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Crown denials can be appealed with help from ADA

October 08, 2018

By David Burger

Editor's note: This is the 19th story in the Decoding Dental Benefits series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care.

Numerous dentists have lodged complaints with the ADA Center for Dental Benefits, Coding and Quality and its staff after third-party payers denied claims for crown procedures.

Photo of Dr. Calitri
Dr. Calitri
Some dentists have even informed the ADA that core buildup procedures are bundled with crowns by third-party payers, even though core buildups are separate procedures and not every crown needs a core buildup.

Bundling of separate procedures to limit a benefit is against ADA policy.

The payers who choose not to cover certain crown procedures do so for a variety of reasons, said Dr. Paul Calitri, a Rhode Island general dentist and member of the ADA Council on Dental Benefit Programs.

One of those reasons is a cracked tooth, Dr. Calitri said. Cracked tooth syndrome occurs when a tooth has a crack that's too small to show up on X-rays, or is under the gum and challenging to identify, he said. He has heard complaints from dentists that claims for cracked tooth syndrome have been denied because radiographs don't show the cracks.

Some dental plans cover crowns when the teeth are broken down and have extensive structural damage due to dental disease or accidental injury — but if the third-party payer doesn't see evidence of that, the claim may be denied. Claims may also be denied if the dental plan's consultant indicates that the tooth has a poor prognosis. In addition, claims for abrasion and attrition are typically denied.

Again the ADA believes that these denials based on the payers determination of the need for the service is improper and intrusive given that the benefit administrators' responsibility is simply to administer the benefit that had been paid for by the patient.

However, in order to assist patients in receiving a benefit from their plan, dentists may choose to include a detailed narrative. The narrative, Dr. Calitri said, should explain why the dentist chose to do the procedure.

DDB LogoIf the procedure is denied, a "respectful" appeal should be submitted, he said. It is entirely possible, Dr. Calitri said, that third party payers could develop a more positive relationship with dentists that includes a reasonable amount of trust.

Sometimes, it's a good idea, Dr. Calitri said, having the patient contact his/her employer's human resources department for assistance in handling the appeal. "Get the employer involved," he said. "They can file a complaint, and the third-party payer will pay a little more attention to the request for assistance from the employer."

To minimize claim denials for core buildups, documentation of the condition that resulted in the buildup should be provided in the initial claim submission, Dr. Calitri said. This could include documentation indicating that the tooth was broken down to the extent that a buildup was necessary for crown retention. But if a dentist submits a core buildup claim every time a crown is placed, that might raise a red flag with the third-party payer.

Even in the face of denials of claims for core buildups, dentists should treat the patient with appropriate care regardless of the patient's insurance coverage, said Calitri.

Communication is crucial, he added.

"It can be very frustrating," Dr. Calitri said of claim denials from outside entities that determine what is appropriate. The dentist then has to explain to the patient why a particular procedure wasn't covered, eroding trust built up in a dentist-patient relationship.

It is important to remember that a denial from the plan simply means the plan as designed does not pay for the procedure; however, any denied procedure can be billed to the patient. Having patients who understand the limitations of their plan prior to treatment may help avoid problems, he said. Dentists should help the patient understand the clinical basis for treatment, in spite of contractual limitations by the plan.

Further guidance is available and can be found in the ADA's members-only manual Responding to Claim Rejections, located at Success.ADA.org/en/dental-benefits/responding-to-claims-rejection.

The ADA has also created an online landing page for dental benefits information that can help dentists address and resolve even their most vexing questions. Go to ADA.org/dentalbenefits, which is part of the ADA Center for Professional Success.

Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related and coding problems, questions and concerns. Call the ADA's Third Party Payer Concierge at 1-800-621-8099 or email dentalbenefits@ada.org.

Previous installments in the Decoding Dental Benefits series are available at ADA.org/decoding.