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How Are My Dental Insurance Claims Handled?

There are thousands of different dental insurance plans through just one insurance company alone. Whether you are looking into the different plans offered through your employer or just looking for an individual dental insurance plan, things can get quite confusing. Not only are there different types of plans offered such as Premier, PPO, HMO and so on, but there are countless limitations to remember, like waiting periods for dental work, frequency limitations for x-rays and much, much more.

Regardless of the type of dental work done, the Affiliated Dentists office staff is skillfully trained to submit your dental insurance claims properly so you don’t have to.

Affiliated Dentists’ Front Office Staff: Insurance Experts

We understand that it can be difficult for anyone to know all the details and limitations of their plan. As the patient (purchaser) of the plan, you should have received comprehensive information through the mail presenting your specific plan details. At Affiliated Dentists, we are here to help you understand your plan once it’s purchased.

Always Keep Your Dental Office Updated When Your Insurance Changes!

Myth – Dental office staff is notified when a patient’s insurance changes.

Many patients think that if their insurance plan changes or terminates, their dental office is notified by the dental insurance, but this is never the case. They do, however, send this information to you, the patient. It is the responsibility of the patient (purchaser) to make sure that all their dental insurance information at our office is up to date. Failure to do so may result in a denied claim and unexpected bills.

How Does My Dental Office Work With My Insurance?

Our staff can do many things to help you when it comes time to process dental claims.

As stated previously, there are too many dental insurance plans out there to keep track of. Your insurance carrier will offer a detailed benefit explanation faxed or mailed to you whenever you call to request one. Many companies now have your benefit information listed on their website. The best way to get the most detailed information though, is to call and speak to a representative at your dental insurance company.

Our dental office staff will, at your request, call your insurance to find out different coverage types for you. It is not something that can be done unless the patient requests but it is something that you should ask them to do for you if you are confused about your coverage or need to know a specific benefit you cannot find.

Pretreatment Estimates

At times there can be stipulations that even if we/you call your dental insurance company, they will not provide us with everything we need. This is when pretreatment estimates will come in handy. This is a claim sent out with needed procedures before the work has even been started. Although a pretreatment estimate is not a 100% guarantee of coverage, it will show you if the procedure is estimated to have coverage and the cost if done within the time period stated. Most dental insurance companies will give a pretreatment estimate that is valid for a designated amount of time. 

It’s always a good idea to schedule the procedure at least 3 or 4 weeks after the pretreatment estimate has been processed. Patients should follow up with their insurance to check the status. If you haven’t checked and your appointment is coming up, call us to see if we’ve received it. If we haven’t, it is up to you to reschedule the appointment a few more weeks out to give your dental insurance more time to process the estimate.

Dental Insurance Claims

After your visit at Affiliated Dentists, the specific procedures performed are submitted to your dental insurance on what is called a dental claim. We submit these claims for you at no charge as a courtesy to you.

Each time you visit us and there is a procedure done at charge, we will submit those charges to your dental insurance, as long as your insurance covers the procedure in some way. Many times we will collect the pretreatment out of pocket estimate portion at the time of your visit and will wait for your dental insurance to pay the rest of the claim. You are responsible for whatever your insurance doesn’t cover, so if the claim comes back denied partially or in full, you will be billed for the rest of the balance. This is why it is so important to communicate with your dental insurance before each of your visits, or request that we do so on your behalf. Regardless of who does contact them, it is still not a guarantee of coverage.

Submission of Claims

Most dental insurance claims are sent electronically either the same day or the day after your visit. This means after the claim has been reviewed by the dental office staff and all necessary attachments and narratives have been included, it is submitted electronically to your dental insurance and received immediately. This process is quick, and dental insurance claims tend to be paid in a matter of days.

Sometimes dental insurance claims have to be mailed, which takes much longer to be received, processed and paid. Another thing that can hold up your dental claim is your dental insurance requesting more information via mail after they have received a claim.

Claim Attachments

Some dental claims need attachments in order to be processed. Claims for routine procedures, such as exams, cleanings and fillings, do not need attachments, but claims for major dental work like crowns or bridges will almost always require attachments and narrative.

  • Narrative: This is a description of the dentist’s clinical findings before and during the procedure. It includes areas of decay, fractures, missing parts of the tooth, large restorations that are failing, or any reason at all that your dental work was needed.
  • Attachments: Can be attached electronically, however, many times a dental insurance will mail us a request for more information, meaning the attachment either wasn’t received, wasn’t sent, or wasn’t something your dental insurance needed for the claim until they received it. The most common claim attachments requested are:
    • X-Rays – Of the tooth or teeth getting the work done
    • Periodontal Charting – for any periodontal work completed, your pocket depths and bone loss must be proven for this work to be covered

Insurance Aging Reports

Sometimes your dental insurance company never receives your dental claim. Things can get lost in the shuffle, but there is no way for us to know if they never received your dental claim, as there is no way for us to get a delivery notification from them. This is where an aging report comes in. Every three or four weeks we run an aging report, which is a list of claims that are outstanding for over 30 days.

For each outstanding dental claim on the aging report, the insurance specialists at Affiliated Dentists call the specific dental insurance the claim was sent to in order to check the status. Most of the time, the claim was never received and we fax it directly to them instead of waiting for another copy to go through the mail. Other times something doesn’t match, such as a patient’s date of birth. In this case we figure out who has the right information – us or the dental insurance company – so it can be fixed. The claim will not go through until it is fixed. It can be dealt with on our end easily if the error is at our office, but if the dental insurance company has the incorrect information, it is the patient’s responsibility to change it with them immediately or the claim could be denied permanently and the patient will have to pay out of pocket for the visit.

Writing Appeals

Occasionally, a claim is denied with no good reason from the insurance company. We’ve seen some crown claims or periodontal claims come back denied with only a sentence from the insurance stating they don’t feel the work was necessary, even if proof was shown in the first place. When this occurs, we will write an appeal letter to your insurance company for you as a courtesy. Most of the time, a single appeal is all it takes. We will not only resend the claim, the denial, any x-rays, photos or charting that helps state our case that you did, in fact, need the work done and type up a letter explaining why it was imperative to your health that the procedure was completed.

It can take up to 30 days after we write this letter and it is received by the dental insurance company before we hear back from them. About 70% of the time an appeal will be approved if done correctly, and the claim will be paid. However, other times it will be denied again, and a second appeal will be needed. If a second appeal is denied, it is up to the patient to contact their dental insurance company to appeal this denial on their own. Sometimes a verbal appeal by the patient is all they need, other times they require a written appeal from the patient as well. Unfortunately, if all appeals are denied, the patient is responsible for the remaining balance of the visit. 

Working With Insurance Can Be a Hassle – Let Us Help!

As we work with insurance on a daily basis, we understand just how confusing it can be for most people. We can’t stress it enough to everyone that it is important to read through your coverage benefits, even before signing up for a plan. We see so many patients come in for work only to have it denied due to a waiting period or frequency limitation they didn’t know about because they declined to read their plan’s benefits. We are here to help you understand your plan, but we won’t know you need help unless you ask! We are happy to go through your plan with you, and if there are any questions we cannot answer, you will be directed to your dental insurance company. Together we will work with you to help you not only understand the plan you’re interested in or have already purchased, but to explain your benefits to you so there are no surprises in the end.

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