Question

What term: a service a dentist recommends to a patient that is on the list of services covered by the patient's dental plan but the dental plan has determined should not be provided to the patient because doing so would not be in accordance with the standard of practice; dentist not allow to bill pt despite rejection of submitted claim bc documentation may be lacking or service was likely improperly billed or performed

Option 1: Preauthorization denial
Option 2: Medically necessary service
Option 3: Denied claim
Option 4: Standard of care exclusion

Answer 1

The correct term for the described scenario is a 'Preauthorization denial.' This occurs when a dental plan decides against approving a covered service based on the standard of care, which may be due to insufficient documentation or improper billing.

Step-by-step explanation:

The term described is a situation where a dental service is recommended by a dentist and is on the list of covered services, but the dental plan determines that providing the service would not be in accordance with the standard of care. In this case, the dentist is not allowed to bill the patient for the rejected service. This scenario is best described by Option 1: Preauthorization denial, which occurs when the dental plan evaluates the proposed service against their coverage policies and the prevailing professional standards before the service is provided and decides not to approve it. This can happen for various reasons, such as insufficient documentation or when a service was likely improperly billed or performed. It's a precautionary measure to ensure that paid services are medically necessary and meet a certain quality threshold. The denial is not necessarily a reflection on the service itself, but on its alignment with the insurance plan's criteria and the necessity for the specific patient.