Unmasking Dental Claim Denials
- Updated:
- October 2023
- Author:
- Rob Linder, eAssist Dental Solutions
- Topic:
- Profitability
In dental billing, there’s nothing spookier than a dental claim denial. When you expect a payment but, instead, get a letter stating the claim was denied, it's all tricks and no treats. But, have no fear, just because you receive one it doesn’t mean your claim is finished. Depending on the situation, you may have a chance to appeal and receive a payment. In the following, we’ll unmask a few common dental claim denials and explain just how to turn those tricks into treats.
All dental claim denials are different
There are countless reasons an insurance company may issue a dental claim denial and it would be impossible to list them all. Each carrier is different and each has its reason for not covering certain treatments. So each time you get a dental claim denial don’t be discouraged. Some claims may indeed end there and there will be no recourse for appeal but there are many other situations when an appeal should be sent and there’s a good chance payment will be received.
Dental claim denial #1 - Plan not effective on the date of service
A common reason for a dental claim denial is that the patient’s insurance was not in effect on the date of service. This may seem pretty straightforward and cause for an immediate adjustment but it’s best to review a few things beforehand. First, contact the patient. They may not be aware that their insurance is termed. There may have been an administrative error and the dental claim denial was issued in error. It’s simply a matter of notifying the insurance of this to receive payment. A more common occurrence is that the patient forgets to update their insurance and you just need to obtain the new information. Simply resend the claim to the new plan and you should be good to go.
Dental Claim Denial #2 - Treatment is covered under primary insurance
This is another common dental claim denial, as many patients have dual coverage, and often each insurance carrier insists they are the secondary plan. Fortunately, there’s a straightforward formula to determine which plan is primary and which is secondary. Let’s look at a few different scenarios.
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The patient is an adult and a subscriber on both plans – the plan with the earliest effective date is primary
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The patient is an adult and the subscriber on one plan and dependent on the other – the plan in which they're a subscriber is primary
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The patient is a child in a two-parent household – the “birthday rule” applies, which is where the plan in which the parent has the earliest birthday month and day is primary (if both birthdays are in the same month it’s the earlier day)
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The patient is a child and the parents live apart – the following applies unless there is a court order that states otherwise:
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Parent with custody: primary
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Spouse of the parent with custody: secondary
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Noncustodial parent: tertiary (or secondary if no overage under spouse of parent with custody)
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Spouse of the noncustodial parent is quaternary (or tertiary if no coverage under the spouse of the parent with custody)
Regardless of the scenario, once the correct primary and secondary coverages are clarified you should be able to resubmit the claim for payment.
Dental Claim Denial #3 - Incorrect CDT code attached
There are hundreds of CDT codes and occasionally the incorrect one is billed with a claim. When this is the case, simply resend the claim with the correct code to receive payment. Include a narrative with the claim stating this is a correct claim, and include the original claim number.
To avoid a dental claim denial for incorrect CDT codes in the future, consider purchasing a coding manual such as Dental Coding with Confidence from Practice Booster.
Denial Claim Denial #4 - Treatment denied for necessity
Necessity can be a very subjective reason for dental claim denial. What a dentist considers necessary an insurance company may think is elective. As the claims reviewer was not there at the time of treatment and is instead interpreting x-rays and narratives they are not seeing the full picture. This is the perfect time to appeal. Enlarge the x-rays and intraoral photos and have the dentist write a detailed narrative explaining just why the treatment was needed. A strong appeal can often lead to a dental claim denial reversal and payment issued.
These are just four examples of dental claim denials and how you can address them. Often a denial is a stumbling block to getting a claim paid, not a barrier. If you’re struggling to keep up with denials and appeals, consider outsourcing. At eAssist, our Success Consultants take the time to submit all necessary appeals so that you don’t miss any potential insurance payments. There are multiple service options available, starting as low as $225 a month, which can accommodate any office size.
