Checklists · 6 min read
Dental Audit Documentation Checklist
A procedure-by-procedure checklist of the clinical and billing documentation dental offices typically gather when responding to an insurance audit.
How to use this checklist
This checklist is a general starting point. Requirements vary by carrier, plan and procedure, and your provincial regulatory college sets record-keeping standards. Always confirm what the specific request asks for.
For every claim line
- Claim as submitted, with procedure codes, tooth numbers, surfaces and fees
- Dated clinical note for the date of service, attributed to the provider
- Medical history review and updates relevant to the visit
- Informed consent documentation where applicable
- Treatment plan showing the procedure was planned and accepted
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Restorative procedures
- Pre-operative radiographs and/or intraoral images showing the condition
- Documentation of the diagnosis and surfaces involved
- Materials used and anaesthetic details
Periodontal procedures
- Current periodontal charting (probing depths, bleeding, recession, mobility)
- Radiographs supporting bone level findings
- Documented periodontal diagnosis and rationale for scaling or root planing
Crowns, bridges, implants and lab work
- Pre-operative images supporting medical necessity
- Lab prescription and lab invoice with dates
- Preparation and seat dates documented in the chart
Before you submit
Confirm that every item is a copy of the original record, the dentist has reviewed the package, and you have retained a copy of exactly what was sent.
This article is general information and is not legal, clinical, regulatory or billing advice. Consult your provincial regulatory authority and professional advisors for guidance specific to your practice.