Proper eligibility adds payment to the claim. Sometimes it is harder to understand whether coding, documentation, or claim submission are vital steps in the billing process. Patient eligibility brings a lot of terms, like coverage, pre-authorization, verification of benefits, active dental benefits,  eligibility, etc. These are different terms but have similar meanings eligibility of benefits or benefit verification. 

Patient insurance eligibility describes the covered treatment by the payer for the patient. The insurance ID card is not a representation of eligibility. It is the provider's responsibility to verify the member's current enrollment status before providing any service. 

Verification of benefits allows the dental practice to understand the patient's plan and go deeper into the specific line of service that you believe is going to get performed later. Dental benefits vary according to the patient's insurance plan. Verifying the eligibility that the service is a covered dental benefit under the insurance plan increases the chances of getting the reimbursement. 

Prerequisites of the Insurance Eligibility Process 

The verification process starts as soon as you hear an appointment scheduling call. Collecting the  patient insurance information during the registration means not just asking which company insurers  them but also getting 

Obtaining the details related to patient demographics results in faster insurance verification and offer several benefits. It also minimizes the work of recordkeeping. 

Once the dental office receives the patient insurance information, the next preferable step is to reach out to the patient's insurer, irrespective if you have or have not worked with them. Reach out to the insurer early to avoid any mess. The insurance company receives many requests daily, and to acknowledge and act on the verification request, would need several days. 

Call on the number you collected from the patient and verify the patient's insurance details from the representative as per the HIPAA-compliant way to transmit patient information further. You can also use the online portals of insurance companies to verify coverage and benefits. However, the online portals are outdated and do not guarantee to provide accurate details. Therefore, calling and speaking to the representative is the fastest way to verify and move with the treatment. 

Asking the right question with the insurance rep about the patient's insurance information gives you the whole picture of the patient's coverage and benefits. It is advisable to confirm all the details you have gathered from the patient and also asks about the current status of the policy with the expiration date. Assuming the policy is active, understand the patient's copay and deductible.

That confirms the basics of the insurance plan. The next step before providing any treatment would be to understand the necessary insurance authorizations along with the documentation and coverage limits. 

Follow the above points before every patient encounter. The patients theoretically switch insurance plans or lose in between at any time. Hence, collecting the patient's insurance information before any service starts helps you clean claims, reduce denial rates, have consistent cash flow, and patient satisfaction. 

Advantages of streamlined Insurance Verification Process 

Insurance verification plays an integral part in the RCM. Therefore, providers can focus on patient care and not worry about financial stability. 

Submitting dental claims is a pain point for many dental practices. They get denied for a myriad of reasons or some trivial mistake or some update in the patient's policies. Whatever the reason, you deserve proper payment for the procedures that you have done. It can feel frustrating if the claim goes unpaid by the insurance. 

This article walks through how to submit a dental insurance claim in the correct form to protect the financial health of the dental practice. 

Verifying the eligibility of the patient before 

The first step for submitting dental insurance claims starts with verifying eligibility ahead of time.  This small step can save a lot of time and energy further. It is the regular step in the claim-submitting process. Many providers try to skip this process, but insurance verification increases revenue. 

Before even the patient visits the office, get this step done to understand the patient's insurance plan,  active dental benefits, and all relevant details, such as: 

Verifying eligibility is key to creating claims that pay. Your team will reduce billing headaches and paperwork. It will show the covered and non-covered treatments in the patient's insurance coverage plan. 

Accurate Coding 

Correct coding as per the procedure increases the chances that the insurance company will pay for the treatment. Inaccurate coding declines the pay and has to start the process again to receive the payment. Refiling increases the claim processing time and the cost to the dental practice as refiling fees. The codes are published and updated by the ADA annually. Keep yourself informed continually and stay on top of the changes in the coding for maximum collection. 

Correct patient information 

First things first, make sure you are filing with the right insurer. When the patient calls the office to make a dental appointment, get some information from the patient, like full name, date of birth,  address, and insurance information with correct spelling. 

The pandemic has led to changes in employment with many patients and lapses in appointments.  Once the patient is in the office, verify the details by looking at the insurance card or driver's license. It seems straightforward, as, on the going, it can save you from errors that could cause delays in processing. 

Include appropriate documents 

Dental insurance companies require additional documentation as proof of the service performed was necessary. Just saying the clinical notes do not suffice the medical necessity of the procedure explaining why the patient needed the particular treatment. Attaching x-rays, charts, and intraoral photos helps you to justify the treatment and provide as much information as possible in the claim submission.

Always consider taking the correct size photos or the correct format to reduce the amount of back and forth. Show them the required pictures in their original condition to speed up the payment.  Different CDT procedures require different types of attachments depending upon the annual updates. 


Create, batch, and submit the claim with the respective insurer. Track the claims if certain days have passed. Nobody likes calling insurance companies for follow-up. However, it is the fastest way to expedite the process and get a timely reimbursement. The insurance company's representatives help answer the question and resolve the claim issues quickly. 

Do not let the insurers dictate your dental claims revenue, and make sure your claims make a swift journey to get processed and paid. Verifying insurance, inputting accurate patient information, and following up is the golden ticket to paid claims. Many claims do not even make it to the insurance company and get denied when they go to the Clearinghouse.  

The Clearinghouse is a bridge between the practice and the insurer. Partnering with the  Clearinghouse assures the quality of the standard procedure, which increases the chances of accuracy and reduces re-work.

What’s a claim?

When you, as a dental service provider, submit a formal payment request to a dental insurance company for the services rendered, it is called a claim. Then, the dental insurance company examines the claim where its accuracy is verified, and based on the details submitted; it’s either approved or denied. 

What happens if a claim is approved or denied?

If a claim is approved, the dental insurance company pays you for the services you provide to your patients. But what happens if a claim is denied? If a claim is denied, it simply means that the insurance company has rejected or denied the claim and will either pay partially or not pay at all the amount you requested for. 

Let’s look at some common claim denial reasons first to understand why claims are denied in the first place. 

Common reasons for claim denial

So, if your claim has been denied due to one of the reasons mentioned or any other valid reason, you need to analyze the claim denial reason first, which is mentioned in the Explanation of Benefit (EOB) letter received from the insurance company. 

The EOB letter mentions the reason for settling or rejecting a claim. Post analyzing the claim denial reason; you can resubmit the claim after making the required corrections as per the insurance company’s guidelines. 

But, if your claim is denied for an incorrect reason, you can raise an appeal against it. To fight a dental claim denial, you should know the appeal process. Let’s first understand what an appeal is.

What’s an appeal in case of dental claims denial?

It’s a formal request to an insurance company to reconsider and reprocess the denied claim. As a dental professional, you can raise an appeal if either a claim is denied or you received less than the required amount. 

Make sure that you have all the supporting documents and a solid argument to succeed. So, analyzing dental insurance coverage is the first thing before processing an appeal. 

Things to consider while raising an appeal:

As a dental professional, you must be extremely careful in providing correct information, supporting documents, bill details, etc., while submitting a claim to avoid claim delay or denial. An in-house billing team is suitable for all your billing and claim-related issues but outsourcing the dental billing services to a reliable partner is even better. 

It’ll save you time, effort, and money, reduce claim denials, and eventually boost the revenue for your practice. 

As per the American Dental Association's council (ADA), it is vital to educate dentists and dental offices to handle claim submissions to avoid rejections from third-party payers. Claim denial and claim rejection get used interchangeably.  

It is crucial to disseminate the difference between a claim rejection and a claim denial: the claim rejection never requires adjudication by the insurer, as they get rejected before. The claim denial gets indicated on the Explanation of Benefits (EOB) to follow the appeal process. 

There are myriad reasons for the rejected claim: 

How to avoid rejections of dental insurance claims? 

At times, dentists may not understand why claims get rejected. To think like an insurer, validate your Is and cross your Ts to avoid them. 

Accurate information from the provider 

Familiarizing with the deadlines 

Limitations, frequencies, and exclusions 

Automated Solutions 

Learn the Claim Format 

Regular Follow-ups 

Medical billing separates these two terms depending upon the services and motivation with the  billing. Physician billing, also known as professional billing, performs both billing and coding,  whereas hospital billing or institutional billing performs billing & collections and no coding. 

Hospital Billing 

Hospital billing is in charge of the billing of claims produced for work performed by skilled nursing  facilities, hospitals, and several organizations for outpatient and inpatient administrations. It also  includes equipment and supplies, radiology and laboratory services, and other additional charges. 

Applicable Forms 

On UB-04, hospital billings get billed. It is a standard case form with the red ink on white paper  claim form used by institutional suppliers for guarantee billing. The electronic rendition of the  UB-04 is called the 837-I, where the I represents the institutional format. 

Duties Performed 

Physician Billing 

Also known as the Ambulatory Surgical Center (ASC) Billing, for the services performed by the  physician for the inpatient and outpatient. All the tasks get offered at the same medical facility, like  welcoming patients, scheduling appointments, registration and enlisting, administrative tasks,  collecting cash, and other assignments such as medical billing. 

Physician billing is responsible for the billing claims produced for work done by suppliers,  physicians, and other non-institutional providers. Many times the role of billers and coders gets  merged. 

Applicable Forms 

On a CMS-1500 form, physician billing gets charged. The CMS form is the red-ink-on-white-paper  claim form used by suppliers and providers for case charging. 

While some claims get charged on paper, Medicare, Medicaid, and most other insurers acknowledge electronic claims as to the primary billing method. The electronic version of CMS-1500 is known as the 837-P, where P represents the professional or physician format. 

Duties Performed 

Boosting Revenue

Irrespective of hospital and physician billing, medical billers are vital to submitting claims  efficiently and boosting the revenue cycle management. 
The medical billing staff have access to a bunch of data for each insurance company and have  accessibility to patients' confidential and private health information and therefore need to know how  to follow HIPAA regulations for clean claims. 

Experienced billers guarantee that no service goes unbilled, and understanding the coordination of  benefits will help boost revenue and avoid making blunders while performing hospital and  physician billing.

If you’re looking for affordable dental care, you can choose a Dental Maintenance Organization (DMO) dental insurance plan. DMO insurers work out negotiable deals with dentists to reduce their dental care costs. DMOs, like dental Preferred Provider Organization (PPO) insurance plans, let patients save money and have complete leverage over their dental care.

A dental management organization (DMO) is a group of dentists and specialists that work together to provide dental treatment at a predetermined price. Participants in the DMO are not required to meet any deductibles or submit any claim forms.

Let us have a detailed look at what DMO dental insurance plans are.

What is a DMO Dental Insurance Plan?

A dental maintenance organization (DMO) is a low-cost dental maintenance plan. You'll be provided a list of dentists in your region who have agreed to provide affordable dental care. You must select one as your physician dentist, who will treat all of your dental needs.

If your dentist concludes that you require the assistance of a specialist, s/he will send you to one without charging any further fees. As long as your plan supports orthodontia, you can see a DMO orthodontist without a referral.

You may not have to pay a deductible and your yearly benefits may not be capped if you have a DMO plan. You won't have to deal with insurance companies because your primary care dentist will handle everything. Premiums and out-of-pocket costs are lower for DMO patients.

You can't see a non-participating dentist or expert without a recommendation if you have a DMO plan. You may have to pay the full fee if you visit without a reference.

How does a DMO Dental Insurance Plan work?

Participants in a DMO plan, including dependents, must select a primary care dentist. Each person insured by the plan can choose their primary care dentist. All normal dental treatment will be provided by this primary care dentist, who will send the participant to a network expert if specialized care is required.

A participant should make an appointment with their primary care dentist for standard dental care such as check-ups and fillings. The participant will pay the appropriate deductible for covered services when visiting the dentist. After getting treatment, the participant is not required to submit a claim form.

The DMO will not pay any benefits if a participant seeks dental care without first consulting their primary care dentist, or if the patient's treatment is not allowed by the plan. Any out-of-network or unauthorized care will be paid in full by the patient.

If you are looking for a dental insurance plan that strikes the optimal balance between the services that are covered and the amount of money saved on dental care, you can consider a Dental Health Maintenance Organization (DHMO) dental insurance plan.

It is a prepaid dental insurance plan that is renowned to reduce out-of-pocket costs for dental care. The DHMO plans offer a wide network of dentists. You can visit any in-network dentists who have partnered with insurance providers to offer you their dental services.

The objective of a DHMO Insurance Plan

The maintenance of good oral health is the primary objective of DHMO plans. They encourage clients to take preventative measures and get treatment for issues that aren't too critical, rather than waiting for the problem to grow more serious in the future. 

For this reason, you will observe that dental coverage for basic care is completely covered, whereas dental coverage for advanced treatment lowers dramatically. If you don’t have major dental issues and are looking for dental insurance that covers basic dental services, a DHMO insurance plan can benefit you a lot.

What Services are included in a DHMO Insurance Plan?

Each DHMO plan covers several dental care treatments, the specifics of which differ depending on the insurance provider. For instance, insurance providers that focus on preventative care will cover dental cleanings, X-rays, and examinations. Whereas some insurance companies will offer other services, like fillings, crowns, or root canals. 

Depending on the condition of your oral health, you can choose an insurance provider after going through the services that they will cover.

How does a DHMO plan work?

Under this plan, you are either allocated or given the option to choose a dentist who is part of the plan's network. Dentists who are part of your dental insurance provider's network have voluntarily entered into professional relationships with the insurance provider and they are paid a fixed amount for it. 

You will have lower out-of-pocket expenditures, and the amount of your copayment will be pre-determined and listed on your Schedule of Benefits, the way it happens with other types of health insurance plans. This will also make it simpler for you to create a budget for the remaining costs associated with your dental treatment.

When compared to other options, such as PPO (Preferred Provider Organization) dental plans, DHMO dental plans are pocket friendly. DHMO dental insurance provides more affordable premiums, does not require any deductibles, and does not impose any yearly spending caps. 

The whole emphasis is laid on preventative care and regular checkups to ensure that you have good oral health. So, if you are on a budget and you are looking for a dental insurance plan that covers basic dental services, you can choose a DHMO dental insurance plan.

It is critical to understand what each dental plan covers to get the best coverage for your specific requirements. Dental insurance is good for those who desire a healthy mouth in the long run because preventative care is one of the things it covers. A Preferred Provider Organization Plan or PPO is one type of dental insurance.

In this blog, we will discuss how a PPO dental insurance plan works and how it is beneficial for all.

What is a PPO Dental Insurance Plan?

PPO plans have contracts with a network of dentists who have agreed to charge specific costs for established policies and procedures. Patients, on the other hand, can employ their benefits at any dentist, regardless of whether or not that dentist is part of their plan's network.

Most PPO plans cover preventative maintenance appointments, screenings, and regular cleaning with no out-of-pocket expenses. Yet, before your coverage steps in, you may have to pay a reserve.

The annual maximum for most PPO plans is the highest dollar amount that the insurance company will pay out for authorized treatments in a calendar year. Typically, the maximum is approximately $1000.

What is covered in a PPO Dental Insurance Plan?

In a PPO plan, patients can choose from a large network of dentists who have agreed to accept a set cost for treatments. This means that instead of charging the entire amount, they charge a discounted fee that is paid in full. Patients pay a portion of the discounted rate when they visit a PPO dentist, with the insurance company covering the rest.

Depending on the treatment, the proportion the patient pays is usually low and is only a portion of a discounted rate. As a result, PPO dental insurance plans generally have the cheapest out-of-pocket expenses.

The following procedures are covered broadly by most PPO policies.

Preventative Care Services (full coverage): Annual or semi-annual visits for cleanings
Fluoride treatments
Basic Procedures with Discounted Co-Insurance Fee: Treatment for Gum Disease
Root canals
Major Procedures with Discounted Co-Insurance Fee: Crowns
Root Canals (on some plans)

What are the benefits of a PPO Dental Insurance Plan?

In addition to having more choice and power over your dental treatment, a PPO plan may save you financially based on the services you desire. You will always obtain the discounted rate and know what the costs are upfront because dentists have agreed to a cheaper fee.

As awareness about oral health is spreading, every second person is opting for a good dental insurance plan. And the two most common and recommended dental insurance plans are: HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) plans.
The plans under HMO are limited to a specific group of physicians under a common network and it is more cost-effective. Whereas in PPO, one can choose any provider whether they are within or outside of the organization's network and the price is negotiated accordingly. 

In this blog, we will explore all about HMO dental insurance plans. So, let’s dive in!

How Does Dental HMO Work?

As a part of the HMO dental insurance, dentists sign a contract that mentions all the services that are covered along with their prices. This allows the insurance companies and members to have clarity on the services and avoid any disputes related to the claims.

HMO is usually chosen by the people who are looking for basic dental services like teeth cleaning. The reason behind this is getting bigger dental issues fixed requires an experienced dentist and since HMO doesn’t give the liberty to choose a dentist, it’s better to choose it for basic dental services.

Dental professionals are paid a fixed amount every month for each patient. They also receive a separate payment for services that are not covered by the insurance.

Perks Offered by an HMO Dental Insurance Plan

  1. The biggest advantage of an HMO plan is the lower cost. The dentists are signed to an agreement for a specific charge for each service, so the lower costs are passed on to the member. Also, there may be several benefits in terms of saving tax. But this depends on who the insurance provider is.
  2. An HMO plan follows a prepaid plan structure, unlike a PPO dental insurance plan. This helps in having clarity about the services that will be offered and the amount of money that is spent. Whereas you can expect higher out-of-pocket expenses if you go for a PPO plan as the pricing is decided by having negotiations between the participating dentists and the insurance company. 
  3. There are no deductibles included in HMO plans. The only expense that has to be considered is the copayment that will be required to make when receiving dental care. (A deductible is an amount that must be paid before the insurance begins to pay for eligible healthcare services. Co-pays are usually charged after the deduction is done.)

HMO dental insurance plans are an excellent choice for people who are on a budget as most of these plans are affordable. But, while choosing a plan, it is important to know the dentists that are a part of the network as unlike in a PPO dental insurance plan, there isn’t the liberty to choose a dentist. With a little research, anyone can make the best out of an HMO dental insurance plan!

Medicaid is the health insurance program run by the US government for people with low income across the nation. The program covers a wide range of health services including dental care and ensures that enrollees can afford it. Based on federal-state collaboration, the program covers 1 in 5 Americans.

Medicaid Dental Insurance Plans include medical assistance as part of a comprehensive set of advantages known as the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) advantage for all youngster registrants.

Dental treatment is a key piece of the EPSDT benefit for most Medicaid-eligible individuals under the age of 21. Let’s explore the dental care covered under Medicaid dental insurance plans.

Dental Coverage under Medicaid Dental Insurance Plans

Each state must create a dental consistency timeframe in collaboration with recognized dental organizations involved in child health care. Dental services for children eligible for EPSDT may not be limited to emergency services.

All services must be provided if clinically indicated, according to the EPSDT benefit. Healthcare requirements are decided by states. If a condition requiring treatment is

discovered during a screening, the state is required to provide the necessary services to treat that condition, regardless of whether these facilities are covered by the state's Medicaid dental insurance plan.

Children's dental facilities should include:

Dental services must be provided at appropriate intervals that meet dental professional standards, as well as at other intervals indicated by clinical indication, to confirm the presence of a presumed infection or disease.

Oral wellbeing is an essential part of overall well-being. Though oral screening may be part of a physical exam, it is not a substitute for a dentist-performed dental examination.

Every child must be referred to a dentist following the state's periodicity schedule. The schedule for other EPSDT services may not be constrained by the time frame for dental services.

Adult Medicaid applicants receive dental coverage at the discretion of the states. While the various states offer urgent dental care to adults, less than half reportedly offer complete dental services. Adult dental coverage has no minimum requirements.

You can call the Medicaid helpline number directly to know more about the dental care coverage under your Medicaid program. You can also visit the official website of the Centers for Medicare and Medicaid Services (CMS) to connect with your local Medicaid office.

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