Responding to Insurance Requests that Do Not Make Sense

“Insurance is asking questions that don't make sense. As a case scenario example: We provided a removable partial denture (RPD), but they are asking for initial placement date, cementation date, etc. One doesn’t cement an RPD, and technically this is their first RPD. How do we respond?”

Sometimes the questions requested by an insurance company are system-generated and as a result are very generic. The way to think about a relatively vague question is not to focus on the exact words they use (which could be incorrect), but instead focus on the type of information they are looking to receive. 

What do insurance companies generally want for high-end multi-visit services like crowns, bridges and dentures?

Detailed History: Information about the past is to make sure the service falls within the frequency limit of the policy. While at first it makes more sense that a detailed history should only be requested if the current insurance policy reimbursed for said service in the past, many policies are actually written to factor in the replacement timing itself and NOT whether the current company/policy paid for the service.

Current Timing Details: Provide the information they are asking. Almost every insurance company will want start and end dates for multi-visit services, so you should expect that question and can automatically send the information if you would like to avoid later requests for information.

The confusion that arose in this situation is because the insurance company asked for the impression and cementation date, instead of the more relevant impression and delivery date. Please understand this is just a system-generated request for information that may not be completely clinically correct in terminology. In a situation like this, take a broader interpretation and assume that the following terms are basically interchangeable to the insurance company:

• Start / Impression / Prep 
• End / Delivery / Seat

You could certainly respond with the more appropriate term, but it really doesn’t matter much.  

The most important response to this question is to provide the starting and ending date of treatment, particularly around a policy year change or the end of a policy. It is important to know whether the policy pays on the start date or end date. It would be incorrect to assume an end date, as industry-wide, about half the companies and policies pay on the end date.

Here is a real-life case example that may be helpful:

Case: The patient is replacing a broken fixed partial denture (Bridge/FPD) of tooth #6x11x13 with a removable partial denture (RPD). After submission of the original claim, the insurance company sent the following request for more information.

• Is this a replacement or is this the initial placement? 
• If it is a replacement, what is the initial placement date as well as the reason for the replacement?
• Is the upper arch a replacement or an initial placement? 
• What are the impression date and cementation date? 

Response:

• ​Replacement of a broken bridge from 6x11x13.
• Initial placement date 10+ years ago.  
• Reason: complete failure/fracture
• Impression date: 7/18/23
• Delivery date: 8/30/23

Are some of the above questions redundant? Yes, absolutely. It still helps to answer them in the order they were submitted to help with claims processing as quickly as possible.

If you notice, the layout of the response is formatted cleanly, and the answers are specific but brief. This way you give the reviewer as little confusion as possible, they are only trying to respond to a checklist of questions given by the company and each will require an answer even if they seem redundant. If we did not respond to the above “reason” question because the answer is in the first line response, often that will just generate the reviewer not taking chances by guessing and sending another request for more information, which will frustrate everyone involved.