Why Dental Prior Authorization Requests Get Delayed and How Better Verification and Workflow Management Can Prevent Claim Denials

Delays in dental prior authorization cause issues for dentists, patients and billing. Lack of radiography, clinical notes, or inaccurate procedure descriptions or payer requirements can also result in extra administrative tasks. The same puts off treatment decisions and makes claim processing difficult too. There is a measurable administrative burden. In 2024, CAQH’s Index had dental eligibility and benefit verification costs of $2.1 billion for 2023. The report called this rise was due to increased volume and “the cost of finishing verification on payer portals.

There is clearly a need in the dental practices for a stable process for benefits verification, deciding on dental prior authorization requests and keeping track of payer choices. There should be clear requirements and responsibilities for each step. The companies can detect issues at a younger stage, minimize manual activities or prevent unnecessary denials for authorizations.

What Is Dental Prior Authorization, and When Is It Required?

A process of consultation with an insurance payer that is conducted before treatment is proposed, involving the submission of details about proposed treatment. The payer assesses the request, according to the patient’s benefit plan, rules of coverage and clinical documentation. Dental prior authorization rules for every dental care payment vary from plan to plan, payee to payee and procedure to procedure. Some crowns, periodontal treatment, oral surgery treatment, or other complicated services may have to be reviewed. Each patient’s plan should reflect the requirement for that patient, and this should be confirmed by the dental team rather than assuming the same plan is required for everyone.

Dental prior authorization is related, but not synonymous with, oral predetermination of benefits. Many preferred provider organisation (PPO) plans and indemnity plans also provide for an option to make voluntary predeterminations, according to the American Dental Association (ADA). Certain dental health maintenance organization (DHMO) plans include specific services that must be preapproved, or specialist referrals are needed.

Predetermination is designed for the sake of helping the practice and the patient to understand how a proposed treatment will be covered. Dental prior authorization is for services that have an applicable authorization requirement. Staff should verify the terminology and process as outlined in the plan; because payers often define the terms differently. A dental prior authorization determination does not mean full payment for the services. The ADA points out that the coverage and payment could change when eligible coverage ends, annual benefits reach the limit or when time limits are exceeded. Practices will check for the patient’s eligibility and remaining benefits for the service provided.

How Dental Prior Authorization Delays Lead to Claim Denials

Claim denials are commonly due to the same issues that cause delays in dental prior authorization. The lack of information, lack of detail in processes, and inconsistent with the requirements from the payers, result in errors while submitting and during claims processing.

Common errors that delay dental prior authorization requests

There are a number of administrative and documentation issues that make it harder for payers to review requests efficiently.

• Incomplete insurance information: Errors in details provided by the subscribers or information regarding the coverage which is outdated makes it difficult to verify eligibility.
• Lack or incomplete clinical records: Payers may require clinical notes, treatment plans, periodontal charts, radiographs and more before making a decision on whether to allow a procedure to be performed.
• Incorrect CDT codes: Leaving the CDT code, tooth number, and surface code incorrect will lead to discrepancies between procedure plan and the dental prior authorization request.
• Unverified payer requirements: Staff may make a request without verification of whether dental prior authorization of the dental care is required or which copies should include.
• Using inappropriate method of submission: Poor choices of portal, form, or method will lead to unnecessary delay in processing.
• Inadequate follow-up management: pending requests don’t have the appropriate staff member to take the next follow-up or escalation action.

Common issues from a dental practice perspective cited by the ADA are that the radiographs are not present in the record, the records are incomplete, and that claims have been submitted more than once. These problems warrant the need for payer specific documentation checking.

How dental prior authorization errors affect claims

When treatment happens without a dental prior authorization that was needed from the mouth insurance plan, it becomes a ‘billing risk’. Other issues that may occur are the approved procedure is different from what was rendered, as well as the presence of an incorrect authorization number in the claim.

Payment decisions are also influenced by eligibility changes and benefit restrictions. If all has changed relating to coverage, a prior verification, or dental prior authorization does not mean that coverage will not have been effectuated on the treatment date. Practices should be aware of the patient’s existing eligibility and insurance coverage restrictions.

Periodontal scaling and root planing are routinely used procedures that are the likely source of denials or need for more information, according to ADA. Periodontal charting and diagnostic quality radiographs are indicated and narratives are clear when reviewing with the payer.

How practices identify and correct recurring problems

If a claim is denied, billing personnel are responsible for confirming on billing explanations of benefits (EOB) or denial notice the reason for the denial. They should be able to differentiate between dental prior authorization denials and eligibility denials, coding errors and other coverage denials.

Three indicators should be used to track the practices to ensure that it remains sustainable:

• The percentage of dental prior authorization returned where information is missing.
• The count of the number of requests in the queue that is waiting longer than the time the payer is expecting to respond.
• The percentage of claims denied due to dental prior authorization issues.

Monthly reviews assist teams recognize documentation gaps and payer-specific issues as they reoccur. Managers should award appropriate corrective, review and retrain staff as required. An appeal is used to appeal when the denial is wrong or the rules of the payer allow it to be reconsidered. Relevant supporting documentation will be submitted by staff and deadlines for appeals observed. An appeal is not a license to waive an authorization requirement.

How Eligibility Verification Prevents Authorization Problems

Eligibility verification can help dental practices avoid benefit restrictions and verify if a patient is still covered before making dental prior authorizations. It is also effective for teams to identify coverage concerns prior to the treatment.

These are some of the questions that should be answered in a comprehensive verification process:

• Is the patient’s insurance in effect for their estimated date of service?
• Do the subscriber details and dependent information match the payer’s records?
• Is the proposed procedure included in the plan?
• Do coverage waiting periods, frequency limits, deductibles or taxes apply?
• Are there any requirements for prior authorization or predetermination by the Payer?
• Do any network restrictions or other conditions apply to any specific plan?

These checks can assist billing teams to identify the difference between the dental prior authorization and benefit exclusions. A dental prior approval may be needed for a crown, and a frequent-usage limit placed on the crown. Taking permission cannot wipe it out of that restriction.

The cost of inefficient verification

Data released by CAQH in its 2024 Index indicated the implementation of fully electronic dental eligibility and benefit verification in 2024 stands at 82%, compared with 75% in 2022. The report also projected a $580 million potential annual savings opportunity for dentals due to increased electronic adoption for dental eligibility and benefit verification. CAQH estimated that there would be an average time-saving opportunity of eight minutes per transaction if the practices transition from manual (or portal) verification to full electronic transactions. This is an industry estimate value that is not a definite saving to every practice.

Electronic verification facilitates routine inquiries, but cannot be a substitute for all payers’ inquiries. When electronic responses do not include coverage details and procedure requirements, staff should follow-up for more information. The date of the verification, the reference number, the relevant benefit details and the instructions for the benefit payers should be recorded. Re-evaluate eligibility when indicated, especially if there is a good lapse of time between the re-evaluation and the beginning of treatment. Billing Care Solutions‘ eligibility verification and benefits-checking processes assist dental offices. This support allows teams to be aware of coverage concerns sooner, and to align requests for authorization with plan requirements.

How to Prepare a Complete Dental Prior Authorization Request

When a proposed procedure is under consideration, accurate documentation provides the payer with information to assess the procedure. The other benefit of a full request is that you have less chance of needing to follow up on another request for more information, of submitting information a second time, and of getting unnecessarily caught up in the process.

Follow a pre-submission checklist

When it comes time to file an dental prior authorization request prior to the dental visit, billing personnel should verify the following:

• Patient and insurance information correspond with the payer’s information.
• The proposed procedure is utilizing the right CDT code.
• Identification of tooth number, surfaces, quadrants and treatment details are correct.
• Proper x-rays and clinical records are available.
• The plan of care and accompanying clinical story line are coherent.
• Forms & documentation for each patient completed.
• The request is made via the correct channel.
• Acknowledgment and reference information is stored when submitting.

Dental records with the correct information, such as treatment notes, diagnostic records, radiographs and treatment plans, are strongly emphasized by the ADA. It also alerts dentists to their continued duty to ensure correct procedure coding of dental records and billing systems. One particular study, clinical documentation, is worth special focus. Staff should ensure that issue radiographs and periodontal charts are complete, legible and in relation to the procedure being requested, should payer need them. If a payer does need supporting justification for treatment, this must be provided in a clinical narrative.

When considering a request for a crown consider radiographs that are not included in the request. The practice may be asked for additional information by the payer, which may require them to go through the effort of obtaining any missing information and returning that information to the payer. Pre-submission review will avoid the delay due to omission.

When the documentation is missing or not consistent with the clinical team, billing staff needs to coordinate in that case. Do not change clinical or other records or contribute information to satisfy claims with the payer that is not supported by the clinical record. Multi-Provider practices are also kept consistent through standardized checklists and practices in the naming of their documentation. The information for each request must include the information specific to that payer for the specific procedure, rather than just using one general packet on which all procedures can be attached.

How Workflow Management Improves Authorization Turnaround

Even so, when asking for a complete authorization, a good tracking mechanism is required. If the requests are not specified who took ownership and how to follow up on them, the requests stay pending and staff are assuming someone else is following up the request from them. The ADA has described a proposed standard for more consistent electronic dental prior authorization and predetermination transactions. This work is intended to help achieve the overall objective of minimising paperwork and administrative follow-up through the sharing of standardised data. Although it is only a proposed standard, it is not required of all dental payers.

Assign responsibility for every request

To ensure there is a point of contact for each authorization for monitoring, answering to inquiries from payers, and documenting the result. This helps to avoid requests being lost between clinical, front-office and billing teams.

Maintain a centralized authorization tracker

The shared tracker allows an employee to use it to mark which requests are in need of attention and which requests are awaiting further documentation.

Establish a consistent follow-up process

Staff to implement as per instructions and expected timelines by the payers. They are to make requests overdue by using proper channels for their payers and document any interaction. If the payer asks for more information, the team member responsible should work with the clinical staff and send all requested records previous to the payer request. Next follow-up action and latest status of the tracker.

Connect authorization decisions with scheduling

If a decision comes back, the applicable procedure, pertinent limitations (if any), authorization number and expiration date should be checked by the team responsible for the decision. Staff need to be given information to support them in planning treatment effectively. Billing Care Solutions assists within the dental prior authorization, Payer Follow-up, and Administrative Coordination spheres. These services offer a way for practices to stay consistently aware of pending requests and to smoothly manage authorization workloads.

How Billing Care Solutions Supports Dental Revenue Cycle Management

The coordination of insurer verification, clinical documentation, communication with payers, and claim processing is required to handle dental prior authorizations. This can result in inconsistent follow up efforts and documentation checks, when these tasks fall to an already busy front-office staff. Billing and revenue cycle support are essential to help practices manage all of these administrative tasks, including metrics such as average billing cycles and payment lifecycle, and that’s where Billing Care Solutions comes in.

Its VOB services and Prior Authorization Services deal with the benefit verification as well as authorisation processing necessities. It has overhead Dental Billing Services for extensive billing. These services apply to practices wanting to coordinate administrative tasks and streamline the process of authorization and claim payment.

The key and core operational needs associated with a structured support process is to consider:

• Checking the eligibility and whether there are any available benefits before treatment is offered.
• Setting-up and generating payer-specific authorizations.
• Following up and monitoring pending requests.
• Keeping a record of authorization decisions and the associated conditions.
• Knowing about authorization-related denials and investigations of suitable corrective measures.
• Keeping track of common administrative problems that impact claims.

The level of support required will depend upon the staffing, systems and services arrangement in place within the practice. Practices need to establish procedures for which work will be performed by the billing partner and which will be managed by the internal clinical/ administrative teams. Payers aren’t guaranteed to approve the activities used in outsourcing, and there are potential denials to be avoided. It offers extra operational assistance to handle administrative responsibilities, document keeping, and for recognizing issues at an early stage. If practices are having regular authorization delays, a billing specialist can review their current workflow.

Build a More Reliable Dental Prior Authorization Workflow

Often, dental prior authorization delays are caused by gaps in verification, documentation, and follow up. None of these issues can be resolved with a series of corrections and/or claim denials upon return of requests. Check approvals that have not yet been received and notification notices of previous denials first. Highlight the most frequent mistakes, designate duties on unmet requests and also present a pre-submission checklist. Review problems that recur every month to identify any changes that need to be made to documentation requirements, payer communication or staff workflows.

The evidence also suggests that there is scope to squeeze out some administrative efficiencies. While CAQH’s 2024 Index revealed significant savings opportunities via electronic eligibility and benefit verification, ADA guidance underscores recurring documentation and claim submission related issues. Billing Care Solutions is a dental billing and verification solutions partner that helps dental practices. Contact Billing Care Solutions if your staff are having trouble with pending requests or authorization issues and billing errors, and talk about how the process could be streamlined.

The intent is simple: to provide complete requests, persist in requesting, and tie authorizations to treatment and claims processing.

Frequently Asked Questions