What is the Process of Dental Insurance Claim?

Medical nsurance policies don’t cover the cost of dental care.  Dental insurance has to be purchased separately and there are several different plans for those.  Just like medical coverage, patients have to pay a certain amount of the cost from their pocket. These are called co-payments or deductibles.  It is essential for a consumer to go through the different plans and pick the one that they need and can afford. 

What every consumer should know:

Every dental plan differs in its reimbursement policies.  Payments are done on the basis of classes of service.  Basic services like preventive care and diagnosing conditions get covered 100%. Services like fillings which are considered restorative are covered 80%, major services like crowns and root canals are covered for 50% of the cost.  Cosmetic procedures are usually not covered.  There are restrictions on how many times a patient can visit the dentist.  Check the plans before signing up – claims can be denied by insurance carriers.

Classes of Service:

A class usually defines the type of treatment that a patient needs.  Dentists will determine it after diagnosing – it could be preventive, basic restoration, major or complex treatment. 

  • Class I includes preventive care like exams, x-rays and cleanings and usually covered 100%.
  • Class II includes restorative care like fillings, root canals etc. and cost is covered up to 80%.
  • Class III care includes major dental care like bridges, dentures and crowns. Only 50% of the cost is covered.
  • Class IV care includes orthodontics like braces.  This care is not covered by all plans and is available only for those who are 18 or younger.

It is essential to know what is included under your plan.  Consumers have a few to choose from - a Dental Preferred Provider Organization, Dental Health Maintenance Organization, Dental Indemnity Plan or a Dental Discount Plan.  

How to File an Insurance Claim:

Most dental clinics do the paperwork on behalf of the patients.  In cases where the patient has to file a claim on their own, they have to do the following:

  • Check the insurance company website and download the claim form
  • Complete all the information and include patient number, doctor office information and treatment received
  • Dentists usually give statements/receipts on payment. Include this form with the claim. A statement of treatment includes basic information on the care received by a patient.  There are specific codes for different treatments – it is best to check with the dentist and get the right one to make the information more comprehensive.  Include information like the Dentist’s National Provider Identification Number, Tax Identification Numbers, License number issued by the state they practice in and the specific code for treatment.
  • Make copies for your records and then mail in the papers to the insurance company and wait for reimbursement.
  • Check with your insurance company on how long it will take for the claim to get processed.  Most insurance companies accept papers filed electronically too.

It is important for patients to understand their plans and available benefits so that they can avoid getting unnecessary treatment.