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Winning A Dental Insurance Appeal

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While the majority of dental insurance billing processes smoothly, occasionally a dental plan may reject a bill or reimburse the service at a level below the expectations of the plan enrollee. Thankfully, there is a process by which an enrollee can dispute a decision on the part of an insurance company. This process is typically referred to as an appeal. Before discussing the appeal process, it is necessary to discuss some of the basic issues that may lead to a dental claim denial in order to help you under which bill denials may be legitimate.

Reasons an Insurance Company May Not Pay Your Dental Bill

There are several reasons why an insurance company may refuse to pay a dental claim. Some of the more common reasons include situations where the dental service was:

  • Not covered by the dental plan’s benefits
  • Provided by an ineligible dentist or dental specialist
  • In excess of the plan’s maximum benefit
  • Received before the expiration of a waiting period

Not Covered: Dental plans are not standardized. Their coverage breadth can vary from only preventive care (e.g. annual check-ups and cleanings) to major care and orthodontics. If a service is not listed as covered (e.g. braces), the dental plan is not obligated to pay for the service.

Ineligible Provider: Some dental plans, such as HMOs and discount dental plans, restrict covered services to those delivered by in-network dental practices. Care received outside these dentists is uncovered.

Maximum Benefit: A maximum benefit is the annual dollar limit on insurance company spending for an enrollee’s dental care. Dental bills in excess of this amount, even for covered services, is the responsibility of the enrollee.

Waiting Period: A waiting period is a delay between the time a person enrolls in a dental plan and when the plan will cover a particular service. Some dental plans have waiting periods of six months to a year for expensive procedures such as a root canal.

No Surprises Act & Dental Insurance

“Surprise billing” is a phrase often used to describe medical bills where charges and fees are in excess of a patient’s reasonable expectations and are only partially paid by an insurer because one or more of the healthcare providers were out-of-network. The limited payment by insurer is called “balance billing” because it leaves a considerable balance to be paid by the patient. This balance billing can be exceptionally aggravating because:

  • A healthcare provider may not have identified him or herself are out-of-network and may not have provided the cost implications
  • Out-of-network care may be received within a facility that is otherwise in-network

While the “No Surprises Act” became effective January 1, 2022, the Centers for Medicare & Medicaid Services has clarified that the Act generally does not apply to dentists and dental insurance. Exceptions may arise in the context of good faith estimates for dental services given to patients who uninsured or otherwise paid for the dental services without the assistance of dental coverage. Additional exceptions may occur with respect to dental care delivered in hospitals or emergency treatment

How to Fight a Claim Denial or a Lower Reimbursement Decision

The first step in challenging a billing issue with an insurance company is to review the specific services listed on the bill (checking for any errors) and then cross-referencing the list with the services covered by your dental plan. If you no longer have your Explanation of Benefits document, you can visit the insurance company’s website to download it. If, for some reason, you cannot find it there, you should be able to call customer service to get assistance on the matter.

If you see that your medical bill correctly lists the service and your dental plan’s benefit explanation covers that service (without any of the issues mentioned in the “Reasons an Insurance Company May Not Pay Your Dental Bill” section), your next step is to call the insurance company’s claims department and explain the situation. Always keep a record of when you called the insurance (date/time) and whom you spoke to in the company. If the claims department does not remedy the matter over the phone, ask for information on the insurance company’s appeal process.

You’ll need to follow an insurance company’s appeal process carefully because you do not want to ignore a requirement that may allow the company to reject your appeal. In some cases, you may need to go back to your dentist to obtain additional information needed for the appeal. For example, the insurance may request additional data or x-rays to justify an expensive procedure such as a crown.

What to Do if You Lose Your Appeal

If your appeal is denied and you still feel that you are in the right, you should consider the use of a lawyer. However, you need to consider the cost of a lawyer as well as the possibility that your claim still may be denied. If you have limited economic resources, you may be able to find a legal clinic offering assistance at reduced rates.