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Claims and payers

Why dental claims get denied

Most dental claims come back unpaid for one of a short list of reasons, and they split cleanly into two groups: things your office can fix on the next submission, and things that are the plan working exactly as it was written. Telling those apart is the whole job, because the first group is worth appealing and the second group is worth a conversation with the patient instead.

A denial is not a rejection

This distinction is not pedantry. It decides who on your team should be looking at the claim, and it is the reason two people can quote wildly different denial numbers for the same practice in the same month.

The path of a dental claim, and the three points where it can stopA claim goes from your office to a clearinghouse, then to the payer, then to paid. It can stop at the clearinghouse as a rejection, at the payer as a request for information, or at the payer as a denial. Only the last of these is a denial.Submittedleaves your officeClearinghouseformat and eligibilityPayeradjudicationPaidor patient balanceRejectionnever adjudicatedNeeds infopending, not refusedDenialdecided, and declinedResolvedoff your board
Three different stopping points, three different fixes. A report that counts all of them as denials is measuring your clearinghouse and your turnaround as well as your payers.
Rejection
The claim never reached adjudication. A clearinghouse or the payer's front door bounced it on a format or eligibility problem, usually within hours. Nobody has decided anything about the treatment. This goes back to whoever prepares claims.
Request for information
The payer has the claim and wants something more before deciding: a narrative, a radiograph, a periodontal chart. It is pending on you, not on them, and the clock is still running.
Denial
The payer adjudicated and declined to pay some or all of it. This is the only one of the three that is actually a denial, and the only one where an appeal is the right instrument.

Reasons your office can fix

These are worth working, because a corrected resubmission usually gets paid. They are also the ones that repeat: if one of these is common in your practice, it is a process gap rather than bad luck.

Missing or insufficient documentation

A fixable reason that repeats. Certain procedures effectively require supporting evidence before a payer will consider them, and which procedures those are varies by payer and by plan. The fix is not to attach everything to everything, it is to know the short list for the payers you see most and attach at submission rather than after the denial.

Tooth, surface or quadrant problems

A restoration submitted without the surface, a procedure on a tooth the payer already has as extracted, or a quadrant that does not match the treatment. These are usually data entry rather than clinical, and they are usually caught by reading the claim once before it goes.

The wrong subscriber

Dependents are the usual culprit. The patient is the child; the policy is the parent's; the claim went out under the child as subscriber. Nothing about the treatment is wrong and the claim will not be paid until it is resubmitted correctly.

Coordination of benefits the payer does not have

When a patient has two plans, the secondary payer will often refuse to process anything until it has the primary payer's decision on file. This is not a denial of the treatment, it is a request for a document, and it stalls indefinitely if nobody notices.

Reasons that are the plan's design

These are not errors and they will not be overturned by an appeal, because nothing was decided incorrectly. The useful response is to know them before treatment rather than after, and to have the financial conversation with the patient in advance.

  • Frequency limitations. The plan covers a given procedure once in a defined period, and this one falls inside it. Very common on cleanings, examinations, radiographs and fluoride.
  • Waiting periods. A new policy does not cover major treatment for some months after it starts. The claim is correct, the coverage simply has not begun.
  • Missing tooth clauses. The plan declines to pay to replace a tooth that was already missing before the policy started.
  • Annual maximum reached. The patient has used the year's benefit. Nothing is wrong with the claim and nothing will change until the plan year turns over.
  • Not a covered benefit. The plan does not include this procedure at all.

The one that is permanent

Every payer sets a window between the date of service and the last day it will accept the claim. Miss it and the claim is finished. There is no appeal for a claim that arrived late, because lateness is not a disagreement about the treatment.

Two things make this worse than it needs to be. Filing windows differ by payer and by plan, so a single mental rule is wrong somewhere. And a claim that has been corrected and resubmitted often shows a recent date, which makes an old claim look new on a report that ages from the last submission rather than from the date of service.

That is why age is the variable to sort by, and why it has to be measured from the date the treatment happened. Everything else on a claim can be fixed later. This cannot.

Working denials without drowning

  1. Sort by reason, not by date received. Ten claims denied for the same missing attachment are one task, not ten.
  2. Then sort by payer. Where a single payer turns out to be behind a large share, that is one phone call rather than a queue.
  3. Handle the permanent risk first. Anything approaching a filing deadline outranks a larger claim with a year of runway.
  4. Write down what worked. The reason a denial repeats is almost never that nobody solved it once. It is that the solution lived in one person's head.
  5. Watch the rate by reason over time. Not against an industry number, which does not exist in a form worth trusting, but against your own last quarter.

The short version

  • A rejection, a request for information and a denial are three different events, and only the third is a payer refusing to pay.
  • Office side reasons are the ones worth appealing: missing attachments, a wrong or missing tooth or surface, the wrong subscriber, and coordination of benefits the payer does not have on file.
  • Plan side reasons are not errors: frequency limits, waiting periods, missing tooth clauses and annual maximums are the policy doing what it says.
  • Timely filing is the only reason that becomes permanent, which is why claim age matters more than claim size.
  • Work denials by pattern rather than one at a time: grouping by reason and by payer is what shows you whether one of either is behind a large share of them.

Read next

Your insurance aging report, decodedWhat the report counts, why it disagrees with your A/R report, and the four things that quietly inflate it.Preauthorization and predetermination are not the same thingWhich one binds the payer, which is only an estimate, and when each is worth the wait.The dental insurance verification checklistEvery field worth capturing, why each one is there, and where to put the answers so they are found again.What is the US dental claim denial rate?There is no published figure, and here is where the quoted one comes from.

Where this sits in Practice Evolved

Practice Evolved groups what comes back unpaid by reason and by payer, out of your own practice software, so the pattern is visible without anyone building a spreadsheet. Claims are aged from the original date of service, which is what keeps the timely filing risk honest: a claim that has been corrected and resent still sorts where its real age puts it.

See your own numbers