Dental claim submission can be tedious and requires precision to ensure every claim is done correctly. It’s especially important to teach new staff members how to run through this process properly, so operations don’t get interrupted, and costly errors are avoided.
Our experts at ProDENT have put together this guide to dental insurance claims processing to help streamline the process. Dental billing is easy when the process is clear!
Key Takeaways
- Dental insurance claims involve submitting accurate treatment details, verifying patient coverage, and coordinating benefits when multiple policies are in play, ensuring proper payment and minimal patient expenses.
- Precise patient details, correct CDT codes, and supporting materials like X-rays or treatment notes are essential for smooth claim processing and avoiding delays or denials.
- Common issues like coding mistakes, incomplete forms, or policy limitations can lead to claim denials. Addressing these promptly and using appeals processes with strong supporting documentation can help resolve disputes.
- Practices benefit from dental claims processing support and advanced tools like ProDENT intraoral cameras, which enhance patient communication and streamline documentation for claims.
What is Dental Insurance Claims Processing?
Dental insurance claims processing is the way dental offices and insurance companies handle payment for dental services for patients on an insurance plan. When a patient visits the dentist, the dental office collects all the necessary information and sends a claim to the insurance company. The insurance company then checks the claim to decide how much they’ll cover based on the patient’s benefits and policy limits.
Sometimes, dental offices need dental claim support to help fix common issues like missing information or coding mistakes. If a claim is denied, this support can help get it corrected and approved. Many dental offices work with dental claims processing companies to make the process faster and simpler.
How to Submit a Dental Insurance Claim: A Comprehensive Guide
In most cases, dental professionals submit dental insurance claims on behalf of their patients. A dental claim form is rarely submitted by the individual who received dental care. Here’s the process:
1. Insurance Coverage Verification
Before treatment, confirm the patient’s eligibility and plan details to see what’s covered and what the patient will pay. Check for any waiting periods, coverage limitations, annual maximums, and deductibles on their dental plan. Be aware of deadlines, like the American Dental Association (ADA) or AARP timely filing rules, which indicate the time limit for submitting claims.
2. Get Prior Authorization
Prior authorization is a process where the dental clinic seeks approval from the insurance company before performing certain procedures. This step helps confirm that the planned treatment is covered under the patient’s insurance policy, reducing the risk of unexpected costs.
To obtain prior authorization, the dentist submits details about the proposed treatment, including procedure codes, estimated costs, and any necessary supporting documents like X-rays or notes explaining the need for the procedure.
It’s important to understand that prior authorization is not a guarantee of payment. Even if a treatment plan is pre-authorized, claims can still be denied for various reasons. For example, the patient might lose eligibility before the procedure, the maximum benefit for that service might have already been reached, or specific time limits may prevent coverage.
3. Record Treatment Details
Complete and accurate documentation — including patient details, treatment notes, correct dental codes, and any necessary attachments, like X-rays — helps to make sure the claim goes smoothly.
Here’s what should be included:
- Patient Information: Basic details like the patient’s name, date of birth, and insurance ID are necessary to verify identity and coverage.
- Treatment Notes: Detailed notes describing what was done during the appointment. These notes should cover specifics, like which teeth were treated, and the surfaces involved (e.g., top, bottom, left side). This level of detail can prevent questions from the insurance company which may lead to delays.
- Procedure Codes (CDT Codes): Each dental procedure has a specific code, known as a Current Dental Terminology (CDT) code. Codes inform the insurer about what specific services were performed. Using the correct code is important for the claim to be accurately processed and reimbursed.
- Additional Information: Sometimes, the insurance provider may need extra proof to approve a claim. This could include X-rays, intraoral images, or periodontal charts if they help justify the treatment. Providing these attachments upfront can avoid unnecessary back-and-forth.
4. Submit the Claim
- Verify All Information: Before submitting, review the claim details carefully. Even minor errors in patient, provider, or procedure information can cause delays or denials.
- Submit an Electronic Claim: Once verified, the dentist submits the claim through the dental practice management software, which connects directly with insurer systems.
- Monitor Claim Status: Dentists can track the claim’s progress using real-time tools in the software or through the insurer’s portal. This allows them to quickly address any issues, such as requests for additional documentation.
5. Navigate Coordination of Benefits (COB)
Coordination of Benefits (COB) applies when a patient has multiple dental insurance plans. The primary plan pays first, followed by the secondary plan, which may cover the remaining eligible costs.
Generally, the plan covering the patient as an employee is primary, while dependent/child coverage often follows the “birthday rule,” using the plan of the parent with the earliest birthday in the year.
To navigate COB, determine which plan is primary, submit the claim to that insurer first, then to the secondary with the Explanation of Benefits (EOB) from the primary claim attached. Tracking both claims helps ensure proper payment and minimizes out-of-pocket expenses.
6. Claims Adjudication Process
Once the claim arrives at the insurance company, they go through their own process to verify it. This is slightly different for each company, but generally looks like this:
| Step | Process Details |
|---|---|
| Initial Review |
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| Automated Processing |
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| Manual Review |
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| Payment Determination |
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| Claim Resolution |
|
7. Payment Reconciliation
Payment reconciliation involves comparing insurance payments received with the amounts billed to spot any discrepancies.
Steps for Payment Reconciliation
- Record Payments: Enter payments into the accounting system as they arrive, to keep records up to date.
- Review the Explanation of Benefits: Match EOB details with billed services to confirm accuracy.
- Identify and Resolve Discrepancies: Address any underpayments, overpayments, or denials by contacting the insurer and providing additional information if needed.
- Update Patient Accounts: Adjust patient accounts to reflect accurate balances and notify patients of any changes.
Managing Denied or Rejected Claims
If a claim is denied or rejected, review the EOB to understand the reason. Common causes include coding errors, inaccurate documentation, or policy limitations. Correct any issues and resubmit with the necessary support.
If the denial continues, consider filing an appeal with extra documentation. Keeping clear communication with the insurer throughout this process can make it go much faster and help you spot issues before they arise. Many insurance companies have dental claim support to help you through.
What are Common Causes for Claim Denials?
In many cases, dental insurance coverage isn’t able to be paid out because of a minor error. If your claim is denied, check these first. Being aware of these beforehand can prevent claim denials.
Coding Errors
Claims may be denied due to incorrect or outdated procedure codes. This often happens when the codes used don’t match the treatment provided or if the coding system guidelines have changed. Staying updated on the latest coding standards and conducting regular staff training on coded procedures can reduce these types of denials.
Inaccurate Documentation
Denials often occur when claim forms are missing important details, like patient information, treatment specifics, or signatures. Even small omissions can lead to rejections. Having a thorough documentation review process before submission helps to catch these mistakes.
Policy Coverage Limitations
Some dental procedures may not be covered due to the patient’s specific plan limitations, exclusions, waiting periods, or frequency restrictions. Insurance verification before treatment is important to prevent claims from being denied after services are rendered. Patients should be informed of their coverage limits in advance to avoid misunderstandings.
How to Appeal a Denied Claim: Step-by-Step Guide
- Understand the Denial Reason: Review the EOB to identify why the claim was denied.
- Gather Supporting Documentation: Collect treatment notes, X-rays, and correspondence with the insurer. Make sure that all information is accurate and complete.
- Contact the Insurance Company: Draft a clear and concise letter explaining why the claim should be reconsidered. Include patient information, claim details, and a summary of supporting evidence. Be polite and professional.
- Submit the Appeal: Send the appeal letter and supporting documents to the insurance company’s appeals department. Follow the insurer’s guidelines for submission, which may include specific forms or electronic submission methods.
- Follow-Up: After submission, monitor the status of the appeal. Keep records of all communications and be prepared to provide additional information if requested.
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Dental Insurance Claims Processing FAQs
How long does it take for dental insurance to reimburse a successful claim?
Dental insurance claims are usually paid out within 15 to 60 days. Simpler claims are often completed in just a few weeks, but more complex claims may take longer. Processing times also vary by insurance provider and can be regulated by state laws, which may set specific deadlines for insurance reimbursement.
Can I file my own dental insurance claims?
Yes, you can file your own dental insurance claims, especially if you visit an out-of-network provider. To do this, fill out the insurance claim form provided by your insurer, attach itemized receipts and any required documentation from your dentist, and submit it as directed. Follow up with the insurer to track the claim’s status and address any potential issues.
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