How to Win Dental Insurance Appeals

Winning Dental Insurance Appeals

As dental professionals, we have a duty to fight for our doctors and their patients to collect as much reimbursement as possible from insurance companies. It’s a chess match, but two can play this game and you can win dental insurance appeals.

It’s a fact, insurance companies work to deny procedures and release the lowest amount of reimbursement possible, period. Among the many downgrades, alternate benefits, and exclusions to your patients’ policies, sometimes procedures are just downright denied that shouldn’t be. You should have read the fine print, am I right?

Here are a few tips to ensure You Win your dental appeals battle.

1. Give the insurance ALL the information you have for a specific claim

When trying to avoid the need to make appeals, give the insurance as much info for a claim as possible. This will cut down on the denials. However, claims may still be denied due to lack of evidence. There are times when an x-ray and narrative aren’t enough. X-rays can’t see what the naked eye can. Utilize detailed narratives and intraoral photos to give as much evidence as possible as to why the procedure was performed.

2. Have a list of appeal information for each insurance: addresses/emails/faxes etc.

Every insurance is a bit different regarding their appeals process. This, of course, is another way to make appeals difficult and for offices not to follow through with the process.

For example, some insurances want a new claim with additional info. Some want the original EOB accompanied with additional info. Some want the new claim and/or original EOB sent to a different PO Box than where normal claims go to. Some want them sent through their web portal.

Gathering this information for each insurance company and cataloging it will shorten the time needed to submit each appeal.

3. Have appeal templates ready for submission

Many of the same procedures are denied or downgraded. Have an appeal template for each type of procedure ready and on deck to save time and be efficient. Switching out a patient’s name and claim number and providing additional information specific to that patient is quite easy if your template is already in place.

4. Don’t accept NO for an answer

The majority of offices don’t follow through on claim research and will accept from insurance what they are given. Most of the time, the first appeal will overturn the original decision and benefits or even extra benefits will be paid out. When working through denials, no pays, and your insurance aging report, if you don’t agree with the decision, appeal it! Do not let insurance dictate your dentistry.

5. Make sure you have your patients’ best interests at heart

For patient retention, professionalism and image, it’s ALWAYS best to collect as much as possible from insurance and leave as much as possible in your patient’s pocket without hurting your own. Patients recognize when an office or dental billing company is fighting for them and keeping their best interests at heart.

BONUS – common reasons why claims are denied and how to win the appeal:

  • Fixed Partial Denture (bridge)- Some insurances downgrade and pay on a removable partial denture- Send in a simple narrative appeal as to why the fixed partial denture was selected over the removable. This will overturn the downgrade.
  • No pay on Buildups- Some insurances, such as Cigna, only need a seat date and if a crown is an initial or replacement. Call and give it to them or send in the info with the denial claim number.
  • No Evidence to support the need for Crowns- Was the majority of tooth compromised? recurrent decay under existing restorations? Fracture lines!! An x-ray isn’t always good enough. Utilize your intraoral photos and detailed narratives to get these denials paid
  • Timely filing- Show evidence from your clearinghouse that claim was submitted. This info can be sent to the insurance with the denial EOB for reprocessing
  • Missing tooth clause- does not apply if an employer switched from one insurance to the other and evidence can be shown that the tooth was extracted while the employee has been employed with the same employer and has always had insurance


– Josh Smith

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