Billing Services

The Vendor is required to provide to address the need for a scalable, compliant, and high-performing insurance billing solution that supports a complex academic dental environment.
- This engagement is to improve revenue cycle outcomes, reduce accounts receivable aged balances, strengthen denial prevention and resolution, and enhance transparency through consistent reporting and performance management. 
- Insurance Billing and Claims Processing
•    Prepare, review, and submit dental and applicable medical insurance claims in accordance with payer requirements and agency policies
•    Resolve claim edits and errors prior to submission to maximize first-pass acceptance
•    Submit electronic claims and required attachments through approved clearinghouse processes
•    Monitor claim status through adjudication and take timely corrective action on rejections or denials
- Oral Surgery and Medical Claims Billing
•    Perform billing for oral surgery services requiring medical insurance claims
•    Apply appropriate CPT, ICD-10, modifiers, and cross-coding methodologies
•    Support prior authorization and precertification requirements
•    Manage medical necessity documentation and payer follow-up
•    Address payer processing issues related to in-network and out-of-network determinations
- Payment Posting and Reconciliation
•    Post insurance payments using EFT/ERA files and manual EOBs as required
•    Retrieve and reconcile Explanation of Benefits when not received with payment
•    Identify and resolve underpayments, overpayments, and posting discrepancies
•    Manage insurance refunds and payer recoupments
•    Identify and resolve insurance credit balances
- Denials Management and Appeals
•    Identify, categorize, and track denials by payer and root cause
•    Submit appeals and follow-up actions within payer-defined timelines
•    Address authorization, eligibility, documentation, coding, and timely filing denials
•    Manage claims with no payer response
•    Perform trend analysis to reduce recurring denials
- Accounts Receivable Follow-Up
•    Monitor outstanding insurance balances across all aging buckets
•    Prioritize high-dollar and aged accounts
•    Conduct payer follow-up and escalation activities
•    Support resolution of legacy and aged A/R balances
•    Resolution of aged and stalled accounts
-    Reporting and Performance Management
•    Provide routine and ad hoc reports related to billing and A/R performance
•    Track and report key performance indicators including clean claim rate, denial rate, days in A/R, and net collection percentage
•    Participating in regular performance review meetings with agency
•    Recommend performance improvement strategies based on data analysis
- Transition, Knowledge Transfer, and Implementation
•    Develop and execute a detailed transition and implementation plan
•    Conduct knowledge transfer sessions with agency staff
•    Support parallel processing and validation activities
•    Participate in go-live readiness review and sign-off.