Dental practices send claims to dental insurance companies every day. However, there are often instances when an insurance company denies a claim. So, why was a dental claim denied, and can you prevent denials from happening as often in your office?

When your office needs to process insurance claims, Dental Intelligence Insurance has you covered from eligibility verification to sending in the claim to the ERA. Dental Intelligence Payments also offers easy processing for patient co-payments. Learn more about insurance claims and how patients may face denials because of clerical or procedural errors in your office.

Reasons Dental Insurance Companies May Deny a Claim

Insurance claims make up a large portion of administrative procedures at dental practices nationwide. However, dental insurance companies often deny insurance claims for minor missteps in their individual claims processes. But what are the most common reasons for a dental claim denial?

Outdated or Incorrect Insurance Claim Forms

Insurance companies occasionally update their forms and the required information to submit claims. If you send the claim form you have on file without the updated documentation, the dental insurance company will likely deny it.

If the insurance company denies a claim for lacking the proper forms, it will take longer to receive the denial and resubmit the claim with the correct forms than to contact the insurance company and verify you’re using the correct forms before submitting the claim. You can also verify insurance coverage while inquiring about the forms.

Failure To Verify Insurance Coverage

One of the top reasons for denial is failure to verify insurance coverage. You must ensure that a patient carries a certain policy and that their policy covers the scheduled procedures. To verify insurance coverage, confirm that your office’s information for the patient matches the information the insurance company has on file for their policyholder.

This includes not only that your patient has a certain coverage plan but also that your office has the correct patient address, contact information, date of birth, and spelling of their name. Even one error in this regard could lead to delays or a denial of the claim.

Failing To Get Pre-Authorization

Pre-authorization is essential for all dental procedures, even if a patient’s dental plan explicitly covers them. Without pre-authorization, dental insurance companies may deny a claim as an “unauthorized procedure.”

Seeking reimbursement for unauthorized procedures can easily become a hassle for your billing department. Ensure your office administration is securing pre-authorization for every procedure. Filing an appeal for a denial without it could lead to a lengthy claim process.

Missing Claim Filing Deadlines

Most dental insurance companies have different deadlines for submitting claims with the appropriate forms and documentation. Busy offices can easily miss a deadline if they manage claim filing in-house. Using a third-party billing system to manage claim deadlines and forms can help even the busiest dental practice file all their claim forms on time and with the appropriate supporting documents.

Certain Procedures Not Covered by Dental Insurance Policy

While verifying insurance coverage for your patient, you should also confirm that their policy covers all necessary restorative dental work. For example, many policies have a “missing tooth clause” where, if a patient arrives at your office with a missing tooth, the insurer can deny a claim for replacement because the tooth may have been missing before their coverage became effective.

Many dental policies also do not cover cosmetic dentistry, such as teeth whitening, veneers, or fixing teeth gaps for reasons other than injury or illness. However, many dental practices offer dental financing plans to help patients achieve their best smiles without insurance approval.

Other Limitations of Dental Insurance Companies and Policies

Some dental insurance companies may try to define an essential restorative dental procedure as cosmetic to keep from having to offer coverage for the procedure. Patients who lose teeth in an accident or because of weakened bone structure in their jaw from cancer treatment should qualify for restorative dentistry procedures, including implants, crowns, veneers, and orthodontics.

Most policies don’t cover cosmetic procedures for aesthetic purposes. Dental insurance likely won't cover these procedures even if a patient could benefit from a more confident smile for their mental or emotional well-being.

Insurance Claims Solutions for Dental Practices

Is one of your patients dealing with an insurance claim denial? Consider whether one of the reasons above contributed to the insurance company denying their claim. Dental Intelligence Insurance can help you with your claims processing needs. Contact us today to schedule a demo for your dental practice.