Is the Insurance Carrier Really Obligated to Pay a Claim?

No, they are not unless you have satisfactorily proven that they are contractually obligated to do so.  Many dental claims are denied not because they shouldn’t be paid but because they are not submitted correctly.  The insurance companies are not there to correct errors or fill in omissions; they are there to reject those claims as unpayable.

The dental insurance carrier is not liable to pay unless:

•         The patient’s plan was in force at the exact date services were performed.  If the employer or the policyholder has not paid the premium, no payment will be made regardless of the patient’s membership card.
•         The person who received care under the insurance must be a beneficiary of the plan.  Custody issues, divorce or student status can complicate this issue.  If there is more than one policy in effect, primary responsibility has to be established prior to billing.
•         The services that are performed must be covered benefits under the plan.  If the placement of a dental implant is not a covered benefit, no amount of narrative is going to change the payment.
•         Proper documentation to prove the diagnosis and the choice of treatment must be conveyed on the claim or you will be denied.  Sometimes the information necessary is more than the usual but the insurance company rarely gives details.  Phone call follow-up is tedious and often time consuming.
•         Claims must be submitted within the statute of payment limitation.  Some policies will not honor payment after 3 months, some at 6 months and some at 12 months.  The appeal process on these claims takes diligent follow-up that can take several weeks to months.
•         The accuracy of claims is crucial.  Answer all questions including gender, date of birth, policy holder, policy holder identification and relationship to subscriber.  All documentation must be labeled correctly and narratives must be legible and use proper grammar.  CDT coding on claims must match the narratives and the treatment rendered.  Without this information, claims will be denied or returned for “further attention.”