Follow These Tips to Navigate Dental Insurance Claims With Ease

We get dozens of questions every day from dental insurance customers about how claims are processed and how they can save more on their dental costs.

To get a clear understanding, I went to the Starmount director of dental and vision claims Julie Estess. Here’s what she had to say.

When Does the Claims Process Start?

Surprisingly, the claims process can start as early as when you choose your dentist. The key to having lower out-of-pocket fees for dental work starts when you choose an in-network or out-of-network dentist. Generally speaking, you will save more when you visit an in-network dentist. If you can’t find an in-network dentist, call your carrier and ask them to help you find one.

Julie’s insight into finding an in-network dentist:

“Sometimes carriers partner with national networks to provide policyholders and group dental plan members with more options when going to the dentist. However, your dentist may not know that your carrier works through a national network, possibly under a different name from your carrier or carrier’s plan. This can lead to frustration on the part of the member and dentists, so we always recommend our members visit our provider lookup site or call us directly.”

In most cases, your routine dental exam will be covered in full. However, your dentist may tell you that you need to have some repair work done. That’s when the claims process starts to affect you most.

The expert’s advice for starting the claims process:

“Different carriers may have different requirements for submitting a claim. Make sure your dentist is following your carrier’s requirements. A good example of this would be if a bridge is being done, the provider should submit x-rays and provide numbers of all missing teeth in the arch.”

What Should You Do After Your Dentist Recommends Repair Work?

Dental repairs can range from having cavities filled to having teeth extracted and replaced with implants, among others. Most likely, your dentist will have you schedule a follow-up appointment to have this work done. For some major services, you may even be referred to a specialist.

No matter what the procedure, be sure to ask what the procedure will cost. If it’s more than you can afford without coverage, you should ask for a pre-treatment estimate, so you can move forward with confidence.

Julie’s tip on major procedures: “If a procedure costs $300 or more, be sure to ask for a pre-treatment estimate. Your dentist should be able to request one for you from your carrier. It is recommended that your provider submit x-rays and/or periodontal charting for faster turnaround time on processing.”

What Should You Do if You’re Referred to an Out-of-network Specialist?

You may find that your dentist refers you to a periodontist, oral surgeon or endodontist that isn’t in network. This is often because specialists thrive off of referrals and don’t wish to partner with carriers. This doesn’t mean, however, that you won’t receive any benefits from your coverage. For many dental insurance plans, your carrier will pay the provider the in-network rate and you will pay only the difference.

Here’s a pro tip for seeing a specialist: “Be sure to check your Alternate Benefit Provision before agreeing to have any major work done, as these could impact your claim. And if the specialist is out-of-network, refer to your policy to see how out-of-network charges are handled.”

What Should You Expect Once the Procedure Is Done?

In the unlikely case where your out-of-network dentist requires you to pay the bill upfront, preventive claims can take up to 15 days to process. Major claims can take up to 25 days to process and complete. Also, most carriers will offer you tools that allow you to track your claims.

Julie’s advice: “The key to this process is to be in control of your own destiny. Ask questions to know what you’re having done and why. That way you know what’s coming and can prepare ahead of time—mentally and financially.”

Why Would Your Claim Be Denied?

There are several factors that could lead to a claim being denied. Some examples include if an Alternate Benefit Provision was listed in your policy that was overlooked, a Missing Tooth Clause in the case of implants, or perhaps a procedure that goes against the American Dental Associations standard practice guidelines.

Advice Julie provides: “Be sure to ask questions and be your own advocate. For example, if your dentist tells you that you need a build-up and a crown, ask if it’s medically necessary or precautionary. This can give you an idea on whether or not it will be covered.”

The key to ensuring this doesn’t happen to you is to stay ahead of your claims by understanding what type of treatment and care you’re agreeing to.


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