7 Common Reasons for Dental Claim Denial

by | Last updated May 12, 2023 | Published on Feb 19, 2020 | Specialty Billing

Reasons for Dental Claim Denial
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A recent survey by the American Dental Association found that approximately 65% of patients have dental insurance. Dental care is often much more expensive than medical care. Dental claim denials can have a significant impact on patients and dentists. Dental insurance verification can prevent claim denial. The process involves verifying the patient’s eligibility, active benefits and coverage with the insurance company before procedures are performed.

Understanding the causes of claim denials is the key preventing them. Here are the 7 common reasons why insurance companies deny dental claims:

  • Insufficient information on claim: Nearly half of dental claims for major and basic services are sent back due to lack of information (www.dentistryiq.com). Dental insurance plans differ in terms of the CDT codes procedures that need written narratives in claims. In addition to specifying the “who, what, where, when and why” to support a claim, the narrative should explain the procedure performed or services provided and their medical necessity. Dental Economics says that providers should send a recent full-mouth series or periodontal charting from the last six months for claims requiring this information, such as periodontal, endodontic, orthodontic, and other basic and major services.
  • Coverage limits: Dental plans come with limitations, exclusions and frequencies. Dental plans set a maximum on the amount will pay for treatment for a year or the individual’s lifetime. Plans may also have frequency limitations, meaning that a patient will be covered only for certain procedures a few times a year or every few years. Due to these reasons, before providing treatments, providers should verify the patient’s benefits to determine limitations, exclusions and frequencies. For costly procedures, dentists can submit a predetermination to learn upfront what the plan will pay, and the difference that the patients will be responsible for.
  • The claim was not filed on time: Every health insurance company has its own deadlines for claim filing. Claims that are filed outside of the policy’s time limit are denied. Best practice is to submit the claim as soon as the treatment is complete. While some health plans have a one year time limit for claim submission from the date of the service, others may allow only 180 days or even 90 days.
  • Data entry errors: Errors in patient information on the claim is a common reason for denial. For instance, if the claim is returned with the remark “beneficiary identification incorrect”, it means that the name and/or the enrollee’s ID number on the claim are wrong.
  • Outdated insurance information: If the patient’s benefits are outdated or the policy has been terminated or modified, it could get the claim denied. Changes in insurance information can occur if patients have switched jobs recently or if they have an updated insurance card. Dental insurance eligibility verification can ensure that patient records are updated in a timely manner.
  • Issues in Coordination of Benefits (COB): COB occurs when a patient has more than one dental plan and can use both to cover their dental procedures. Delays in payment can occur due to COB-related problems such as incomplete or inaccurate COB information on file with the plan or payer, or failure to attach the Explanation of Benefits (EOB) from the primary payer when billing the secondary payer (www.aap.org). To prevent COB issues, providers need to collect and/or confirm primary and secondary insurance information at each visit. They also need to know plan and payer rules for payment and determine primary and secondary payers so that claims can be sent to the primary payer first. As secondary payers require a copy of the Explanation of Benefits (EOB) provided by the primary payer to process and pay a claim, practices must make it routine practice to attach EOB to claims filed with secondary payers.
  • Pre-certification or authorization was not obtained: Some dental treatments such as reconstructive procedures and oral surgery require prior authorization. Not obtaining prior auth will lead payment to be denied. Providers need to knowing which insurers require pre-authorization and for what. Predeterminations on complex, costly procedures should be submitted as close to the date of proposed service as possible.

According to a Dentistry IQ article, to win with dental insurance, practices must educate patients about their coverage. Strategies to educate patients include:

  • Providing a brochure explaining what dental insurance is in simple terms, what’s generally covered and what’s not covered, and how copayments work
  • Having a face-to-face discussion to help patients understand the facts of dental insurance
  • Communicate the practice policy on collecting copayments

Dental insurance verification and authorization service providers support dental practices in their efforts to help patients maximize their insurance benefits. These experts verify benefit coverage during each patient’s initial visit by following up and checking insurance companies’ websites and by calling payers. They check claim forms carefully for errors and if any mistakes are found, correct them before claim submission. Companies providing dental billing services also work with practices to appeal denied or late payments. Their dedicated support optimizes claim processing for practices and helps patients receive the maximum reimbursement to which they are entitled.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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