Are​ ​Dental​ ​Benefits​ ​Available​ ​for​ ​my​ ​Crown?

November 3, 2017

When a new patient calls your office to schedule an appointment, one of the first questions asked is whether dental insurance will be considered as part of the payment for services. The focus is on whether dental benefits are available for the eligible patient.

Plan benefit information is available online for contracted providers or by phone or fax. However, experienced dental business staff understand that benefit statements can be misleading, as many services listed as covered may not be paid when submitted.

Why Listed Dental Benefits Are Often Not Paid

Many dentists become frustrated fighting PPO insurance plans for reimbursement on claims they believe represent legitimate, warranted services. In reality, payment decisions are based on the payer’s processing policy rather than whether dentistry is deemed professionally necessary.

Claims for dental procedures are processed according to the limitations and exclusions established by the plan document and enforced through the processing policy manual.

Understanding PPO Processing Policies and Plan Limitations

Many dentists sign PPO contracts without carefully reading the PPO Processing Policy Manual. Understanding the intended language of the dental plan contract and processing manual should be required for all employees involved in claim submission and procedure processing.

While dentists often receive benefit summaries, patients can obtain the full plan document through their HR department or directly from the payer and share it with the dental practice.

Processing policy manuals are typically available through the provider relations department or, in some cases, on the plan’s website.

Why Appeals Matter (Even When They Feel Futile)

Filing appeals can be a long and often frustrating process, but it is always recommended to appeal a denial and inform the patient that the practice is actively working to resolve the claim.

In some cases, insurance companies will review claims and allow benefits on a case-by-case basis.

Case Example: Crown Coverage on an Implant

A claim was submitted for a patient receiving a crown on an implant. This was an initial placement crown, as the tooth had been extracted and did not previously have a crown.

The insurance company repeatedly denied the claim, citing frequency limitations and stating the crown had already been paid. The patient disputed the bill and withheld payment.

After further investigation and escalation to a supervisor, it was discovered that the crown had been paid — but to the surgeon who placed the implant, not the restorative dentist who completed the work.

The restorative dentist was ultimately reimbursed by the surgeon, resulting in a successful resolution

Key Takeaway for Dental Practices

Dental practices are far more successful navigating reimbursement when they verify patient eligibility, review plan limitations and exclusions, and clearly communicate these details to patients before beginning treatment.

Need Help Navigating PPO Claims and Denials?

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