The Ultimate Guide To Getting Dental Insurance Claims Paid Quickly

Dental insurance claims can be demanding for dentists given the strict rules and intricate processes. Having a sizable number of patients in the clinic might look promising, however, if the payment collections are not keeping up with the service rendered, it can lead to inconsistent cash flow.  

Therefore, it is mandatory to follow proactive steps to get paid quickly for dental insurance claims.  Unlike any other business, insurance is a way to make money. This means that the collection of dental insurance claims can become difficult.  

With that in mind, here is a comprehensive guide by Capline Dental Services exploring the requisites of dental insurance claims and concerns like supporting documentation, dental insurance coverage, authorization, and more. 

Track eligibility and dental insurance coverage details ahead of time 

Before a patient comes into the dental office, it is crucial to take time to confirm their eligibility and benefits. This step might be time-consuming, but it ensures that the patient has all the necessary dental insurance coverage to pay for their treatment.  

It is advisable to check their service history, any divisions for rudimentary or preventive services,  waiting periods, frequency limitations, and missing tooth clauses. Doing so can help avoid any confusion or complications down the line. 

This information helps dental offices to collect what the patient is financially responsible for upfront. It’s crucial to possess specific details to ensure eligibility. These details include the Payer ID  for insurance, the maximum limit of the plan and its usage, the amount of the deductible utilized,  the mailing address to file claims, the plan’s effective date, and the relationship to the subscriber. 

Submitting the Dental Insurance Claims 

The successful processing of a dental insurance claim hinges on the accuracy and completeness of the claim form, comprising 58 individual fields. These details get automatically populated by the practice management software (PMS) and must be up-to-date to ensure timely payment. The PMS  captures critical information in four key areas: insurance details, patient details, coding, and billing details. 

1. Insurance details include the insurer’s name, claim payer ID (a specific code), and mailing address. 
2. Patient details, such as name, date of birth, address, and ID, are entered into the PMS by office staff during registration. 
3. Coding errors can lead to claim rejections. Dental offices often seek the assistance of third-party providers like Capline Dental Services to ensure that insurance claims get coded correctly and submitted to the right place. 
4. Finally, billing provider information must be accurate and current. It ensures that claims get paid promptly. 

By adhering to these guidelines, dental offices can maximize their chances of receiving timely reimbursement from insurance providers.

Dental insurance claims processing 

After submitting a claim, three common scenarios may occur – 

1. If the coding, PMS details, and insurance information are accurate, the dental office will receive an Explanation of Benefits electronically. This shows the amount paid by the insurance for each procedure, and if the patient balance is $0.00, the claim process is complete.  If the patient’s payment balance is not $0.00, the dental office should contact them for payment or collect it at their next appointment. 
2. If the dental insurance claim gets denied, the insurer may request additional information such as an x-ray, period chart, or a narrative. In this case, the claim is not closed, and further information should be submitted along with corrected claim details, denial EoB, and the initial claim number to prevent duplicates.  

If the insurer requires additional information from the patient, such as evidence of employment or a  copy of the divorce decree, the dental office should contact the patient. It is important to note that the patient is responsible for their insurance and claims. 

1. If the insurer stops responding, they are required by law to notify the dental office within 30  days through EoB, denial EoB, or a letter confirming receipt of the claim. If no notification is received, the dental office should contact the insurer to clarify why the claim is not on file.  Regardless of the reason, the claim should be resubmitted with additional details through fax, print, and mail to the address, online portal, and electronically.