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Dental Insurance Claims Frequently Asked Questions

My patient told me their new benefit plan will not allow coverage for out of network providers. How can that be?

Understanding the ins-and-outs of patient’s dental insurance plans can be a complicated and frustrating task for many dental offices. Find out how to increase your chances of a successful claim submission, and what to do when you receive a claim rejection.

If your questions have more to do with coding, take a look at our Frequently Asked Questions Regarding Dental Codes.

Resources and tools for claims assistance

  • Succeeding in Claims Submissions: Part One [Webinar]
  • Succeeding in Claims Submissions: Part Two [Webinar]
  • Responding to Claim Rejections [PDF guide]
  • How to File an Appeal [PDF guide]

Find answers to the most commonly asked questions to better handle the benefits needs of your patients

  • I was told by my patient that her new benefit plan will not allow coverage if s/he sees an out of network provider. How can that be?
  • The dental insurance carrier will not allow me to increase my fees with their plan. What can the ADA do for me?
  • My patient was paid directly by the dental plan even after he/she authorized assignment of benefits on the dental claim form to my office. What can I do?
  • If I participate with two PPOs, which fee am I allowed to charge the patient? The higher fee, if secondary, or the fee allowed by the primary carrier?
  • The dental insurance carrier changed the procedure code that I submitted on the dental claim form. Is this legal?
  • Even though the dental plan did not cover a certain procedure, the EOB indicated I could only charge the patient the plan’s maximum allowable fee and not my full fee. Can they require this?
  • The dental insurance carrier states that an overpayment has been made to my office and now they are telling me that future payments will be withheld in order to recoup the overpayment. On what authority can they do this?
  • My patient’s claim was denied and the explanation of benefits (EOB) said it was due to a poor prognosis; however, I do not agree with the dental insurance plan's decision. What can I do about this?
  • Dental insurance plan annual maximums have not increased in 50 years. What is the ADA doing about this?
  • I placed a posterior composite on my patient and the plan is only reimbursing for an amalgam restoration. Why am I not being paid for a posterior composite?
  • The dental plan keeps losing my x-rays and it is taking longer to get my claims paid. What can I do?
  • Is sending images captured on a cell phone to a dental plan via text or email a HIPAA violation?