The Velscope

Insurance Claim Submission Guide (US)

CDT Code

The American Dental Association approved in 2005 a CDT code for adjunctive tests intended to aid in oral mucosal examinations. This code (No. D0431) reads “Adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including pre-malignant and malignant lesions not to include cytology or biopsy procedures.” The VELscope examination does fall under this definition!

More and more dental insurance plans are covering this procedure code and, while not all insurance companies are currently reimbursing for it, an increasing number of insurance carriers are seeing the value and cost savings of early detection and diagnosis.

Please check with your patient’s individual plan for policy coverage.

Submission Guidelines

The following are guidelines on how to submit claims to insurance companies for reimbursement on the VELscope examination:

It is recommended to file your submissions electronically in order to avoid delays and excess documentation.
When submitting for the first time, it generally is not necessary to include a narrative for the code CDT D0431 (a.k.a. a “clean” claim form). The claim will likely be processed «automatically», which will result in the greatest possibly of it being paid also automatically as a diagnostic procedure code, regardless of whether it is submitted electronically or in paper.
If it is refused, it is suggested to attempt a second submission with a narrative similar to the ones proposed below:

If re-submitting in paper format:

“Performed a comprehensive and enhanced oral mucosal examination utilizing a direct fluorescence visualization examination procedure to assist in the early discovery of Oral Cancer and other mucosal abnormalities.”

If re-submitting in electronic format (usually it needs to be 88 characters or shorter):

“Enhanced oral mucosal exam utilizing a direct fluorescence visualization exam procedure.”

If the claim is rejected again, it is suggested to submit a third time, and send a copy to the patient and his/her HR department, so as to call the attention of both the employer and the insurance carrier with regard to coverage of a procedure that may be considered as vital, and is as such in the best interest of the patient.
If the claim is rejected again, the insurance carrier should supply a written explanation as to why the procedure code D0431 is not covered under the patient’s policy. If the insurance carrier does not provide this information, it is recommended to place a written request with the insurer for such explanation.
Further action may be required in case of refusal.

For additional advice on how to submit claims, please contact us and a Customer Sales Representative will be happy to assist you.

Last updated 01/09/2007.