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Dental Claims

Top 6 Reasons Claims are Rejected

Posted by Jason Penrod on Jan 17, 2019

With January now in full swing, the signs of the new year are all around us. As gyms fill up with resolutions and homes take the Marie Kondo approach to tidying up, dental practices everywhere are receiving code validation failures.

Every year, the American Dental Associate releases their updated Current Dental Terminology (CDT) codes. Practices that forget to update their codes in the new year can lead to one of the more common reasons why dental claims get rejected. Here are a few other common reasons why your claims might be getting rejected and what steps you can take to fix them.

ADA Code Validation Failure

This can be as simple as using an invalid procedure code. It could also be the case that you have the correct code, but the insurance company requires a different code to process the claim (Ex. D4342 was submitted with a tooth number, but the insurance company wants an oral cavity code). Make sure that your practice is staying current with annual code revisions.

Subscriber Not Found

This issue indicates that the subscriber isn’t on file or that the submitted ID doesn’t match the insurance company’s records. If you find that you’re receiving this error even though you have verified the subscriber ID, make sure the information is matched with the correct insurance company.

Missing or Invalid Subscriber ID

This is the policy holder’s subscriber ID number. If you are having issues with the subscriber’s ID, try inserting their SSN (social security number) in the subscriber ID field and type the subscriber ID in the SSN field. If this doesn’t solve the problem, you will want to contact their insurance company.

Missing or Invalid Patient Information

Covering any information regarding the patient. If the patient is not on hand to verify their details, you can get this information by reaching out to their insurance company or by checking their EOB (Explanation of Benefits).

Incorrect Entity Address

Including the address for the patient or the subscriber. Always confirm the address your patient provides matches what their insurance company has on file for them. The error could be as simple as your patient moving and forgetting to update their records. If you think you have the correct information but are still having issues, you can verify the address on to confirm the zip code and the formatting.

Duplicate Claims

Duplicate claims are caused if you submit the same claim multiple ways (Remote Lite, mail, practice management system, etc.). Typically this means that the insurance company accepted the original claim and is only rejecting the duplicate. However, this can potentially lead to billing issues regarding the claim. It is best that your practice sticks to a single method for submitting claims.

Outside of these six, many rejections come from specific requirements that the insurance company might have or the patient’s coverage. Your practice can get in front of many these rejections by using a claim processing service that works with an insurance clearinghouse.

Having a direct connection to payer information will provide more detail on your rejections and the best course of action to resolving any issues. For example, Renaissance’s partnership with Tesia provides RPractice users recommended solutions for 95% of the most common claims rejections. Knowing exactly why your claims are getting rejected and what to do next will help your practice spend less time on the phone resolving issues for patients.