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What is the dental claim process?

How long do dental insurance claims take?
December 23, 2021
Why would insurance deny claims?
December 30, 2021

The dental claim process involves multiple steps – from patients receiving treatment to filing a claim, getting reimbursed until the final payments are made. In other words, a dental insurance company receives, reviews or investigates, and acts on a claim submitted by a dental services provider or a patient to define the dental claim process.  

Dental claims are submitted via paper and online. The entire dental claim process usually takes around two weeks. This period may go up to 60 days if the dental insurance provider demands additional details/documents related to a patient’s treatment.  

The blog will explain all the details of the dental claim process and the things to know about dental claims!

Dental Claim Process
The process begins with you receiving dental treatment from your dentist. After treatment, either your dental service provider can submit your claim, or you can choose to submit it yourself. Generally, dentists submit claims on behalf of their patients. 

A dental claim is submitted via paper or online through a dental claim form. You can refer to the official website of the American Dental Association (ADA) to check how a dental claim form looks and what fields you need to fill in and the list of required documents to submit a claim. 

Primarily, the dental claim process involves three major steps:

  1. Adjudication: It involves insurance companies checking pre-authorization approval, patient’s eligibility for a claim, duplication in the claim, validation of claim request amount, medical necessity of the treatment received, the correctness of the dental codes used in the claim, etc. 
  2. EOBs (Explanation of Benefits): Post adjudication, the insurance company sends EOB to your dental service provider along with their reasoning for settling or rejecting the claim. Based on their findings, details submitted in the claim, and the plan’s coverage, the insurance company settles the claim either fully or partially.
    The details mentioned in the EOB are the amount approved, the amount paid, discounts, covered amount, final amount (if any) the patient needs to pay, etc.
  3. Settlement of claims: As the name suggests, this is the final step wherein the insurance company settles the claim by paying the approved amount to the dental service provider for the services rendered to the insured. 

The dental claim process is not always smooth. A lot of times insurance companies reject or deny claims. And there can be a lot of reasons behind that such as incorrect information submitted in a claim, usage of wrong dental codes, false information, etc.  

Dental professionals need to be extremely careful while submitting a claim to avoid claims denial. Collecting accurate patient information is the first step to ensure a smooth dental claim process. Dentists can either have an in-house team for billing and claims or they can outsource the process to a reliable dental services provider.. 

Capline Dental Services is a one-stop solution for all dental billing and collection, dental insurance verification, dental credentialing, and patient statement services. Renowned as one of the topmost dental billing outsourcing companies, Capline has successfully executed thousands of claims.