Denial code 290 is when a claim is received by the dental plan, but the benefits for that particular claim are not available under the dental plan. In this case, the claim is then forwarded to the patient's medical plan for further consideration.
Common causes of code 290 are:
1. Inadequate dental coverage: The patient's dental plan may not provide coverage for the specific treatment or service mentioned in the claim. This could be due to limitations in the plan's coverage or exclusions for certain procedures.
2. Incorrect plan selection: The dental claim may have been submitted to the wrong dental plan or the patient may have multiple dental plans, resulting in the claim being sent to a plan that does not cover the treatment.
3. Coordination of benefits: The dental plan may require coordination of benefits with the patient's medical plan. In such cases, the dental claim is forwarded to the medical plan for further consideration and determination of coverage.
4. Lack of pre-authorization: Some dental plans require pre-authorization for certain procedures or treatments. If the claim was submitted without obtaining the necessary pre-authorization, it may result in code 290.
5. Plan limitations or exclusions: The dental plan may have specific limitations or exclusions for certain treatments or services. If the claim falls under these limitations or exclusions, it may be denied with code 290.
6. Incorrect patient information: Errors in patient information, such as incorrect identification numbers or demographic details, can lead to claim denials. This can result in code 290 if the dental plan cannot verify the patient's coverage.
7. Out-of-network provider: If the dental provider is not in-network with the patient's dental plan, the claim may be denied with code 290. Out-of-network providers may have different coverage limitations or reimbursement rates.
8. Non-covered services: Certain dental plans may not cover certain treatments or services altogether. If the claim includes a non-covered service, it may result in code 290.
It is important for healthcare providers to review the specific denial code and corresponding explanation of benefits to determine the exact cause of the denial and take appropriate action to address it.
Ways to mitigate code 290 include:
1. Verify eligibility: Before submitting a claim, ensure that the patient's dental plan covers the specific benefits being claimed. This can be done by checking the patient's eligibility status with the dental plan provider.
2. Coordinate with the medical plan: If the dental plan does not cover the claimed benefits, it is important to coordinate with the patient's medical plan. Provide all necessary documentation and information to the medical plan to support the claim and request their consideration for coverage.
3. Prior authorization: In cases where the dental plan does not cover certain benefits, consider obtaining prior authorization from the medical plan before providing the treatment. This can help ensure that the medical plan will cover the costs and prevent denials based on lack of coverage.
4. Clear communication with patients: Educate patients about their dental plan coverage and limitations. Clearly explain any potential out-of-pocket expenses they may incur if certain benefits are not covered. This will help manage patient expectations and avoid surprises when claims are denied.
5. Stay updated with plan changes: Dental plans may periodically update their coverage policies. It is crucial to stay informed about any changes in coverage criteria or limitations. Regularly review the dental plan's policy updates to ensure claims are submitted correctly and in accordance with the latest guidelines.
6. Appeal denied claims: If a claim is denied due to benefits not being available under the dental plan, consider appealing the decision. Provide additional supporting documentation and any relevant information that may help overturn the denial. Follow the appeal process outlined by the dental plan to maximize the chances of a successful outcome.
By implementing these strategies, healthcare providers can minimize the occurrence of code 290 denials and improve the overall revenue cycle management process.
The steps to address code 290 are as follows:
1. Review the patient's insurance information: Verify that the patient's dental plan is correct and active. Ensure that the patient's medical plan information is also available.
2. Contact the dental plan: Reach out to the dental plan to confirm the reason for the denial. Request clarification on why the benefits are not available under this plan. Obtain any necessary documentation or additional information required by the dental plan.
3. Communicate with the patient's medical plan: Forward the claim to the patient's medical plan for further consideration. Provide all relevant details and supporting documentation to the medical plan. Include any correspondence or explanations received from the dental plan.
4. Follow up with the medical plan: Stay in touch with the patient's medical plan to track the progress of the claim. Inquire about any additional information or documentation they may require. Keep a record of all communication with the medical plan for future reference.
5. Appeal if necessary: If the medical plan also denies the claim, evaluate the possibility of filing an appeal. Gather any additional supporting documentation or evidence that may strengthen the case. Follow the appeal process outlined by the medical plan and submit the necessary paperwork within the specified timeframe.
6. Educate the patient: Keep the patient informed throughout the process. Explain the reasons for the denial and the steps being taken to address it. Provide guidance on any actions the patient may need to take, such as contacting their employer or insurance provider for further assistance.
7. Document and track: Maintain detailed records of all actions taken to address the denial code. Keep track of dates, times, and individuals involved in each step of the process. This documentation will be valuable for future reference and potential audits.
By following these steps, healthcare providers can effectively address denial code 290 and work towards resolving the issue with the patient's dental and medical plans.