How Long Do Dental Insurance Claims Take?

The time it takes for a dental insurance company to process a claim varies. At least 38 states have passed legislation requiring dental insurance companies to pay claims promptly (ranging generally from 15 to 60 days). Contact your state’s insurance commissioner if you want to submit a complaint about a late payment. They want to know if your insurance carrier fails to pay within the time limit set by state law.

How do dental claims work?

Your dental insurance provider will review your claim after it has been properly submitted to ensure that the procedures you received are covered under your plan. If the insurance company approves the claim, they will send the proper reimbursement to your dentist for the services you received. However, if you pay the cost in full up front, the insurance company will reimburse you.

If you make a claim and your insurance carrier doesn’t cover part or all of the services included in the claim, things could get complex. In this instance, your dentist will most likely call you directly to request an out-of-pocket payment. Alternatively, your insurance company may contact you about any payments you owe your dentist because they don’t cover the entire cost of treatment.

What are the different methods for filing insurance claims in dental?

Dental insurance claims can be submitted both on paper and online. Claims go through numerous phases once a patient visits a dental professional before the patient receives their final bill:

Which of the following is not covered under a dental insurance plan?

In a dental insurance plan, which of the following is not covered? A dental plan’s coverage for lost dentures is specifically excluded.

Which factors help ensure successful accurate dental claims processing?

These pointers came from conversations with insurance company dentists, dental consultants, and clinics that have effectively followed process to increase the success of their dental insurance claims.

X-rays

You must include a stamped self-addressed envelope if you want your x-rays returned.
Periodontal surgery is a technique that is used to treat gum disease (gingival flap procedure, osseous surgery, crown lengthening, bone grafts)
For restorative, endodontic, periodontal, and surgical procedures, send pre-op.
Send a post-op x-ray to document root canal treatment for build-ups, posts, and where periapical pathology was seen in the pre-op x-ray.
Send a post-op x-ray demonstrating successful results for teeth with a doubtful prognosis.
Send a post-op x-ray documenting that the post is truly a custom post and not a prefabricated post for bespoke indirectly produced posts.
Pre-op refers to the time preceding any operating surgery, like as crown prep, filling removal, endo access, and so on.
Take a look at the x-rays your office sends out; you might be surprised at the (lack of) quality!
Ensure that the contrast is sufficient and that the intricacies of the tooth, restorations, bone, and disease are visible.
For many disorders, periapicals and bitewings are usually more diagnostic than a panoramic x-ray.
A panoramic x-ray may reveal a complete tooth that needs to be pulled that isn’t seen with periapicals.
We take multiple x-rays because different x-rays provide different information. As a result, incorporate them.
Don’t just send one periapical when filing for a perio procedure. If bitewings are available, please send them as well. Send a full mouth series if one is available. If a pano is available, please send it as well.
A bitewing may only show the crown of a tooth and not the root. The periapical displays the entire root but excludes the crown. If that’s the case, send them both.
Don’t send photographs that are excessively large; bigger isn’t always better. Although having one x-ray occupy a whole page may appear to be a smart idea, it is actually overkill and can slow down processing. Large printed x-rays are frequently blurry and difficult to view.
Annotations should not, however, be written in such a way that they obscure other vital information.

Periodontal Chart

Periodontal procedures (gingival flap procedure, osseous surgery, crown lengthening, bone grafts, gingival grafts)
At a minimum, the perio chart should include pocket depth measurements for all teeth in the operation region, as well as missing teeth.
Gingival margin level, furcation involvement, mobility, bleeding spots, and associated gingiva width are also beneficial.
Make sure your handwriting is neat. Make sure the numbers are legible to a third party.
Include your diagnosis on the perio chart if you’re treating periodontal disease. Remember that scaling and root planing is a disease therapy that requires a verified diagnosis of the ailment.

Clinical Photographs

Send a photograph if the x-ray does not adequately document the tooth condition. It’s fairly uncommon for an initial claim to be refused but later approved after a photo is submitted since the necessity is seen on the photo but not on the x-ray.
Make sure the photo clearly depicts the tooth or condition in question, as well as any supporting material for the operation you’re submitting.
Photos of crowns or veneers on anterior teeth are useful in demonstrating that the operation is not just aesthetic.
When it comes to periodontal grafting, pictures can indicate recession and a lack of connected gingiva that an x-ray cannot.
Large buccolingual widths of existing fillings can be seen in photos that aren’t visible on x-ray.

Narratives

When you write “open margin,” you mean “open margin.” It does not imply that degradation occurs on a regular basis. If there is any degradation, include it as well.
“Open contact” just means “open contact,” but it doesn’t specify what, if any, problems that open contact is causing.
If your narrative is too long to fit on the claim form, write it on a separate page and note it in the narrative area of the claim.
“Scaling and root planing are required in the treatment of periodontal disease.”
“Periodontal treatment is required to improve the general health of the mouth and the dental environment.”
If you’re going to use acronyms, make sure they’re well-known and understood.
To make the story more readable, use proper grammar, punctuation, and spelling.
It will have no impact on the speed with which your claim is processed or approved.
It’s unnecessary to remind the insurance firm of the rules, regulations, standards, and laws that apply to them. They are well aware of this; in fact, they are probably far more aware than the claimant.
Citing legal examples has no beneficial impact on a claim and, in fact, can undermine credibility because many of the instances cited are not applicable to dental insurance claims.
“Please be advised that if the claim is not paid within 30 days of its creation, the insurance commissioner will be alerted.”
“We will file an official complaint with the insurance commissioner unless this claim is settled or denied within 30 days.”
The more personalized the narratives are for this patient, the more credibility and effect they will have.
It’s fine to use a pre-made template or form as long as it’s filled out in a fashion that’s clearly particular to the submitted claim and customized for each treatment or tooth.
Including every possible conclusion that could lead to a surgery being covered can jeopardize the credibility of the procedure.
Include anything that has been documented in the patient’s records…but leave out anything that has not been documented in the patient’s records.

Claim Form

Make a careful note of whether a crown, bridge, or other fixed or removable prosthesis is a replacement or not.
Note when the existing one was placed if it is not an original placement (prior placement).
Crowns, bridges, inlays, onlays, veneers, and detachable appliances are all examples of prior placement. It isn’t referring to the placement of fillings beforehand.
In the Billing Dentist area, enter the correct entity, and in the Treating Dentist part, enter the correct dentist.
In the Provider Specialty Code area, specialists can indicate their specialty.
The Area of Oral Cavity is required by some standards, whereas the Tooth Number is required by others. This is determined by the CDT code and the insurance company’s policies.
If a patient discount is granted, it must be clearly recorded on the claim, either as a distinct line item or in the Remarks, if it is not already calculated into the fee on the claim form. Otherwise, a bogus claim will be submitted.

Miscellaneous Tips

If you plan to do more scaling/root planing or osseous surgery in other quadrants later but won’t be submitting for all of them on the claim, attach x-rays and a perio chart for all four quadrants regardless. Some consultants will automatically pre-process all four quads and save them in the computer if you do this, saving you time on future submissions.
Make sure to use the proper wording. If it’s a “diagnostic,” for example, don’t write “prognosis.” If a restoration is genuinely a “inlay,” don’t call it a “onlay.”
Get to know the CDT codes and descriptors inside and out. Reread them on a regular basis to refresh your memory on the descriptors for codes you don’t use often. Ensure that everyone in the office, including the doctors, is familiar with them.
If you get a request for information after filing a claim, send the information requested…plus more. This indicates that rather than being processed by a computer, the claim is being evaluated by a human. Make sure to include material that clearly documents what you did, as well as the necessity for doing it. Explain it in a narrative and/or give images if it isn’t immediately apparent on the x-ray.
Requesting a phone contact in the goal of increasing the possibility of payment should only be done if you have information that has to be conveyed. Insurance companies are not more inclined to pay a claim simply to avoid having to call them. Any request for a phone call will cause a delay in the claim’s processing.
Exam findings and any specific exam actions should be documented (such as how a cracked tooth was diagnosed, pulp tests and specific results, Diagnodent use and readings).
Any x-rays obtained should be documented, as well as the fact that they were read and which dentist evaluated them.
Document each tooth’s decay discoveries, including how it was discovered and the surfaces where it was discovered.

Appeals

Send supplementary paperwork if you’re resubmitting a claim on appeal. Don’t simply resubmit the claim in the hopes of a different review the next time.
If a claim is being resubmitted with updated information, label it “Corrected Claim” and emphasize the updated information.

Things To Remember

Payment for a procedure may be denied, but it does not always mean you cannot have it done. It simply indicates that the benefit isn’t included in the insurance plan that the patient’s employer purchased on their behalf.
Send in high-quality x-rays. Nobody at the insurance company can notice the condition in question if you can’t see it on the supplied x-ray.
Do not defraud an insurance company. In terms of legal fees, refunds, and dental board fines, this can be very costly. Fraud can take many different forms, including:
Using a date of service that is not the same as the day you performed the treatment on the patient.
Submitting a fee that is not the same as the fee you want to charge the patient (unless you have a contract with the insurance company).
Using a CDT procedure code that isn’t the most correct for the process that was actually performed.
Providing fillings for more dental surfaces than were actually filled.
Submitting a perio chart that depicts the patient’s perio pockets to be deeper than they are.
Insurance firms can normally obtain copies of records in order to investigate the veracity of any claim that has been filed (this concept is true for any insurance claim, not just dental insurance claims). Keep in mind the legal experts’ philosophy…

What is a missing tooth clause?

A “missing tooth provision” is included in the great majority of dental insurance plans. A missing tooth provision prevents the insurance company from covering the cost of replacing a tooth that was lost before the policy was issued. To put it another way, if you lost a tooth before getting dental insurance and then intended to replace it with a partial, bridge, or implant, your insurance company would not cover any of those services if your plan had a missing tooth provision. Your insurance company may also include a restriction indicating that they will not pay to replace a partial, bridge, or implant that you had placed prior to having that specific insurance coverage, or that they would not pay to replace it before a certain time limit has passed.