What happens if an insurance claim gets denied?

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

• Incorrect or missing patient information, including name, address, date of birth, etc. 
• Usage of incorrect CDT code.
• Supporting documents missing, such as bills, x-rays, etc. 
• Claim submitted after last submission date.
• An out-of-network dentist submits the claim.
• Pre-authorization can also be one reason a claim is denied, and it’s valid for your dental insurance plan. 

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:

• Make sure you are not appealing for any service which is not a part of the dental insurance plan.
• Make sure that any medically unnecessary therapy is not included in the claim because that also can be one of the many reasons for claim denial.
• Every dental insurance company has a different appeal process, so please ensure you strictly adhere to the process of the dental insurance company.
• Make sure you check all the details, including patient information, details of the services provided, etc., and attach all the required supporting documents to strengthen your claim. 
• Keep open communication with the dental insurance company so that you know what exactly they need. It’ll improve your chances of a successful claim. 

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.