Top Reasons for Dental Claim Denials

Hi, this is Amber Darst, Dental Coordinator for Managed Outsource Solutions. I would like to take a few moments to review the seven most common reasons for dental claim denials.

A recent survey by the American Dental Association found that approximately 65% of patients have dental insurance. With that high percentage, dental claim denials can have a pretty significant impact on both the patients and the dentist.

The following proper dental insurance verification guidelines can help prevent these claim denials. The process involves verifying the patient’s eligibility and confirming the coverage benefits with the insurance company before the procedures are performed.

First, understanding the causes of claim denials is the key to preventing them. Here are the 7 most common reasons why insurance companies deny dental claims:

1. Insufficient information on a claim: Nearly half of dental claims for major and basic services are sent back due to the lack of information on claim. Dental insurance plans differ in terms of the certain CDT codes procedures that need written narratives included in the 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 the medical necessity behind it. Including extra supporting materials such as full-mouth series X-rays or periodontal charting are great examples of what dental advisors look that aid in their approval for claim payment as well.

2. Coverage limits: Dental plans come with limitations, exclusions and frequencies. Dental plans also set a maximum on the amount they will pay for different types of treatments; some will pay a maximum for a benefit year or just consider once in an individual’s lifetime. A lot of times that would be orthodontics, that is, once in a lifetime, that is a good example. Plans may also have frequency limitations, meaning that a patient will only be covered for that procedure in a certain amount of times per year or every few years. Due to these reasons, before providing any treatment, providers should always verify the patient’s benefits to determine these limitations. For more costly procedures, it’s best to administer a predetermination to learn upfront what the plan will pay, and the difference that the patient will be responsible for. This will help the dentist and the patient know what the final outcome will be.

3. The claim was not filed on time: Every dental insurance company has its own deadline for claim filing. Claims that are filed outside of the policy’s time limit will be denied. It is always best to submit the claim for the treatment the same day of the service to avoid this particular issue. While some health plans have a one year time limit for claim submission from the date of service, others may allow only 180 days or even just 90 days.

4. Data entry errors: Errors in the patient information portion of the claim is a common reason for denial. For instance, if the claim is returned with the remark “beneficiary identification incorrect”, it can mean the name, the enrollee ID with the date of birth on the claim are wrong. A quick look at the patient chart to review their personal information before submitting the claim can save the headache of the denial down the road.

5. Outdated insurance information: If the patient’s benefits are outdated or the policy has been terminated or modified, this too could result in an obvious claim denial. Changes in insurance information can occur if patients have switched jobs recently or if they just made changes to their current insurance policy. Again, this is where dental insurance verification can assure that the patient’s records are up to date before performing any procedures or services.

6. Issues in Coordination of Benefits (COB): COB is 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 a COB-related problem, that is, things are incomplete or there is inaccurate information is on file with the plan or the payer, or there is a failure to attach an Explanation of Benefits (EOB) from the primary payer when billing to the secondary payer. To prevent COB issues, providers need to collect and confirm primary and secondary insurance information at each visit. They also need to know plan and payer rules for payment and determine who the primary and secondary payers are to ensure that claims be sent to the primary payer first, and as mentioned above, secondary payers require a copy of the Explanation of Benefits (EOB) that is provided by the primary payer so that the secondary can pick that up and pay their portion for the claim. Even without being prompted by a clearing house, practices should always make it routine to just go ahead and attach the copy of the primary EOB to the claim filed with the secondary payer.

7. Pre-certification or authorization was not obtained: Some dental treatments such as reconstructive procedures and oral surgery require prior authorization. Not obtaining a prior authorization will inevitably lead to a claim denial. Providers need to know which insurers require pre-authorization and for which specific procedures. Predeterminations on complex, costly procedures should be submitted as close to the date of the proposed service as possible. You always want to allow them time to approve it, and make sure that you are attaching all the materials we were talking about before — the narrative, X-rays, periodontal charting, anything that they would need to review, to approve. Authorization is key to getting a quick return and a quick approval. Prior authorizations do expire so make sure to look for that date on the preview letter as well.

And that’s it! I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thanks for listening!