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Why Are Dental Claims Denied

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Dental claims must be submitted after the services provided are completed. Not filing the claim on time is an easy excuse for the insurance company to deny the claim. Most PPO plans require that the claim be filed within one year from the date of service. There are also some local union plans that have even shorter application periods, such as 90 days.

If the claim remains unpaid after these deadlines, you will be at the mercy of the untimely filing rule and you can expect the claim to be rejected if you resubmit it. You may be able to request an appeal, but in most cases this request will also be denied. Failure to file the claim on time is an easy reason for the insurance company to deny the dental claim. Most PPO plans require that the application be submitted within one year of the date of service.

There are also some local union plans that have even shorter on-time filing periods, such as 90 days. If the claim remains unpaid after these deadlines, you will be at the mercy of the untimely filing rule and you can expect that claim to be denied and unpaid if you resubmit it. You may be able to request an appeal, but most of the time this request will be denied. Be sure to submit a recent whole-mouth series or periodontal record for the last six months for claims that require this information, such as periodontal, endodontic, orthodontic, and other basic and major services.

A great way to ensure that your claims are not denied is by attaching high-quality images and x-rays to your claim. Exercising your right to deny payment of claims based on this literature ultimately results in decreased payments and increased profits for the insurance company. These are the three most common ways that insurance companies can deny dental claims and some ways you can avoid them. EZ Dental Billing can help you classify denied claims to ensure the growth and financial health of your dental office.

Understanding these mistakes can help your dental team avoid them in the future, so that insurance claims are paid so that your office can collect what is owed. Denied dental claims place a heavy burden on both patients and dentists; a potential denied claim could mean that the patient cannot afford the service after the procedure has been performed, leaving your office unpaid. They must have time to verify that all spaces and blanks have been accurately filled in on the claim forms. Improve your dental coding education and get claims paid faster by enrolling in the Dental Claims Academy.

If you are unable to explain or document a reason why a procedure should be performed, the insurance company will most likely approve the claim. Be sure to submit a full mouth series or periodontal record for the past six months for claims that require this information, such as periodontal, endodontic and orthodontic procedures, as well as other basic and primary services. You file the appropriate insurance, but the insurance company denies the claim because “the missing tooth was removed before the patient’s dental coverage and its replacement is not a covered benefit. Not adding an explanation of treatment to claim forms or adding an “explanation for non-compliance” is a very quick way to get your claim denied.

Each dental procedure varied in terms of needs to be included, with some requiring dental narratives that provide detailed explanations of why the procedures were performed and the medical need behind them.

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