What to do if Dental Insurance Company Denies Your Claim

Dental and health insurance coverage helps people stay healthy and get the help they need.  Insurance coverage can be purchased by anyone on their own through savings plans or get coverage through their employer.  Dental insurance helps to defray a portion of the cost of dental care for a monthly premium.  It is up to a consumer to pick the type of insurance he wants based on need. Depending on the type of policy, consumers may have to file claims on their own.

There will be instances when an insurance claim is denied after being filed.   It is essential to look at the paperwork and refile to avoid footing the entire cost of dental treatments.  

Reasons for Denial of a Dental Claim

The reasons for denying a claim are quite a few.  Some of them are:

  • Unreadable or incomplete information: This is one of the most common reasons for denial.  Make sure that all the information is filled in properly to make it easier to process.
  • Checking clauses: If your policy doesn’t cover missing teeth, then the patient has to pay their own bill. It is essential to check available benefits before going in for dental work.
  • Contracts: Again, it is essential to check whether a required service is covered by your insurance policy.  If it isn’t, then be prepared to pay for it out of pocket.  Other contractual limitations are age, frequency of treatment and required waiting periods.  Check all this information before going – even if treatment is essential. Let the dentist and the insurance company help out with the right information at the right time.
  • Proper accompanying documents: If an x-ray or chart is hard to read, then a claim can be denied.  Make sure to get clear x-rays and readable documents to submit.
  • Explaining replacements:  In case a crown or bridge has to be replaced due to functionality issues, then it has to be explained clearly in the documents being filed for reimbursement.
  • Wrong codes: In many cases, using the wrong codes can lead to a denial of claim.  Make sure to include the right codes to file papers.
  • Duplication: There can be instances of filing the same papers twice for the same procedure. If this is the case, following up on the old paperwork is a better idea than trying to file a new claim. 

Why it is essential to Appeal Denial

It is important to follow up and find out why a claim was denied.  Make a phone call first and follow it up with a letter. Before writing a letter, read your insurance policy thoroughly and understand your rights – this will help in figuring out which part of the policy was violated, resulting in a denial.  Here are the steps to follow:

1. State the fact: Make sure to include your name and address and the policy number.  Mention the facts of the case and why the procedure should be paid for.

2. Include paperwork: Get all the relevant documents and facts from the dentist’s office. Include this with the letter – this will ensure that the case is not thrown out on a technicality.  Wrong codes can be entered by mistake and this can be fixed. 

3. Keep it short:  Keeping the letter short and to the point will help a case representative deal with issues effectively and fast.  The letter is sent to help you get your problems resolved.