What is what to do when dental insurance won t pay?

When your dental insurance denies a claim, don't immediately give up. Here's a breakdown of what you can do:

• Understand the Denial: Carefully review the Explanation of Benefits (EOB) or denial letter. Pinpoint the exact reason for the denial. Common reasons include:

  • The procedure isn't covered under your plan (see your policy details).
  • You haven't met your <a href="https://www.wikiwhat.page/kavramlar/deductible">deductible</a>.
  • You've exceeded your annual maximum.
  • The procedure is considered "not medically necessary".
  • Pre-authorization was required but not obtained.
  • Missing information on the claim form.
  • <a href="https://www.wikiwhat.page/kavramlar/Coordination%20of%20Benefits">Coordination of Benefits</a> issues (if you have multiple insurance plans).

• Contact Your Dental Office: Your dental office is a crucial ally. They can:

  • Verify that the claim was submitted correctly with the proper codes and documentation.
  • Help you understand the reason for denial from a clinical perspective.
  • Potentially resubmit the claim with additional information or corrected coding.
  • Offer a payment plan or discount if you're responsible for the balance.

• Contact Your Insurance Company: Call your insurance company's customer service department. Be polite but persistent. Ask them to clarify the denial reason and what steps you can take to appeal. Take detailed notes of your conversation, including the representative's name, date, and time.

• File an Appeal: Most dental insurance plans have an appeal process. Follow the instructions outlined in your denial letter or on the insurance company's website. When appealing, be sure to:

  • Submit your appeal in writing within the specified timeframe.
  • Clearly state why you believe the claim should be paid.
  • Include all supporting documentation, such as:
    • The original claim form.
    • The denial letter.
    • Your dental records relevant to the procedure.
    • A letter from your dentist explaining the medical necessity of the procedure.
    • Any other information that supports your case.

• Review Your Policy: Carefully read your dental insurance policy documents. Understand your coverage limits, exclusions, waiting periods, and appeal procedures.

• Consider a Second Opinion: If the denial is based on "medical necessity," consider getting a second opinion from another dentist. A different dentist may have a different perspective on the treatment's necessity.

• Escalate if Necessary: If your appeal is denied, you may have further options. Check if your state's insurance department offers assistance with resolving disputes. You could also consult with an attorney specializing in insurance claims, but this is generally only worthwhile for larger claims.

• Negotiate a Payment Plan: If all else fails, and you are responsible for the bill, try to negotiate a payment plan with your dental office. Many offices are willing to work with patients to make treatment affordable.