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- Incorrect personal information or outdated claim information: Incorrect personal details can lead to denials.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 member’s identification number is valid (most times the identification number is not a member’s social security number) name, address, and date of birth entered correspond correctly to the member’s plan and the patient.
- Coordination of benefits: If you are eligible for coordination of benefits with another dental plan, complete the other plan information with the other member’s information, member’s valid identification number (most times the identification number is not a member’s social security number) full name, address, date of birth, and insurance carrier. This an important step to ensure the order of benefits are correct.If it is determined that, for example, Delta Dental is the secondary carrier, a complete primary EOB is required to ensure the claim is processed timely.
- Incorrect Provider Information – Just as you need to double-check your personal information, be sure you have the correct provider who completed the services or is requesting a preauthorization and the information is in the correct fields. The provider’s full 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 recommend require a pre-authorization or pre-treatment estimate from your dental insurance company. The pre-treatment estimate will let you know if a procedure is covered before treatment begins, preventing surprise costs.
- Service is not covered by the dental insurance plan: Before moving forward with a procedure, it’s a good idea to call or check your benefits online 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.
- Eligibility – A few things can cause eligibility issues, including no coverage at the time of treatment, student documentation not received, or a dependent is over the age limit.
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 member’s identification number is valid (most times the identification number is not a member’s social security number) full name, address, date of birth, and insurance carrier, are all filled out accurately. It’s important to take your time when filing a claim form and update your personal information if there has been a change since your last dental visit.
- Coordination of benefits: If you are eligible for coordination of benefits with another dental plan, complete the other plan information with the other member’s information, member’s valid identification number (most times the identification number is not a member’s social security number) full name, address, date of birth, and insurance carrier.This an important step to ensure the order of benefits are correct.
- 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.
- Coordination of benefits: If you are eligible for coordination of benefits with another dental plan, complete the other plan information with the other member’s information, member’s valid identification number (most times the identification number is not a member’s social security number) full name, address, date of birth, and insurance carrier. This an important step to ensure the order of benefits are correct.
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?
