Dental Insurance Frequently Asked Questions

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.

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Streamlining Claim Submissions [Webinar]

Many concerns reported to the ADA by dental offices are claim denials and requests for additional information.

Succeeding in Claims Submissions: Part One [Webinar]

Succeeding in Claims Submissions: Part Two [Webinar]

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Find answers

Browse our claims assistance tools and answers to commonly asked questions.

Resources and tools for claims assistance

Dental Insurance Guides

When a dentist signs a participating provider agreement, they agree to abide by the dental plan’s processing policies. Download the following documents to gain a better idea of common scenarios related to claim rejections from third-party payers.

Responding to Claim Rejections [PDF guide]

Responding to Claim Rejections

Making sense of claim rejections from third-party payers can be a little frustrating at times. With the onslaught of patients using new consumer-directed employee benefit plans, knowing how to correctly code procedures and responding to claim rejections has become even more important.

Navigate the sometimes complicated world of claim rejections with this special guide. The guide covers the following topics:

  • Common Claim Denials
  • Preventing and Resolving Errors
  • Cost Containment Features
  • Coordination of Benefits (COB)
  • Provider Contract Issues
  • Explanation of Benefits (EOB) Language
  • Electronic Claim Submissions
  • How to Receive Assistance
  • ADA Resources

How to File an Appeal [PDF guide]

How to File an Appeal

When a patient's claim is denied by a third party carrier, exhaust all reasonable avenues for resolution. This means using all levels of appeal and make sure that all supporting documentation is included with the claim. This document provides briefs tips to appropriately file an appeal.

Introduction to Dental Benefits [PDF guide]

Introduction to Dental Benefits

Chances are, a fair amount of the time you spend at your practice each week has very little to do with your clinical training and everything to do with your patient's dental benefits plans. There are multiple types of dental plans such as PPOs, DHMOs, indemity plans, and point of service plans. This document discusses the differences between various types of dental benefit plans.

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?
Your patient may be covered under an emerging model of benefit plan, called an exclusive provider organization (EPO).

A preferred provider organization (PPO) is a managed care plan combined with a network of dentists under contract to the third party carrier to deliver specified services for set fees according to the provisions of the contract. Traditional PPOs pay a percentage of the maximum allowable fee to the contracted dentist. EPO plans are very similar to PPOs but require that patients use only participating dentists for services covered by the plan (these are also referred to as “closed panel plans”). In EPO plans the patient will need to bear all costs of care if they choose to go to an out-of-network dentist, whereas in a PPO the patient may incur greater out of pocket costs but would still receive a benefit. There is no benefit payable to an out-of-network dentist under an EPO plan. While such closed panel plans have typically been used by DHMOs they are now starting to gain popularity with PPOs as a mechanism to control costs.

Dentists should be prepared to talk to patients about the repercussions of these types of closed panel plans. For example, does the patient understand that they will not be able to receive a benefit from their dental insurance plan if the patient sees an out-of-network provider? Do they further understand that the patient is responsible to the dentist for the dentist’s full fee? It is always a good idea to have your patients discuss any kind of concerns about their dental plan with their human resources department, especially before the employer makes a decision to switch the type of dental plan offered to its employees. Dentists can refer patients to Types of Dental Plans for basic information on varying kinds of dental benefit plans.

The dental insurance carrier will not allow me to increase my fees with their plan. What can the ADA do for me?
Federal anti-trust laws prevent the ADA from negotiating fees on behalf of dentists; however, dentists are free to negotiate fees on an individual basis. The ADA legal division has information on anti-trust concerns available to members.
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?

Staff has been working with state dental societies to pass assignment of benefits legislation aimed at preventing this exact scenario, and we are aware of 23 states that have passed such legislation. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance.

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?

Many factors can determine what fee a doctor can charge in this situation, including but not limited to state insurance statutes, participating provider agreements and the carriers processing policies. It is recommended that you check with the carriers to determine what fee you are ultimately allowed to bill the patient. You should also check with your state dental society to determine if there is legislation in your state that addresses which fee should be allowed.

The dental insurance carrier changed the procedure code that I submitted on the dental claim form. Is this legal?

There is an important distinction between changing the submitted procedure code and paying for a different procedure code based on the plan’s design and processing policies. It is not uncommon for third-party payers to acknowledge the code submitted, but to then pay an alternate benefit. They are allowed to do this. What they cannot do is substitute a different code without acknowledging the original code submitted. You should submit the procedure code(s) that most accurately describes the procedure performed. Any pressure from a payer for you to submit a different code other than the one that most accurately describes the procedure you performed, in order to conform to their payment policies, should be aggressively resisted. Additionally, if you feel the claim was not properly adjudicated, you should appeal the decision.

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?
If you signed a participating provider agreement with a dental plan that has this provision, and there are not state statutes in your state to prevent it, then you may be contractually bound to only charge the patient the carrier’s maximum allowable fee for the non-covered procedure(s). ADA staff has been continually working with state dental societies on non-covered services legislation and 40 states have passed legislation preventing third party carriers from capping what a dentist can charge a patient for a non-covered service. This means that the dentist could charge his or her full fee in the above scenario. If your state has not passed this type of legislation, it is recommended you contact your state dental society for assistance.

You may encounter situations in which a payer will allow you to charge your patient for non-covered procedures if the patient is willing to sign a consent form. The ADA has created a sample form for third party payer payment (PDF) that you may customize to meet your particular needs.

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?

If you have signed a participating provider agreement with the dental plan, you may have contractually agreed to this. Please check the provisions of your signed provider agreement. If you are not in-network with the plan, please check with your constituent dental society for information on how this may be handled in your state. The ADA is currently working with dental insurance plans to find an equitable solution.

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?
Sample letters that dentists can use to send to dental insurance plans and employers regarding dental services that the carrier does not consider necessary are available for members to use. In addition, it is highly recommended that you appeal the decision in writing and be sure you supply any additional information that would help explain the rationale for providing the service and why it is in the patient’s best interest to have this procedure done. This type of response from a payer may be inappropriate based on the amount of information they have at their disposal. The ADA has more information on how to properly file an appeal.

Dental insurance plan annual maximums have not increased in 50 years. What is the ADA doing about this?

Although the ADA has no authority over dental plans to increase annual maximums, for years it has advocated for annual maximums to keep pace with the cost of living and recent surveys are starting to show increases. In 2016, 89% of plans where patients saw a network dentist, had maximums ranging from $1,000 - $2,500 – up from 79% in 2011.

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?

This happens for purely economic reasons and to lower the amount a carrier has to pay on a claim. This is usually based on the benefits purchased in a given plan to keep the cost of the plan down. If you are a non-participating dentist with the plan, you may bill up to your full fee. If you are a participating dentist, please check with the carrier for the amount you can bill the patient. If you feel the claim is not being adjudicated correctly, it is recommended you appeal the decision with the carrier.

The dental plan keeps losing my x-rays and it is taking longer to get my claims paid. What can I do?

If you participate with the plan, it is recommended you contact your provider relations representative for assistance. If you are a non-participating dentist, it is a good idea to call the carrier to find out what happened to the radiographs you sent. It is recommended that you send duplicate radiographs to the carriers and not your originals as some carriers may not return the radiographs to your office. It is ADA policy (Guidelines on the Use of Images in Dental Benefit Programs (Trans.1995:617; 2007:419) that all images submitted to third-party payers should be returned to the treating dentist within fifteen (15) working days, but unfortunately that is not binding on payers.

Is sending images captured on a cell phone to a dental plan via text or email a HIPAA violation?

Potentially, yes. A dental practice risks a breach of patient confidentiality whenever it sends unsecured electronic protected health information over an open network. A dental practice must also consider the risks associated with storing ePHI on a device that can be lost or stolen.

Sending unsecured images and text over a cellular network is a violation of HIPAA Security Rule requirements for transmission security if the dental practice has not:

  • De-identified the information; OR
  • Done a risk analysis of its transmission security, AND
  • Implemented appropriate safeguards; OR
  • Has not obtained written authorization from the individual to send the information in an unsecured manner. CAUTION: written authorization must include the individual’s acknowledgement of any risk to their privacy. The Acknowledgement of Receipt of Notice of Privacy Practices form signed by new patients does not grant authorization for sending unsecured ePHI.

So the answer is "maybe." To avoid a breach a dental practice must be mindful of the following:

  • What the dental practice is sending?
  • How it is being sent?
  • What safeguards are in place, and are the safeguards reasonable, based on a current risk analysis?
  • If the information is not being sent in a secure manner, has the patient authorized and instructed this transmission in full knowledge of risks?

The dental practice must employ appropriate safeguards for data “in motion” where appropriate. Some examples of transmission methodologies that might work include, but are not limited to:

  • A secured payer web portal that permits uploading of images by trusted users
  • An encrypted email service
  • A health care image sharing app that employs sufficiently strong transmission encryption
  • A Direct Trust validated Health Information Service Provider

Another, far greater risk is the threat of loss or theft of the cell phone itself, especially if it stores images on its memory card that are not encrypted.

Lost or stolen unsecured devices are a major cause of large breaches affecting thousands of individuals. In turn these breaches result in complaints and expensive, highly publicized settlements and sometimes levied federal civil monetary penalties. No dental practice wants this.

Using personal phones without appropriate security features is extremely risky and could be ruinous if lost or stolen. As such, it is HIGHLY inadvisable to use a non-dedicated, unsecured cell phone or unsecured app that does not also encrypt images stored on the cell phone’s memory card or in the phone’s cloud-based storage. If a secured phone is lost or stolen, the encryption can still provide safe harbor against breach notification requirements, provided it conforms to methodologies named in the HITECH Breach Notification Rule’s Safe Harbor provisions.

If a secured, encrypted phone or app is used in your dental practice, make sure the encryption algorithm and strength have been independently tested and validated for conformance with HHS Guidance.