The Difference Between “We Submitted the Claim” and “We Got Paid”**
In PPO-driven practices, revenue doesn’t depend on what was diagnosed or even what was treated.
It depends on how the claim was submitted.
Two offices can perform the same procedure on the same day with the same insurance plan—and receive completely different outcomes. One gets paid correctly and on time. The other faces denials, downgrades, delays, and write-offs.
The difference isn’t luck.
It’s process.
This tutorial outlines PPO claim submission best practices that reduce denials, speed up reimbursement, and protect the value of your PPO contracts. It’s designed for office managers, insurance coordinators, and growth-focused owners who want predictable collections—not constant follow-up.
1. The Ideal PPO Claim Workflow (From Verification to Payment)
High-performing practices don’t rely on memory or “how it’s always been done.”
They follow a repeatable workflow.
Here’s the ideal PPO claim lifecycle:
- Eligibility & benefit verification
- Coding and documentation review
- Pre-submission claim check
- Claim submission with attachments
- Tracking and follow-up
- Payment review and reconciliation
Skipping any step introduces risk.
2. Step 1: Eligibility & Benefit Verification (Done Correctly)
Eligibility verification is not a single question.
It’s a procedure-specific investigation.
Best Practices for PPO Eligibility Verification
Verify the following before treatment:
- Active coverage on date of service
- Frequency limitations
- Replacement clauses
- Waiting periods
- Downgrade policies
- Alternate benefit provisions
- Coverage exclusions
Many denials occur because offices verify coverage generally—but not per procedure.
For example:
- Crown denied due to replacement clause
- SRP denied due to frequency limit
- Perio maintenance denied due to timing
These are predictable and preventable.
3. Step 2: Accurate Coding Aligned With PPO Logic
Coding must reflect not only what was done—but what PPOs expect to see.
Best Practices
- Use CDT codes intentionally, not automatically
- Double-check high-risk codes (crowns, SRP, buildups, replacements)
- Avoid “default coding” habits
- Verify code selection aligns with documentation
Coding errors don’t always result in denials—they often result in silent downgrades, which are harder to catch and correct.
4. Step 3: Documentation That PPOs Actually Approve
PPOs don’t reimburse based on clinical opinion alone.
They reimburse based on evidence.
Documentation Best Practices
Every claim should answer:
- What is wrong?
- Why is this treatment necessary?
- Why is a less expensive option not appropriate?
Strong documentation includes:
- Clear narratives
- Relevant clinical details
- Supporting attachments
Weak documentation invites downgrades.
Narratives: Your Most Powerful Approval Tool
Effective narratives:
- Are specific, not generic
- Reference clinical findings
- Explain treatment necessity clearly
Example (ineffective):
“Crown needed due to decay.”
Example (effective):
“Tooth #30 presents with recurrent decay undermining existing MOD restoration. Remaining tooth structure insufficient to support direct restoration. Full coverage crown required to restore function and prevent fracture.”
This level of clarity reduces automated downgrades.
5. Step 4: Attachments That Support the Claim (Not Hurt It)
Missing or incorrect attachments are one of the most common reasons PPO claims deny or downgrade.
Attachment Best Practices
- Submit pre-op X-rays (not post-op)
- Ensure images are clear and readable
- Match attachments to the specific tooth and procedure
- Upload perio charting when required
- Confirm attachments are actually transmitted
Offices often assume attachments were sent—only to discover they weren’t received.
Always confirm.
6. Step 5: Pre-Submission Claim Review Checklist
This is where top offices separate themselves.
Before submitting any PPO claim, confirm:
- Correct CDT codes
- Eligibility verified per procedure
- Frequency and replacement checked
- Narrative included (if required)
- Attachments included and verified
- Provider credentialing confirmed
This step alone can reduce denial rates by 30–50%.
Rushed claims cost more time later.
7. Step 6: Submission Timing & Tracking
Submitting a claim is not the end of the process.
Submission Best Practices
- Submit claims promptly
- Track submission confirmation
- Monitor claim status regularly
- Identify stalled claims early
Claims that sit unnoticed often become write-offs—not because they weren’t payable, but because follow-up never happened.
8. Step 7: Follow-Up & Escalation Protocols
Every practice needs a claim follow-up system.
Follow-Up Best Practices
- Track claims by aging category
- Identify denial reasons immediately
- Appeal with corrected documentation
- Escalate repeated payer issues
- Track appeal outcomes
Follow-up should be systematic—not reactive.
9. Step 8: Payment Review & Reconciliation
Getting paid doesn’t mean getting paid correctly.
Payment Review Best Practices
- Compare EOBs to contracted fees
- Identify downgrades
- Catch underpayments
- Appeal when appropriate
- Adjust patient balances accurately
Many practices accept underpayments unknowingly—reducing effective PPO fees over time.
10. Step 9: Reducing Rework & Resubmissions
Resubmissions drain staff time and morale.
To reduce rework:
- Fix root causes, not symptoms
- Track denial patterns
- Update documentation standards
- Refine checklists
- Train consistently
Denial prevention is always more efficient than denial management.
11. Step 10: Credentialing Must Support Claim Submission
Credentialing errors quietly sabotage claims.
Credentialing Best Practices
- Verify provider participation regularly
- Confirm correct NPI usage
- Audit taxonomies
- Ensure delegated credentialing is active
- Update credentialing before adding providers
Claims submitted under incorrect credentialing often deny after submission, delaying revenue unexpectedly.
12. The Financial Impact of Strong PPO Claim Systems
Practices that implement these best practices experience:
- Lower denial rates
- Faster payments
- Fewer write-offs
- Reduced staff stress
- Improved cash flow
- Higher realized PPO reimbursement
This is how practices grow without increasing production.
13. Why Claim Submission Must Align With PPO Negotiation Strategy
Negotiated PPO rates are only potential revenue.
Claim submission determines realized revenue.
Without strong billing systems:
- Negotiated increases don’t materialize
- Denials persist
- Revenue gains evaporate
This is why PPO Negotiation Solutions treats billing optimization as a core revenue strategy, not a side service.
14. When Practices Should Seek Outside Support
If your practice experiences:
- Denial rates above 10%
- Frequent downgrades
- High write-offs
- Inconsistent billing results
- Staff burnout around insurance
- Stagnant collections despite strong production
…it’s time for a deeper billing and PPO review.
PPO Claim Submission Is a Revenue Discipline
PPO claims don’t fail randomly.
They fail when systems fail.
By implementing:
- Structured workflows
- PPO-aligned coding
- Strong documentation
- Pre-submission reviews
- Consistent follow-up
Practices turn billing into a revenue protection system.
That’s how PPO reimbursement becomes predictable—and profitable.
Want to Strengthen Your PPO Claim Systems?
PPO Negotiation Solutions helps practices:
- Audit PPO billing workflows
- Reduce denials and downgrades
- Improve collections
- Align billing with PPO strategy
👉 Schedule a Billing Optimization Consultation
Protect the revenue you’re already producing.