Administrative and clinical denials by a large dental insurance provider.

Abstract:

:The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both) made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into 'administrative', 'clinical' or 'both'. The data were tabulated and submitted to uni- and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05). It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.

journal_name

Braz Oral Res

journal_title

Brazilian oral research

authors

Miranda GE,Siqueira MC,Ferreira RL,Delwing F,Daruge Júnior E

doi

10.1590/1807-3107BOR-2015.vol29.0041

subject

Has Abstract

pub_date

2015-01-01 00:00:00

eissn

1806-8324

issn

1807-3107

pii

S1806-83242015000100232

journal_volume

29

pub_type

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