Have you or a loved one ever had a dental insurance claim get denied?
Having a dental insurance claim get denied can be frustrating and time-consuming, but understanding the common reasons behind denials can help you avoid them and save yourself the hassle.
Here are the most common reasons dental insurance claims are denied and simple steps you can take to help ensure your claim gets approved the first time.
Why dental insurance claims get denied
Common reasons dental insurance claims get denied include:
- Incorrect personal information or outdated claim information: Incorrect personal details can lead to denials. Be sure the name, address, and date of birth entered correspond correctly to the plan subscriber and the patient.
- Incorrect Provider Information – Just as you need to double-check your personal information, be sure you have the correct provider information in the correct fields. The dentist’s name, not the office name, needs to be listed in the treating provider field.
- Incorrect coding: When a claim is submitted, providers use specific codes to identify the procedures performed during a visit. If a code is incorrect or doesn’t align with the diagnosis, it can lead to a claim denial. In addition, some procedures require submission of an X-ray or doctor’s chart notes. Submitting a claim without the correct documentation will likely lead to the insurance company denying the claim. Your provider should be able to help you collect the proper documentation.
- Using an out-of-network provider: Claims may be denied if the dental procedure was performed by a provider outside of Delta Dental of New Jersey and Connecticut’s network.
- Lack of pre-authorization: Some treatments and procedures require a pre-authorization or pre-treatment estimate from your dental insurance company. These let you know if a procedure is covered before treatment begins, preventing surprise costs. If you submit a claim for a procedure that required pre-authorization and did not submit it, your claim could be denied and marked as an unauthorized procedure.
- Service is not covered by the dental insurance plan: Before moving forward with a procedure, it’s a good idea to call your dental insurance provider to verify what’s covered under your specific plan or ask your dentist to submit a pre-treatment estimate. Dental offices sometimes assume all Delta Dental plans offer the same coverage, which can lead to confusion. However, there are many different plan types, and coverage can vary. Taking a few minutes to confirm your benefits ahead of time can help you avoid unexpected costs.
Tips to avoid dental insurance claim denial
- Know your dental coverage and verify your plan: Before any procedure, talk with your dentist to confirm that it’s covered by your insurance. Claims are often denied when dental work is performed under the assumption of coverage that isn’t actually included in your plan.
- Provide correct personal information: Misspelling personal information when filling out a dental insurance claim form can lead to claim denial. Verify that your full name, date of birth, insurance carrier, and member ID number are all filled out accurately. It’s important to take your time when filing a claim and update your personal information if there has been a change since your last dental visit.
- Get pre-authorization if needed: Ensure your dental plan includes your upcoming dental procedure by getting pre-authorized. To get a pre-treatment estimate, talk to your dentist about the procedure so that they can submit the treatment plan. After the documents are reviewed, you will receive a cost estimate. This process helps prevent any surprise expenses.
- Keep records and follow up: After your dental insurance claim is submitted, monitor its progress. Follow up with your insurance provider or log in to the Delta Dental of New Jersey and Connecticut Member Portal to see the status of your claim.
Two types of dental insurance claim denials
When a dental insurance claim is denied, it’s important to understand that there are two main types of denials. The first is a denial for additional information. This doesn’t mean the claim won’t be paid, but rather that the insurer needs additional details before it can be processed. In this case, you can simply submit the requested information, and the claim will be reviewed again.
The second type is a hard denial, which typically means the service isn’t covered under your plan. If you believe this decision was made in error, you have the option to begin the appeals process to have the claim reconsidered.
What can you do if your dental insurance claim is denied?
Appealing a dental insurance claim might sound complicated, but it doesn’t have to be. Take your time, investigate why the claim was denied, and reach out to your dental benefits provider to see if anything can be corrected or updated. The appeal process can be straightforward and stress-free, but it may require coordination with your provider.
Appeals often must be submitted within 60-180 days of the date of processing, depending on the plan and company.
Feel confident when it comes to filing a dental insurance claim
Filing a dental insurance claim shouldn’t be overwhelming. By following these tips, taking your time, and understanding your coverage, you can feel confident that your claim won’t be denied. If you have more questions about dental insurance claims, contact us for additional support.
Looking for more information on understanding dental insurance? Check out this blog: When is Dental Insurance Worth it?
