Knowledge Bank | Call Flow Summary

Segments of the call Guide

“Thank you for calling DentaSure. My name is ___. May I have your name
Call Opening please?”

Ask for the concern (Greet the caller) How can I help you today?
Acknowledge the callers concern and make sure to express willingness to help
in resolving the issue

Examples:
Acknowledge Statement and
Willingness to Help  I can absolutely help you with (specifically acknowledge the
request).
 I’d be happy to help you with (what the customer is requesting).
 I’d be glad to assist you with (what the customer is requesting).

Ask for the following pieces of information to verify the policy. Do not
provide hints to the information on file. Have the caller verify the
information.
 Dentist’s Tax ID Number
Security and Verification  Dentist First and Last Name
 ID number of the Policy Holder
 Patient’s Name and Date of birth

NOTE: Ask for the name to be spelled out, if doing a name search.

Gathering information  Probe (Ask clarifying question, if necessary)

 Explain the claim status. Research the claim by checking the following tabs.

o Review Claims – used to review the claims submitted for the

patient
o Plan Benefits – used to review the plan information
Issue Resolution
o
o History – used to review the patient’s history of services

 Provide time expectancy, as instructed.

• Select the call reason, put notes based on the caller’s concern and the
Documentation resolution provided.

Proper Call Closing  Confirm is the caller needs further assistance

 Close the call using the suggested script

Example:

“Was I able to resolve everything for you today, Mr./Ms. ________? Thank you
for calling DentaSure, once again, this is (state your name). I hope you have a
 good day!”

 Click the Wrap Up Call button

Knowledge Bank | Call Opening

Open the call using the suggested spiel:
“Thank you for calling DentaSure. My name is ___. May I have your name please?”

Greet the caller:

How are you doing, (Caller’s Name)?

Ask for the concern:

“How can I help you today?” Ask clarifying questions, when necessary.
Examples:
 What is the date of service?
 What was the procedure done?

Acknowledgement & Empathy

To express acknowledgement and empathy to your customer’s situation, please refer to the guide below.
 Recognize the concern of the customer
 Express sincerity (apologize if needed)
 Assure customer that you will be helping them

Examples:

 I can absolutely help you with (specifically acknowledge the request).

 I’d be happy to help you with (what the customer is requesting).
 I’d be glad to assist you with (what the customer is requesting).

Knowledge Bank | Security Verification

To pull up dentist information,
1 Ask for the Dentist Tax ID number and enter into the appropriate field, and hit search.

Note: If no results are found, confirm and enter the following in the search fields to retrieve the records:

 Dentist First AND Last Name

Note: If multiple records appear, verify the correct one by asking for either the dentist name or the
office address.

2. Select the correct record by clicking “Verify.”

3. On the next page, click on the green radio buttons to confirm the pieces of information obtained from the caller,
then click “Verify” to proceed.

To pull up customer information,

1. Ask for the ID number of the policy holder and enter into the appropriate field, and hit search.

Note: If no results are found, you may ask the customer to confirm the following:

 Insured’s First Name

 Insured’s Last Name
 Insured’s Date of Birth

Note: All three should be entered altogether at the same time to proceed.

2. Ask for the patient’s name and date of birth.

3. Select the correct record by clicking “Verify.”
4. On the next page, click on the green radio buttons to confirm the pieces of information obtained from
the caller, then click “Verify” to proceed to the Policy Information page.

Knowledge Bank | Resolution

Once Policy information is loaded and claim details are verified,
1. Access the Review Claims tab and check the status of the claim in question.
2. Research the definition of the chargeline edit code that is displayed and follow the instructions below.
3. While doing research, you may check other tabs such as Plan Benefits and History to understand the claim
status further.

CHARGELINE EDIT 01
Definition: Charge incurred when insurance was not in effect (This means that the claim is denied because the
coverage was not in effect at the time of service).
Research required:
Check the effective date of the plan and verify if the date of service falls between the start date and the cancel
date. (Note that if the cancel date is 12/31/9999, this means that the policy is currently active.)

If Then What to do
If date of service is within active Claim was denied in error Advise caller that the claim was denied in
coverage period and claim is error and DentaSure will have the claim
denied reprocessed. Updated payment will be given
within 10-15 days after claim is reprocessed.

If date of service is outside active Claim is correctly Explain that the claim is denied and provide
coverage period processed details referencing to the date of service and
the effective date of the plan

CHARGELINE EDIT 20
Definition: Periodontal Maintenance is denied because of lack of qualifying prior periodontal treatment

Overview:
Periodontal procedures are used to treat gum diseases. After a periodontal treatment is done, a Periodontal
Maintenance is needed to maintain healthy gums. When a Periodontal Maintenance is done, this indicates that
active treatment has been provided and the patient is now in a state of maintenance.
For a Periodontal Maintenance to be paid, the following conditions must be met.
 Patient must have had a prior periodontal treatment done within the last 24 months
 Prior periodontal treatment could be any of the following acceptable codes: D4341, D4342 and D4910.

If Then What to do
If above conditions are met and Claim was denied in error Advise caller that the claim was denied in
claim is denied error and DentaSure will have the claim
reprocessed. Updated payment will be given
within 10-15 days after claim is reprocessed.

If above conditions are not met Claim is correctly Explain that the claim is denied and provide
processed details referencing to the condition that was
 not met

Knowledge Bank| Documenting the call

To keep track of what happened to the call, documentation must be done. Below are guidelines for
documentation.
1. Once all concerns have been addressed, click on the “Back” button to go back to the Policy Information
page.

1. On the Policy Information page, select the call reason drop down menu and tag the call accordingly based
on the main reason for calling.

o Coverage Inquiry – if the caller is asking about plan information and benefit coverage
o Claim Status – if the caller called about claim status
o Check Inquiry – if the caller wanted to know payment details

2. Once done selecting the call reason, enter your notes on the text box then hit the save notes button.
Notes will disappear then a message will show “Saved.”
o Notes should contain a short description of the customer’s concern, what was done and what
happened to the call.
Example: CX called re claim status for DOS 01/01/2021 // status explained // timeframe
given

Knowledge Bank| Call Closing

Note: In closing the call, make sure to follow the guidelines below:
1. Offer additional assistance.
2. State your name and the caller’s name.
3. Close the call.

Example: “Was I able to resolve everything for you today, Mr./Ms. ________? Thank you for calling
DentaSure, once again, this is (state your name). Thank you for calling DentaSure. Have a great day!”
4. Click Wrap up call to close the case.