints the claim form. The instructions are illustrated with the relevant portion of the form, and include codes (area of the oral cavity, tooth number, provider specialty) that are used when preparing a claim form. These codes are the same codes that are used in the HIPAA standard electronic dental claim transaction—another example of the march toward standard data content.

Additional information on claim form use and completion is found in the CDT 2009-2010 Question & Answer section, the CDT Companion and the council's half-day Code Workshop presentation. Council staff provides information about the form to dentists, office staff, third-party payers, practice management system vendors and government agencies that write or call with questions.

Future:
When will the need for a paper claim form end? Will there always be an ADA Dental Claim Form? Despite continuing progress toward a paper-free, or at least a paper-limited dental practice, there is no set timetable for such goals. For the foreseeable future, the ADA Dental Claim Form fulfills the need for a standard paper dental claim format.

Dental benefits industry perspective

One simple step to improve paper claims filing:
In 2008, 51 percent of all dental claims were submitted to dental benefits companies electronically and 49 percent of dental claims were submitted on a paper claim form. While the Health Insurance Portability and Accountability Act of 1996 mandates a standardized format for electronic claims, no such mandate exists for a standard paper dental claim form.

This lack of uniformity creates a paper dental claim processing system that is unnecessarily complex, cumbersome and costly. The situation calls for the adoption and use of a single standardized paper dental claim form—the American Dental Association Dental Claim Form.

Unnecessary Costs:
Although 49 percent of dental claims are submitted on paper, the data is typically converted to electronic formats. This conversion takes place via manual data entry or by scanning and using Optical Character Recognition. The lack of a standard dental claim form increases the costs of claims processing in both the data entry and OCR processes.

Required data is not entered in the same place on every form. Dental benefits industry staff entering the data must look in multiple locations for the same information. When a few additional seconds of staff time are multiplied by the hundreds of millions of claims processed each year, the impact to processing, staff costs and delays in reimbursement become clear.

This issue also impacts OCR processing. OCR programs can recognize and convert data from a paper form into electronic data. However, the lack of consistency in the location of information can make the data difficult to retrieve and negatively impact the efficiency of the data captured. In some cases, the data location is so skewed that the paper form is transferred to a staff member so data can be re-entered manually. This doubles the amount of time needed to compile data prior to review and adjudication.

Paper chase:
Affiliated Network Services, one of the larger clearinghouses for dental claims, reports almost 50 different claim formats can be received for processing in any given month.

Why so many different claim forms? In some cases, providers submit old, outdated forms to use up a stockpile they may have purchased. While this may seem to be an efficient use of office inventory, this "efficiency" actually impedes the timely processing of claims. It's the same as using old letterhead after a move to use up stock when it would actually increase confusion and cause delays.

Still other claim forms can be generated as printouts from practice management systems dental offices use. The three most widely-used practice management software systems have the ability to produce the current paper ADA Dental Claim Form. However, many providers have not updated the software and the printouts are in outdated formats. What appears to be a savings by not updating the software can actually slow down the processing of outdated formats as they end up being manually processed.

In other cases, a large employer may request a dental plan administrator to customize a claim form to brand the employee benefit programs. This is similar to customization requested by self-administered plans such as labor unions. Brand marketing may seem logical at first, but this customization actually leads to delays in claim processing.

The additional cost and complexity added to the claims processing system by the use of outdated, nonstandard or personalized claims forms supports the use of a single standardized dental claim form across the dental industry.

Simple solution:
Education is key in helping those in the dental industry see how a simple solution can quickly and easily reduce the unnecessary costs involved with processing claims and expedite payment to providers.

While the complete solution is to move to processing claims via electronic data interchange, the second best option is to adopt, implement and use the ADA Dental Claim Form for all dental paper claims. If there is only one standardized dental claim form, dental office staff members do not have to coordinate claim forms with different dental plans. When filing secondary insurance, coordination of benefits would be made easier as office staff and benefit plans would have a consistent data format to compare coverage.

Utilizing the readily and easily available ADA Dental Claim Form can:

  • increase consistency;
  • increase claims processing speed;
  • reduce the potential for human error;
  • streamline the process;
  • reduce costs.

In one simple step, providers and dental offices can move toward a more efficient and productive paper claims processing system to benefit everyone involved in the process.

NADP encourages the adoption of the ADA Dental Claim Form as the single standardized paper claim form for all aspects of the dental benefits industry to increase efficiency and efficacy while reducing confusion and costs. n

—Compiled by Arlene Furlong