Dental Billing Audit - USA

Dental billing audit template for US practices. This checklist covers insurance verification, CDT coding accuracy, claim submission, denial management, and patient collections.

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Dental Billing Audit - USA



Patient Intake And Insurance Verification

1. Patient demographic details (name, DOB, address) match the information on file with the insurance carrier.


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2. The subscriber relationship is correctly identified (self, spouse, dependent) in the practice management system.


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3. Insurance group number, policy number, and payer ID are accurate and current.


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4. Patient eligibility has been verified before or on the date of service.


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5. Annual maximum, remaining benefits, and deductible status have been confirmed for the current plan year.


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6. Frequency limitations for the patient's plan have been reviewed and noted before treatment (e.g., prophylaxis, bitewings, fluoride, crowns).


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7. Waiting periods and missing tooth clauses have been checked and flagged where applicable.


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8. Coordination of benefits is documented for patients carrying dual coverage.


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Clinical Documentation (Spot Check)

1. The clinical narrative supports every CDT code submitted on the claim for this visit.


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2. Tooth numbers, surfaces, and quadrants are documented and match the codes billed.


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3. A diagnosis and statement of medical necessity are present for each procedure that requires clinical justification.


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4. Periodontal charting is current and consistent with the category of periodontal treatment billed.


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5. The treating provider has signed and locked the clinical note before claim submission.


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6. Notes are original to the visit and not copied, cloned, or templated from a previous appointment.


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CDT Coding Accuracy (Spot Check)

1. The CDT code billed reflects the actual procedure performed (no substitution of similar but incorrect codes).


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2. Diagnostic codes are applied correctly (D0120 periodic exam vs. D0150 comprehensive exam vs. D0180 detailed periodontal exam).


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3. Preventive vs. periodontal coding is appropriate (D1110 prophylaxis vs. D4910 periodontal maintenance vs. D4341/D4342 scaling and root planing).


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4. Restorative codes accurately reflect the number of surfaces restored.


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5. Bundled procedures are not unbundled and billed separately.


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6. No evidence of upcoding (billing a more complex procedure than performed) or downcoding (billing below the level of service provided).


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7. Modifiers are applied correctly where required by the payer.


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8. All CDT codes on the claim are current and no retired or outdated codes have been submitted.


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Claim Preparation And Submission

1. The claim is submitted within the payer's timely filing window.


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2. The rendering provider's NPI matches the clinician who performed the procedure.


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3. The billing provider (practice TIN) is correct on the claim form.


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4. Required attachments are included with the claim (radiographs, perio charting, intraoral photos, narratives).


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5. Attachments are legible, properly labeled, and relevant to the codes billed.


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6. Pre-authorization has been obtained for procedures that require it before treatment.


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7. The claim has been run through a scrubber or validation check and all flagged errors have been resolved before submission.


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8. For patients with dual coverage, both primary and secondary claims are prepared.


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Payment Posting And Reconciliation

1. Insurance payments are posted to the correct patient account and matched to the corresponding claim.


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2. Contractual adjustments and write-offs match the amounts specified on the Explanation of Benefits (EOB).


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3. Write-offs are only applied in accordance with the practice's contracted fee schedule and written adjustment policy.


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4. Patient responsibility (copay, coinsurance, deductible) is calculated correctly and posted to the patient ledger.


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5. Secondary claims are generated and submitted promptly after primary EOB is received.


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6. No unallocated credits, suspense balances, or unresolved payment discrepancies remain on patient accounts.


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Denials, Appeals, And Accounts Receivable

1. Denied and rejected claims from the review period have been categorized by denial reason.


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2. The most frequent denial reasons are identified and tracked month over month to detect patterns.


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3. Denied claims are corrected and resubmitted or appealed within the payer's deadline.


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4. Appeal submissions include all required supporting documentation (clinical notes, radiographs, narratives).


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5. Outstanding insurance claims older than 30 days are actively followed up.


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6. Claims aging beyond 90 days have been escalated or written off per practice policy.


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7. Follow-up activity on each outstanding claim is documented with dated notes.


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Patient Collections

1. Patient statements are generated and sent within the practice's defined billing cycle.


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2. Balances older than 30 days are flagged and patients are contacted per the collection protocol.


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3. Payment arrangements are documented and monitored for compliance.


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4. Revenue lost to uncollected patient balances is tracked as a percentage of total production.


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Compliance And Risk

1. No copays or patient portions have been routinely waived without documentation and a financial hardship policy on file.


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2. Fees submitted on claims match the practice's UCR fee schedule or the payer's contracted rate.


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3. No dates of service have been altered after the original entry.


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4. Claim handling and patient billing records are stored and transmitted in compliance with HIPAA requirements.


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5. Staff involved in billing and coding have completed training on current CDT codes and payer policies within the past 12 months.


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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