What are claims in dental insurance?

What are claims in dental insurance?

Let’s see you visit a dentist either for a regular check-up or to receive dental treatment. Whatever services you receive during your visit, your dentist will submit a claim form to your dental insurance company requesting payment for the services rendered. In simple words, a claim is the formal payment request submitted by your dental service provider to your dental insurer. A dental claim explains the services and procedures provided by your dentist and his team during your visit.

Dental Claim Process
Once your dentist submits the claim to your dental insurance provider, it’ll go through numerous phases of reviews/approvals before you receive the final bill.  

  1. Billing: A bill for service charges is submitted to your dental insurance provider, except for any charges paid via copay or deductible at the time of check-in.
  2. Adjudication:  This is the process of examining the claim by a certified claims processor. S/he verifies the accuracy of the submitted claim and compares it to the insurance policy to determine whether or not the services performed are covered by your dental insurance plan.
  3. Reconciliation: If the services are covered by the insurance plan, the insurance company will pay the claim. Depending on the plan, the insurance company may pay the whole claim in full; else, the patient would be invoiced for the remaining balance.
  4. EOB: A full account of services rendered, how much was covered by insurance, how much the provider paid, and what remains to be billed is stated in an explanation of benefits (EOB) delivered to the patient.
  5. Final Billing: If applicable, a final bill will be given to the patient for payment.
  6. Payment: Before settling the claim, the patient should examine the EOB and final bill to confirm that everything is proper. A mismatched process code or other clerical error might cause balances to misalign. Claims can be modified and corrected without incurring any penalties.

Purchasing dental treatment coverage is advisable so that you do not wind up paying for charges on your own or postpone treatment. With a dental plan in place, you will be free of worries of any kind and will be able to focus on receiving high-quality dental care.

What is covered in dental insurance?
Dental insurance policies, unlike medical insurance, have a limited number of covered areas. As a result, it's simple to keep track of which dental procedures are covered and how much each service costs under your dental plan.

  • Preventive medicine (also called diagnostic services)

Cleanings, oral examinations, x-rays, fluoride, and sealants are among the services and treatments available. Periodontal (gum) care and deep pocket cleanings are examples.

  • Services that are part of Basic and Major Treatment

Fillings, crowns, root canals, extractions, oral surgery, and specialty treatments for the gums and teeth (periodontics), the insides of teeth (endodontics), artificial removable teeth (prosthodontics), and braces are among them (orthodontics).

These dental services are reimbursed at varying percentages, often 50%, 70%, 80%, or a flat cost. Each of these procedures should be included separately in your dental plan contract, along with the percentage of coverage or the flat fee cost. The remaining costs will be your responsibility.

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