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How do you fight a dental claim?

How do I claim dental insurance expenses?
December 16, 2021
How long do dental insurance claims take?
December 23, 2021

Fighting a dental claim straight away means that the claim you or your dental service provider submitted to your dental insurance company has been rejected or denied, which means your insurer is not going to pay the claim amount you have asked for. It can be a little bothersome for both you and your dentist but there are valid reasons behind claims denial. 

In this blog, you’ll get to know about the major reasons for claims denial and how you can appeal against it to get reimbursed properly.  

Top Reasons for Claims Denial
First, you need to figure out why your claim was rejected in the first place. Let’s take a look at the top reasons due to which claims can be denied:

  • Missing or inaccurate patient information on the claim (name, address, date of birth, etc.)
  • Incorrect CDT (Current Dental Terminology) code
  • Missing supporting documents (bills, x-rays, etc.)
  • Did not obtain the required pre-authorization (valid for some dental insurance plans)
  • Claim was filed after the last date of submission
  • Using an out-of-network service provider

So, it becomes significantly important for you to understand the appeal process in order to fight a dental claim denial.

What’s an Appeal?
Anyone insured by a dental insurance plan has the right to appeal. You have the right to appeal a decision on a dental claim if it is not favorable. Most insurers have many stages of appeal, but you must have a compelling argument to succeed. 

Though you have the right to appeal, you are unlikely to succeed in some cases, such as attempting to appeal a claim refused for a service that your plan does not cover. Consult your dentist to determine whether the therapy in issue is medically essential.

Your dental insurance provider will provide at least two levels of appeal, each with its own group of reviewers. You can appeal verbally or in writing.

“An appeal is the process of requesting your insurer to reconsider and reprocess the denied claim. Appeals are usually made when your claim is either rejected or denied or if you have received less than the required claim amount”.

Filing an Appeal

  1. As a dental professional, first, know about the appeal process of your patient’s dental insurance provider as every insurance may have a different appeal procedure.
  2. Prepare a formal letter and mention all the details such as you and your patient’s name, address, contact information, claim no, member ID, insurance plan ID, etc. Use your official letterhead if possible.
  3. Right from filling in the claim form and supporting documents, ensure that each and every piece of information is filled out correctly and the supporting documents have all the details mentioned clearly and accurately. 
  4. Provide all the required documents/information to the insurer. Sometimes, claims are denied due to lack of information or documents. Please ensure the information provided is correct and the claim is accompanied by all the supporting documents (bills, x-rays, clean photographs of the treatment received, if any). 
  5. Keep clear communication with the insurer and do not give them a chance to say ‘no’ to your claim.