The 4 Most Common Reasons Why Dental Claims Get Denied—And What To Do

Posted Jan 2023

By Delta Dental of Arkansas

Tagged out-of-pocket expenses, pre-determination of benefits, premium dental insurance, basic dental insurance, x-rays, input errors, typos, annual maximum, out-of-network dentist, in-network dentist, denied dental claims

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The 4 Most Common Reasons Why Dental Claims Get Denied—And What To Do


Man looking dismayed as he’s examining bills

Ugh—you just received an unexpected bill from your dentist. Why? You have dental insurance!

Why was the claim denied or only partially covered?

Here are 4 reasons why a dental treatment might not be covered the way you thought it would be. The explanations may surprise you. 

1. Obtaining Dental Care From an Out-of-Network Dentist

You will receive the full insurance benefits and the most value for your money if you obtain your dental services from network” or “in-network” providers. These are dentists who have contracted with insurance companies to care for their members at agreed-upon prices. As a result, covered members tend to have lower out-of-pocket expenses.

What can you do?

To maximize your dental insurance benefits, try to obtain dental care from in-network providers.

If you switch dental insurance companies, e.g., after a job change, check that your current dentist is in their network. If they are not, you still have the choice of staying with them, but know that you will most likely be responsible for higher out-of-pocket expenses.

To verify that your dentist is part of the Delta Dental of Arkansas networks or find a new network provider, use this handy dandy “Find-A-Doctor” tool.

 

2. Input Errors or Incomplete Claim Forms

Even in our age of digital record-keeping, input mistakes and human error happen, causing a claim to be denied, at least initially.

The mistakes could have started with you. When completing your dentist’s paperwork, you might have inadvertently

  • provided an incorrect Social Security number
  • transposed the dates of your birthday
  • ·neglected to update your last name following marriage or divorce
  • listed invalid insurance coverage. This frequently happens in January after a new, employer-provided insurance plan has become effective, but members still need to receive their new ID cards or remember the switch.

It’s also possible that your dentist’s office might have

  • entered your information incorrectly into their computer system
  • coded the dental treatment incorrectly on the claim forms they submitted to Delta Dental of Arkansas
  • provided the wrong National Provider Identifier (NPI) information
  • ·neglected to include all required claim information, e.g., x-rays.

What can you do?

If you have dental coverage with Delta Dental of Arkansas, call our customer service at

  • 1-800-462-5410 (if you have coverage through your employer) or
  • 1-844-368-6484 (if you purchased individual/family coverage directly from Delta Dental of Arkansas).

Our customer service representatives can investigate further and help resolve the issue. If a simple typo is to blame, your dentist can submit a corrected claim for reprocessing.
 

3. Exceeding the Annual Maximum

Each dental insurance plan specifies an annual maximum. That’s the maximum amount the insurance company will pay per year for your dental treatments.

Your insurance benefits for preventive dental care (semi-annual oral exams, cleanings and x-rays) should not exceed the annual maximum. But if you need costlier procedures such as root canals, crowns, bridgework or oral surgery, you may reach that threshold. 

What can you do?

  1. Choose the dental insurance plan that’s right for you.

    Inexpensive, basic plans carry relatively low maximums, such as $500. If your teeth are in great shape and all you ever need is a check-up and cleaning every 6 months, you may feel reasonably confident that a plan with a low maximum will meet your dental care needs and budget.

    However, premium plans may be a better choice for you if you require extensive dental work. They cost more each month than basic plans, but they offer more generous benefits that can lower your out-of-pocket expenses. Some have annual maximums of $2,000 or even $2,500.

    Your employer may offer basic dental insurance. But if you think it doesn’t provide adequate protection for your oral health care needs, consider purchasing additional individual/family insurance. Delta Dental of Arkansas offers several options.

  2. Time your dental treatment
  3. Proceed with caution. This advice doesn’t work for everybody.

    Let’s say you are approaching the maximum of your annual dental plan benefit and it’s late in the year. Consider postponing the recommended dental procedure until the beginning of the next calendar year. That’s when benefits reset and start anew, including your annual maximum.

    But check with your dentist first. You may require urgent treatment that should not be put off.

4. Incorrect Estimate of Cost and Coverage for Dental Procedures

If your dentist recommends major dental procedures like crowns, root canals, oral surgery and the like, you will probably want to ask right there and then, “How much is that going to cost?”

Hold that question. Your dentist’s ballpark estimate may completely miss the mark.

Instead, ask their office to request a “pre-determination of benefits” from your insurance company. You are entitled to a written document detailing the procedure code(s), the estimated benefits paid by the insurance company and your out-of-pocket costs.

Your dentist’s office should be happy to handle that request. Delta Dental of Arkansas typically processes pre-determinations within 2 weeks, usually valid for 1 year.

What can you do?

Don’t rely on the dental office’s estimate. Be sure to obtain the pre-determination of benefits so you’ll get a better idea of how much you may have to pay out of pocket. Your final costs may differ slightly (it’s an estimate after all), but not significantly. 

 

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