Insurance

Question 1

Claim

Answer 1

A formal request made by a dental practice or patient to an insurance company for payment or reimbursement of covered dental services

Question 2

What is the claim process?

Answer 2

Service provision: The dentist performs a dental procedure or provides a service to the patient.

Claim submission: The dental office submits a claim to the patient’s insurance company, detailing the services provided, including specific procedure codes and charges.

Claim processing: The insurance company reviews the claim to verify coverage, ensuring the service is covered under the patient’s policy and that all necessary information is provided.

Claim evaluation: The insurer assesses the claim based on the patient’s policy terms, coverage limits, and any applicable deductibles.

Payment decision: The insurance company either approves the claim and issues payment, or denies it with an explanation.

Payment distribution: If approved, the insurance company typically pays the dental office directly, though in some cases, the patient may receive the payment and then pay the dentist.

Patient responsibility: The patient is responsible for any portion of the bill not covered by insurance, such as copayments, deductibles, or services exceeding coverage limits.

Question 3

Appeal

Answer 3

A formal request for reconsideration of a claim that has been processed and denied by the insurance company (typically an email with the rendering provider’s signature)

Question 4

What is the process for submitting an appeal?

Answer 4

1. Reviewing the denial reason on the Explanation of Benefits (EOB)
2. Gathering supporting documentation
3. Writing an appeal letter
4. Submitting the appeal to the insurance company

Question 5

What are common reasons for appeals?

Answer 5

1. Timely filing issues
2. Downgrades in coverage
3. Alternate benefits applied
4. Medical necessity denials
5. Any incorrect denials