Dental Billing Accuracy Audit Form
Use this form to review dental billing records for accuracy, document discrepancies, and record corrective actions.
Audit Identification
Audit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Auditor Name
*
Clinic/Practice Location or Department
*
Billing Period Being Audited
*
Audit Reference Number
Patient Visit and Billing Record Details
Patient Chart / Record ID
*
Visit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treating Provider / Dentist Name
*
Claim / Invoice Number
*
Insurance Plan / Payer Name
Please Select
Aetna
Blue Cross Blue Shield
Cigna
Delta Dental
Guardian
MetLife
UnitedHealthcare
Other
Submission / Claim Status
*
Draft
Submitted
Paid
Denied
Corrected
Other
Procedure and Documentation Review
Billed Service Line Items
*
Documentation Completeness
*
Treatment notes present
Signed treatment plan present
Radiographs attached if applicable
Supporting clinical evidence sufficient
Treatment Notes Present
*
Yes
No
Not Applicable
Signed Treatment Plan Present
Yes
No
Not Applicable
Radiographs Attached if Applicable
Yes
No
Not Applicable
Supporting Clinical Evidence Sufficient
*
Yes
No
Line-by-Line Documentation Match Review
Rows
Documented in Chart
Matched to Supporting Notes/X-rays/Images
Procedure 1
1
2
Procedure 2
3
4
Procedure 3
5
6
Accuracy Assessment and Discrepancies
Overall Billing Accuracy Rating
*
1
2
3
4
5
Discrepancy Type
*
None Found
Underbilled
Overbilled
Duplicate Charge
Missing Documentation
Incorrect Code
Incorrect Quantity
Other
Discrepancy Severity
*
Please Select
Low
Medium
High
Estimated Affected Amount
Common Error Categories
Procedure Code
Quantity/Units
Missing Documentation
Charge Amount
Patient Coverage
Timing/Date Entry
Duplicate Entry
Other
Comments on Discrepancy
Corrective Actions and Follow-up
Corrective action required
*
No action
Internal correction
Resubmission
Refund/credit review
Provider education
Other
Responsible party
*
Please Select
Auditor
Billing specialist
Provider
Office manager
Compliance team
Other
Follow-up due date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Re-audit needed?
*
Yes
No
Final auditor notes or recommendations
Submit Audit
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