Stopping the claim that will come back for one field
Most first pass rejections come down to a single absent field. A restorative code sent without the tooth number or the surfaces, a scaling claim sent without the quadrant. Which of these a given payer actually enforces varies enough that a generic edit list catches less than a rule set built from what this practice has had returned, keyed by payer and by procedure code. Those rules go stale. A rule that fires on claims which would have paid costs more than the rejection it was written to prevent.
Electronic eligibility answers whether a patient is covered, and then somebody opens the payer portal anyway to find out what is actually payable.
There is a mandated electronic standard for eligibility, and it works. It confirms that a plan is active. What it routinely omits is the detail the front desk actually needs: frequency limitations, waiting periods, alternate benefit provisions and remaining annual maximum. That gap is the origin of most manual verification in this sector.
- Open Dental
- Dentrix
- Availity
When this is the wrong thing to build
Pick something else if claim volume is low across a narrow set of codes, or if submissions already pass through a clearinghouse edit package the practice pays for, since a second scrubber in front of the first mostly generates argument about which one was right.
The constraint that shapes it
A practice is a covered entity, and any vendor that creates, receives, maintains or transmits protected health information on its behalf is a business associate, which requires a written agreement in place before any disclosure. More on how this sector works.
Run the rules of the other side first, so the submission does not come back. Read what this shape is, or start from one of these.
- Counting the clock that public marketing starts on a listing
- Checking for a signed buyer agreement before a tour is confirmed
- Catching a filing rejection before the clerk does
- Catching the invoice lines an e-billing gate will reject
- Checking that a technician may legally take the call
- Filing a backflow test report the purveyor will accept
- Why do claims get rejected for missing tooth number?
- What fields does a dental claim need for an implant crown?
- How do I stop the same claim rejection happening every month?
- Which dental codes require a quadrant on the claim?
- Is there a way to check a claim before sending it to the clearinghouse?
Back to medical and dental practices, or see how this is priced and scoped.