Wondering What to Do When a Dental Claim is Rejected?

In this article we discuss a handful of things you can do when a dental claim is rejected. No one wants to get a returned claim where the insurance company has “disallowed” the services that were provided. Even those very experienced with submitting claims or dental claims will occasionally receive a denial that will be a disappointment and a big surprise to them. It is critically important to have a good understanding of the claim language and know what steps to take to appeal the payment decision to obtain a reversal.

See also: What You Need To Know About Medical Billing For Dentists

What to do if Your Dental Claim
is Rejected

This means the claim cannot be processed the way it was submitted. The claim or a dental claims contains errors that were made when it was filled out. The errors do not match with the information that is on file with the insurance company for the patient or subscriber. Most likely the explanation of benefits (EOB) will not be included with the claim denial. Therefore, you will review the claim and then check the information that you have on file, make any corrections, and then resend the claim.

The dental claim is ‘not billable to the patient’ or is

A decision is made by the insurance company that the service(s) that were provided do not qualify under the plan for reimbursement. This means the patient cannot be billed by the practice. No statement and no payment means no revenue.

For example, if you report on the same date D2940 Protective Restoration and D3120 Pulp Cap it can cause D2940 to be denied, because, with most plans, this procedure is considered to be inclusive (global) of a pulp cap procedure. Alternatively, an insurance payer might not pay the D3120 but pay on D2940. It would be an exception for them to pay on both. Whatever the decision is, the patient can not be billed for the services provided.

What to do if the the dental claim
is denied

This means that the request doesn’t qualify for reimbursement. The reason for the denial will be stated on the EOB and then sent by email or mail. There might be filing errors and/or some information that might be missing that supports the medical or clinical necessity of the claim. When a denial is appealed properly it often results in contractual fees being reimbursed.

In order to avoid being rejected again, the appeal process that the insurance company dictates should always be followed. If the practice is unable to fulfill the request of providing the right information, then the patient will not be able to be billed and the claim will not be paid.

When a dental claims is disallowed because of contract language, then the patient will be able to contact his or her employee benefits manager from the human resources department. A self-funded plan exclusion may be overridden by the employee benefits manager and maybe put in a word in the future for coverage to be included.

Insurance payors do make errors sometimes.

Sending out “clean claims” that are free of mistakes is essential. All necessary documentation needs to be included, and be knowledgeable of the exclusions and benefits of their patients’ dental plans. When you are current on everything and check all the boxes off, you can be confident that you have correctly filled the claim.

We hope this article has shed some insights on what to do when a dental claim is rejected. If you’re looking to learn more about how to help your practice grow – don’t forget to download our FREE 43-page Report on Increasing Case Sizes and Collections.

Hi, I'm Viennie and I'm the Social Media and Email Marketing Manager at OneMedAll. I am also a contributing Author to our company's website. Typically I will write about educational articles related to dentistry, interviews of Speakers from different events (such as: CDA, ADA, AGD, or IAOMT). Besides Social Media and Email Marketing, I also have a passion for creating thoughtful content that crafts a narrative without any words needed. This can be seen on our social channels such as: Instagram and Facebook. Definitely check out our YouTube if you'd like to learn more and see our interviews!

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