What is the missing tooth clause? 4 questions answered for dentists

What is a missing tooth clause in dental insurance? It’s no wonder dental teams struggle to understand this clause - the fine print within patients’ insurance plans is hard to follow. But for the sake of your patient’s out-of-pocket amount, it’s crucial to know.

Dental Claim Support helps dental teams deliver excellent dental experiences to patients by relieving them of insurance claims work. Through 10 years of service, Dental Claim Support has repeatedly seen the missing tooth clause topic come up among teams. 

And helping dental teams understand insurance terms is also a priority for us because it can affect the relationship with your patient. 

In this article, we will answer the following questions: 

1. What is a missing tooth clause?
2. Why is it important to understand the missing tooth clause?
3. Why is there confusion surrounding the missing tooth clause?
4. How can a better understanding of the missing tooth clause affect your dental practice?

Through this deep dive, your confusion about the missing tooth clause will be cleared up, and you will feel more confident when reading the insurance fine print. This knowledge will help you guide patients in making decisions about their oral health. You will be able to be transparent about what their out-of-pocket could be depending on their missing tooth clause. 

What is the missing tooth clause in dental insurance?

The missing tooth clause is a clause in the dental insurance plan that will not cover any dental treatment that replaces a tooth that was extracted or missing prior to the date the insurance coverage started.  

So if your patient has a tooth removed before their insurance starts, the insurance will not cover any treatment to replace the extracted tooth with a fixed partial denture, removable partial, or implant. 

If there is no missing tooth clause in the patient’s plan, the patient will most likely have insurance coverage for the treatment to replace the tooth. But you still need to check for the following: 

• Waiting period limitations
• Date of eligibility
• Alternate benefits or least expensive alternative treatment (LEAT) towards other less expensive treatments (downgrading).
• Implant coverage/riders
• In and out of network benefits
• Percentages
• Deductibles
• Max allowance and amount remaining
• Benefit year
• Any other plan limitations or exclusions

All of these factors can affect your patient’s out-of-pocket expenses. When verifying the patient's eligibility and coverage details, be sure you have asked the proper questions and be diligent in researching the insurance plan details.  

It seems simple enough - so why is there confusion surrounding the missing tooth clause? We’re glad you asked!

Why are dental professionals confused about the missing tooth clause?

The reason there is confusion about the missing tooth clause is that the patient’s insurance plan may state that the prosthesis is covered at 50%. 

And if the details such as a missing tooth clause are not understood, or missed in the fine print - it can result in the patient paying a considerable amount more than estimated. 

Most practice management software programs cannot estimate the patient’s out-of-pocket properly if a missing tooth clause applies. It is often overlooked and it requires an experienced person who has time to pay attention to additional specific details of the insurance plan; such as clauses, and exclusions. 

Plus, in general, keeping up with dental insurance lingo, terms and abbreviations can be challenging. It changes and updates, which is why we always recommend continuous dental billing education and training for teams. 

Take a course on insurance verification to earn CE credit or many other insurance billing courses by enrolling in Dental Claims Academy.

Why is understanding the missing tooth clause so important for dental teams?

Understanding the missing tooth clause is crucial for your team because the patient’s coverage may include coverage for implants, fixed partials/bridges, removable partials, or dentures. So the missing tooth clause might apply to some of your patient’s insurance plans thus limiting their coverage for replacing a tooth or teeth that were missing.

If a missing tooth clause applies to the patient’s insurance plan, their insurance will most likely not cover the treatment and the patient will pay entirely out of pocket. 

And this can get expensive. As you know, all of the instances we mentioned above where a missing tooth clause may apply - are usually major treatments with a higher cost to the patient.

If the patient had an existing bridge, implant, partial, or denture in place before their insurance coverage began, and they need an old fixed partial denture replaced, then the plan's missing tooth clause should not apply because they had the tooth replaced over ten years ago and you are replacing the fixed partial denture.  

You just need to give the insurance company a narrative for the date of prior placement, the reason for replacement (diagnosis), and prognosis along with x-ray and other supportive documentation as required by the plan. 

Check the details of the insurance plan for dental treatment replacement policies, we see an average of 5 to 10 years on crowns, fixed partials, bridges, etc. 

This can really help out the patient, but knowing to do this requires an understanding of the missing tooth clause and proper billing. Your dental biller should be educated on all of these clauses in the policy and more!

And that’s why it’s so important. 

How can misunderstanding the missing tooth clause affect a dental practice? 

There are two big effects misunderstanding the missing tooth clause can have on the dental practice: 

• Loss in insurance claims revenue
• Loss of patient trust 

When you submit a patient’s insurance claim after you've replaced their missing tooth, and the claim is denied, you are missing that income. You then have to go back and see why the claim was denied, and you’ll notice the missing tooth clause. This is revenue you were expecting to receive but did not. This can hurt the revenue cycle of your dental practice. 

And when the claim is denied it can hurt the goodwill of the practice, specifically with the patient. If the patient realizes they now have a large bill because their insurance actually does not cover the replacement of their missing tooth, they will put the blame on your team. Sure, the patient should understand their own insurance benefits, but they rarely do. 

So it is your responsibility as the oral care provider to try to educate the patient on their benefits, and help the patients use the benefits to their… well - benefit! 

Having patient trust is an intangible asset that contributes highly to the value of a practice. Reputation is vital to a practice's growth and success. 

You never know who is going to get a surprisingly high bill from your office, then give you a low Google rating all due to oversight on the plan’s missing tooth clause that was not taken into consideration. 

You can prevent this from happening if you understand the missing tooth clause, and help patients take advantage of their insurance coverage. This will create a trust that will lead to lifelong patients who refer their friends and relatives to your awesome practice!   

Let experts keep up with complex insurance knowledge while you focus on patients

The missing tooth clause can create confusion due to the different start and stop dates of insurance coverage and that is hard to correlate with when the tooth was extracted or missing. 

Plus it is fine print that can be easily passed over if you are not paying attention to minute details during insurance verification. 

But now you know to look for that missing tooth clause when dealing with an implant, bridge, removable partials, or denture patients. Knowing about this clause and explaining it to your patient can prevent claim denials, but also help your patient strategically use their insurance benefits.