Looking for ways to help your dental patients cover the cost of treatment? Many patients’ dental insurance doesn’t cover all the care they need. In fact, about 60% of dental preferred provider organizations (PPOs) have a maximum annual benefit of $1,500 or more, according to the National Association of Dental Plans. Submitting claims to medical insurance, when appropriate, can stretch their coverage and make essential care more affordable.
That’s why learning how to submit medical reimbursement claims is so important. More procedures qualify for medical billing than many dentists realize, and not submitting them can mean missed reimbursements for patients and lost revenue for the practice. Since the process can be confusing for teams accustomed to dental billing, this resource breaks it down with practical tips to simplify claims, improve collections, and avoid common mistakes.
Why Medical Dental Billing Matters
To submit medical claims for dental work successfully, it is essential to understand the difference between medical and dental billing.
“Medical insurance pays for medically necessary treatment, meaning a medical condition is either manifesting itself in the oral cavity, or the condition of your oral cavity is making your medical condition worse,” says Kimberly Pajak, CPB, Director of Internal Education/ Global Operations Project Manager/ Medical SME at eAssist Dental Solutions.
Dental insurance generally covers preventative care, such as cleanings, exams, and X-rays; basic care, including fillings and extractions; and restorative care, including crowns, root canals, and dentures. In some cases, dental plans cover orthodontics or implants.
A good rule of thumb is to save dental insurance for things that medical insurance won’t pay for, says Pajak. Let’s say a college student needs to have impacted wisdom teeth pulled. “If you send their entire claim to dental, that’s going to wipe out their dental for the whole year,” says Pajak. “How likely are they going to be to come back for exams and cleanings? If that patient has medical coverage for those impacted wisdom teeth and the IV sedation, then medical pays for that service, and dental gets saved for the things medical wouldn’t pay for.”
Despite the advantages, many practices fail to capture revenue from what could be successful medical claims due to the complexity of billing.
Common Mistakes in Dental Billing
By avoiding common mistakes, it’s possible to increase reimbursement rates for medical billing.
Incorrect coding
Confusing dental codes with medical codes can lead to denied claims, so it’s essential to understand which ones to use. Dental billing utilizes CDT codes, whereas medical billing requires both CPT codes and ICD-10 codes. A dental medical claim must include a primary diagnosis code. “The primary code is always going to be the main reason the patient comes to you,” says Pajak.
Lack of documentation showing that a procedure was medically necessary
Unlike dental billing, medical billing requires detailed written explanations of medical necessity to support claims. “When you get into medical billing for dentistry, you are following medical rules,” Pajak explains. “Your chart notes must be medical quality, which most dental chart notes are not.”
The acronym SOAP, short for subjective, objective, assessment, and plan, is a good way to remember the elements your claim must include. The subjective section lists the patient’s chief complaint. The objective narrative explains what the dentist observes in the patient’s mouth. The assessment connects a patient’s complaints to the diagnosis. Finally, the plan usually includes three options for care.
Taking detailed chart notes during each visit can streamline the submission of medical claims. To write up notes correctly for a diabetic patient, for instance, be sure to ask if the diabetes is controlled or uncontrolled and if the individual takes insulin so you can include this information in a medical claim, says Pajak. It is then essential to use the correct diagnosis codes. “If a diabetic patient with periodontal disease needs scaling and root planing, there is a specific diagnosis code for Type 1 and Type 2 diabetes with periodontal disease,” says Pajak.
Or, with a patient who has had a cancer diagnosis, ask what type of cancer it was, if they are in remission or active treatment, and if so, if they are undergoing chemotherapy, radiation, or both. It is then essential to describe the effects of these medical conditions on the oral cavity in the chart notes and claim.
- Not verifying medical benefits: Many dentists assume dental coverage is the only route to reimbursement, so they don’t verify procedures with the patient’s medical insurance upfront. That can result in reimbursements if you later discover that their medical plan would have covered a procedure.
- Missing pre-authorization: This can lead to avoidable denials. “For medical claims, if a pre-authorization is required, you must do it before you perform the service, or they’ll deny your service,” says Pajak. “There’s often no retroactive authorization.”
- Improper claim forms: Using dental forms isn’t acceptable to medical providers. Submit all medical claims on CMS-1500 to avoid claim denials.
Best Practices to Avoid Errors
To ensure the best possible reimbursement rate, here are some best practices to embrace:
Train your staff to verify medical eligibility up front
Make medical insurance verification a part of the check-in process for patients. Make sure to ask if a treatment under a given code is covered, if it requires prior authorization, and if there are any plan exclusions—for instance, coverage for implants is often limited to cases of accident or injury.
Learn which procedures qualify for medical reimbursement and standardize documentation
Many oral procedures involving structures outside the tooth, such as the jawbone, periodontal structures, and oral hard and soft tissues, may be covered by a patient’s medical plan, according to a report by the American Association of Pediatric Dentists.
These include:
- Procedures for traumatic injuries to the mouth, such as endodontic, removable or fixed prosthetic procedures, as well as wiring, splinting and fixation of the teeth and jaws, and treatment of fractures.
- Exams and consultations are performed to prepare for a surgical procedure such as periodontal surgery, implant reconstruction, or extraction of impacted teeth.
- Exams performed to diagnose hard or soft issue pathological lesions
- Emergency treatment of periodontal abscesses, incisions and drainage, and mucosal alterations, like canker sores.
- Stents and guides are used to place and position dental implants
- Diagnostic radiographs
- Biopsies and excisions
- Extractions of impacted teeth
- Surgical procedures involving bone atrophy or infection, such as periodontal and implant surgery, bone and connective tissue grafts, and anesthesia used in the procedures
- Oral prosthetics for traumatic injuries
- Oral appliances for bruxism, temporomandibular joint dysfunction, sleep apnea, and sometimes palatal expansion.
Utilize proper CPT and ICD-10 coding, along with detailed narratives
This begins with keeping detailed notes on the patient’s complaints, diagnosis, and treatment plan, along with the reasons why it’s medically necessary. As Pajak explains, “With medical billing, it’s not what you’re billing, it’s why you’re billing it.” She adds, “Providers often ask what services are covered under medical insurance. I often say ‘everything,’ as long as you have a medical reason to send it to the medical insurance.”
Track authorizations and appeal denials consistently
“My recommendation is using a spreadsheet and checking it daily or at least twice a week,” says Pajak. “Be consistent with your follow-up dates and have somebody responsible for the follow-up process.”
Leverage specialized billing support
Outsourcing can streamline medical and dental billing by reducing errors, speeding payments, and improving cash flow. This is where a partner like eAssist can help.
How Outsourcing Simplifies Medical Dental Billing
eAssist supports practices with two specialized services: Advanced Medical Billing and OMS Specialty Billing. Both services provide access to specialists trained in CPT, ICD-10, and cross-coding, using proven processes to minimize denials and maximize reimbursement. In addition, eAssist helps register dental offices with medical providers so insurance companies can recognize them properly.
Instead of leaving medical reimbursement on the table, eAssist helps practices capture it with confidence. Meanwhile, outsourcing frees dental staff to focus on patients rather than paperwork.
“Most offices are not necessarily equipped to follow up on their dental claims,” says Pajak. “Then the follow-up process for medical billing can make that problem more difficult. By outsourcing medical billing, they could have a dedicated team that does their pre-authorizations and follows up on their claims.”
Take Action Today
Medical dental billing doesn’t have to be overwhelming or a source of lost revenue. With the right systems in place or the right partner, practices can unlock new revenue streams, help patients afford treatment, and enhance their financial stability.
If you’re ready to simplify medical and dental billing and start getting paid for the procedures you’re already performing, schedule a free consultation with eAssist today.
