Have you or a loved one ever had a dental insurance claim get denied?
Having a dental insurance claim be denied can be frustrating and time-consuming, but understanding the common reasons behind denials can help you avoid them and save yourself the hassle.
Here are the most common reasons dental insurance claims are denied and simple steps you can take to help ensure your claim gets approved the first time.
Why dental insurance claims get denied
Common reasons dental insurance claims get denied include:
- Incorrect personal information or outdated claim information: Incorrect personal details can lead to denials. Be sure the name, address, and date of birth entered correspond correctly to the plan subscriber and the patient.
- Incorrect dental provider information – Just as you need to double-check your personal information, be sure you have the correct dental provider information in the correct fields. The dentist’s name, not the office name, needs to be listed in the treating provider field.
- Incorrect coding: When a claim is submitted, dental providers use specific codes to identify the services and procedures delivered during a visit. If a code is incorrect or doesn’t align with the diagnosis, it can lead to a claim denial. In addition, some procedures require submission of an X-ray or dentist’s chart notes. Submitting a claim without the correct documentation or supporting records will likely lead to a claim denial. Your dental provider should be able to help you prepare and collect the proper documentation and records to expedite the processing of claims and minimize denials.
- Using an out-of-network provider: Claims may be denied if the dental procedure was performed by a dental provider who does not contract with Delta Dental of New Mexico. Using an out-of-network dental provider may result in higher out-of-pocket expenses. Out-of-network dental providers may also Balance Bill you for billed amounts that exceed allowed amounts. In some circumstances, you may need to file your own claim if the out-of-network provider does not accept insurance or cooperate with dental insurers.
- Lack of prior authorization: Some dental treatments or services may require a prior authorization or a pre-treatment estimate from your dental insurer. These let you know if a procedure is covered before treatment begins, preventing surprise costs. If you submit a claim for a procedure that required pre-authorization and did not submit it, your claim could be denied and marked as an unauthorized procedure.
- Service is not covered by the dental plan: Before moving forward with a proposed dental procedure, treatment or service, it’s a good idea to call your dental insurer to verify what’s covered under your specific plan or ask your dentist to submit a pre-treatment estimate or prior authorization. Dental offices sometimes assume all Delta Dental plans offer the same coverage, which can lead to confusion. However, there are many different plan types, and coverage can vary. Taking a few minutes to confirm your benefits ahead of time can help you avoid unexpected costs, getting you, your dental provider, and Delta Dental of New Mexico aligned.
Tips to avoid dental insurance claim denial
- Know your dental coverage and verify your plan: Before any procedure, talk with your dentist to confirm that it’s covered by your insurance by reviewing your Summary of Benefits and handbook (or Evidence of Coverage). Claims are often denied when dental work is performed under the assumption of coverage that isn’t actually included in your plan.
- Provide correct personal information: Misspelling personal information when filling out a dental insurance claim form can lead to claim denial. Verify that your full name, date of birth, insurance carrier, and member ID number are all filled out accurately. It’s important to take your time when filing a claim and update your personal information if there has been a change since your last dental visit.
- Get prior authorization if needed: Ensure your dental plan includes your upcoming dental procedure by getting prior authorization. To get a prior authorization or pre-treatment estimate, talk to your dentist about the procedure so that they can submit the treatment plan. After the documents are reviewed, you will receive a cost estimate. This process helps prevent any surprise expenses.
- Keep records and follow up: After your dental insurance claim is submitted, monitor its progress. Follow up with your insurance provider or log in to the Delta Dental of New Mexico Member Portal to see the status of your claim.
Two types of dental insurance claim denials
When a dental insurance claim is denied, it’s important to understand that there are two main reasons for a claim denials. The first is a denial for additional information. This doesn’t mean the claim won’t be paid, but rather that Delta Dental of New Mexico needs additional details or records to process the claim in accordance with your coverage. In this case, you can simply submit the requested information or records, and the claim will be reviewed again. The second reason is that the service isn’t covered by your plan. If you believe that a claim denial was made in error, you or your dental provider can file a formal appeal with Delta Dental of New Mexico to have us review and take another look at the claim denial.
What can you do if your dental insurance claim is denied?
Appealing a dental insurance claim may sound complicated, but it doesn’t have to be. Delta Dental of New Mexico has a packet and a dedicated Appeals Coordinator that provide you with all the information and assistance you need to request an appeal. The process is designed to assure you, your dental provider, and Delta Dental of New Mexico that the right action was taken for the claim based upon your coverage and available information. The Appeal process can be straightforward and stress-free, but it may require coordination with your dental provider.
Feel confident when it comes to filing a dental insurance claim
Filing a dental insurance claim shouldn’t be overwhelming. By following these tips, taking your time, and understanding your coverage, you can feel confident that your claim won’t be denied. If you have more questions about dental insurance claims, contact us for additional support.
Looking for more information on understanding dental insurance? Check out this blog: Benefits of Using Delta Dental of New Mexico Dental Insurance Early in the Year.