Dental Insurance Verification – Overcome Claim Denials due to Eligibility Issues

by | Last updated Nov 15, 2023 | Published on Apr 17, 2017 | Specialty Billing

Dental Insurance Verification
Share this:

Claims status inquiries and eligibility and dental insurance verification are two of the important tasks that dental practices need to handle. Dentists’ offices need to work with carriers to process claims and keep their patient base viable. They need to be aware of the extent of coverage dental health plans provide as well as how to file insurance claims accurately, understand patient payment responsibilities, and get paid.

Obtaining patient insurance information before services are provided is important. Insurance eligibility verification involves checking the following aspects regarding the patient’s active coverage:

  • Type of health plan – One of the first things to check out is the type of plan the patient has. There are different types of dental health insurance plans:
    • Direct Reimbursement programs reimburse patients a predetermined percentage of their total dental care expenses for different types of treatments. Patients can see the dentist of their choice.
    • “Usual, Customary, and Reasonable” (UCR) programs pay a fixed percentage of the dentist’s fee or the plan administrator’s “reasonable” or “customary” fee limit, whichever is less. This type of plan also allows patients to see the provider of their choice.
    • In Table or Schedule of Allowance programs, services are listed with their dollar coverage. These plans will only pay for these treatments or procedures. The patient has to pay the remaining cost of the services that the dentist provides.
    • Under capitation programs, the insurance company pays dentists a fixed amount (typically per month) for the enrolled family or patient. Patients are covered for specific types of treatment at no charge though some treatments may have a patient co-payment.

Preauthorization – Some insurance companies require pre-authorization. The dentist has to submit a treatment proposal to the carrier before providing the service. The insurance company will then determine the patient’s eligibility, eligibility period, services covered, patient co-pay and maximum limitation. In most cases, emergency services do not require prior authorization.

  • Annual benefits limitations: Insurance verification is also needed to understand if the patient’s dental insurance plan places limits on benefits by the number of procedures and/or dollar amount in a given year. This information also allows dentists to work with their patients to plan treatment so as to minimize the patient’s out-of-pocket expenses while maximizing advantage of the compensation that the benefits plan offers.
  • Patient demographic information: This includes verifying preauthorization number, deductibles, plan exclusions, claim mailing address, policy status, and more.

Reviewing patients’ dental insurance plan coverage will also involve checking the following details:

  • In network and out-of-network coverage
  • If the plan covers diagnostic, preventive, and emergency services and to what extent
  • The plan’s limitations and exclusions
  • Whether the plan allows referrals to dental specialists
  • When coverage goes into effect and if annual maximum has been met, and how much remains
  • Crown frequency and frequency limitations of exams and x-rays
  • Whether the patient has dual coverage
  • Medicare/Medicaid coverage
  • Medical health insurance coverage – exclusions in the patient’s dental plan may be covered by their medical insurance

A nationwide survey conducted in 2012 by the American Association of Dental Office Managers (AADOM) found that 50 percent of the dental offices that did not verify insurance eligibility and benefits prior to service said the process was simply too time-consuming. So it’s hardly surprising that two-thirds of denied dental claims are associated with a failure to check eligibility or the use of inaccurate eligibility data.

Fortunately, many dental practices have resorted to outsourcing their insurance verification and authorization tasks. Insurance verification service specialists check patient coverage benefits in advance of the office visit. They do so through the carrier’s website or by calling up payers directly. This ensures accurate information for claim submission, which promotes faster turnaround times and fewer returned or denied claims due to eligibility issues.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

More from This Author