Remark code N138 indicates a dental advisor's opinion can be contested by submitting additional information and radiographs for a second review.
Remark code N138 is an alert indicating that if there is disagreement with the Dental Advisor's opinion regarding a dental claim, additional information, such as radiographs, can be submitted to the Dental Advisor Unit at the patient's dental insurance carrier for a second Independent Dental Advisor Review.
Common causes of code N138 are:
1. Submission of a dental claim without sufficient diagnostic evidence, such as radiographs, to support the necessity of the treatment.
2. The initial review by the Dental Advisor determined that the treatment was not covered under the patient's current dental plan or did not meet the plan's criteria for medical necessity.
3. The Dental Advisor's opinion may indicate that the treatment provided was not in accordance with generally accepted dental practice standards.
4. There may have been a lack of detailed documentation or explanation of the treatment provided, leading to an initial denial or request for additional information.
5. The claim may involve a procedure that is frequently reviewed for appropriateness and necessity, triggering the Dental Advisor's opinion to be a standard part of the claim process.
6. The provider may have previously submitted similar claims that were flagged for review, resulting in increased scrutiny of subsequent submissions.
Ways to mitigate code N138 include ensuring that all relevant radiographs and supporting documentation are submitted with the initial claim to provide a comprehensive view of the necessity for the dental procedure. It's also important to maintain clear and detailed patient records that justify the treatment, as well as to stay updated on the latest dental coding practices to ensure that the codes used accurately reflect the services provided. Regular training for coding staff on dental procedures and the importance of accurate documentation can also help prevent this code. If a claim does receive an N138 code, promptly gather any additional information or radiographs that may have been initially overlooked and submit them to the Dental Advisor Unit for review. Establishing a protocol for quick response to remark codes can help streamline the resubmission process and minimize delays in reimbursement.
The steps to address code N138 involve gathering the necessary additional information that supports the case for the dental procedure in question. This typically includes updated or more detailed radiographs, patient records, and any other relevant documentation that can provide further evidence or clarification. Once compiled, submit these materials directly to the Dental Advisor Unit at the subscriber's dental insurance carrier. Ensure that the submission is in accordance with the carrier's guidelines for an Independent Dental Advisor Review, including any specific forms or cover letters that may be required. It's also advisable to include a detailed explanation or narrative that highlights why the initial opinion should be reconsidered, referencing specific clinical findings or guidelines that support the case. After submission, monitor the claim for updates and be prepared to respond to any additional requests for information from the Dental Advisor.
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