Best practices for claim submissions

Henry Schein One is currently processing claims with DentalXChange during the Change Healthcare cyber incident, and you may be seeing some new or unfamiliar claim statuses. We want to help you get paid as fast as possible, so we've developed tips for the most common claims issues: resolving claim statuses and avoiding claim rejections.

Tips for Resolving Claim Statuses

The statuses listed here are the most common ones you may be seeing in your practice management system right now. Use this information to understand the claim status and what you can do to resolve any errors.

1. Claim Status: Claim Rejection Due to Zip Code Invalid.

   This error happens when there are problems with the ZIP Code on the provider, patient, and/or subscriber address.

   To correct this, check the address information for ALL addresses on the claim. Make sure the ZIP Code is valid, has the ZIP+4 format, and matches the city and state of the address. You can use this USPS look up tool for help: https://tools.usps.com/zip-code-lookup.htm.

   Correct any invalid address information and resubmit the claim.

2. Claim Status: Field "Tooth" - Cannot Be Blank.

   You will see this error when one or more procedure codes on the claim require a tooth number that was not submitted on the claim.

   Verify that the correct tooth number is attached to the procedure and resubmit the claim.

3. Claim Status: The Claim/Encounter Has Invalid Information as Specified in the Status Details and Has Been Rejected.

   This rejection means the ZIP code provided for the city listed in the subscriber and/or patient address is not correct. This often happens when a number is mistyped in the address (e.g. 45631 instead of 46531).

   To correct this, check the address information for ALL addresses on the claim. Make sure the ZIP Code is valid, has the ZIP+4 format, and matches the city and state of the address. You can use this USPS look up tool for help: https://tools.usps.com/zip-code-lookup.htm.

   Correct any invalid address information and resubmit the claim.

4. Claim Status: The Procedure Code Identified Is Invalid. Required Field "Fee" - Cannot be Blank or Zero. The Item Charge is Less Than One Dollar.

   You may see three different messages related to this claim rejections. "Amount must be greater than zero," "Required Field Fee- Cannot be blank or zero," or "The item charge is less than one dollar".

   This happens because Clearinghouse validation rules are in place that will reject claims that include one or more $0.00 procedures for certain payors. Even if the clearinghouse validation allows the claim to be forwarded to the payor, some payors will then auto-reject claims that include these procedures. When possible, it is best to not include any procedures without an assessed fee from claims.

   To resolve this, delete the claim and recreate it without including procedures with a $0.00 fee.

5. Claim Status: Group Number is Invalid. It Can Only be 4 to 8 Digits (Numeric Only).

   This error happens when N/A or any other letters are entered in the group number field. This field can only contain 4-8 numbers (no letters).

   If a plan does not have a group number, leave the field blank. Correct the group number and resubmit the claim.

Tips for Avoiding Claim Rejections

The tips outlined here represent the most common reasons we are seeing for claim rejections right now. Use this information to adjust your claims to help them get to the payors faster.

1. Verify the ZIP Code on All Addresses on the Claim.

   One of the biggest claim denial reasons we are seeing right now is incorrect ZIP Codes. Claims go through a USPS validation on all addresses on the claim, including patient, subscriber, and provider. If the ZIP Code does not match the state listed or is an invalid ZIP Code, the claim will be rejected.

   Before you submit claims, check that the ZIP codes match the city and state for all addresses on the claim. This includes the billing provider, rendering provider, patient, and subscriber. You can use this USPS look up tool for help: https://tools.usps.com/zip-code-lookup.htm

   Make sure you are including the ZIP + 4 information for the billing and rendering providers to comply with payor requirements. Some payors may also request this information for patients, so it is a good idea to add that for patient addresses as well.

   How to update contact info for billing and rendering providers: Editing user accounts

2. Exclude Procedures with a Zero Balance.

   You may see a claim error indicating that a procedure code cannot be blank or zero. You can fix this by not including procedures with a zero fee on the claim. To fix this, delete the claim and recreate it without including the zero-balance procedure. Then resubmit the claim.

3. Follow All Special Enrollment Steps.

   Some payors require practices to complete special enrollment forms before we can submit claims on your behalf. You can take steps to make sure this enrollment goes as quickly as possible.

   We have added a Special Enrollment Forms page to help you enroll with payors who have special requirements for claims and/or ERAs. We will submit your claims to those payors once you have completed the enrollment.

4. Ensure Patient Subscriber ID and Group Number are Accurate.

   Claims will be rejected if the subscriber ID is the same as the group policy number. This often happens when the same number is entered in both fields in your practice management software.

   Verify each patient's insurance information at each visit and make sure the correct numbers are entered in their patient file.

   How to update subscriber information: Updating insurance information for patients

5. Include Line-Level Adjustments and Total Amount Billed on Secondary Claims.

   We have seen some claim rejections for incomplete information on secondary claims. When you submit secondary claims, include the line-level adjustments and total amount billed from the primary claim.

   How to update information included on secondary claims: Changing claim details