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Denied dental insurance claims can feel like a major roadblock – especially when you are counting on that coverage. Whether your claim was denied for something routine or a more complex procedure, you don’t have to accept the decision right away. This guide walks you through the steps you can take to understand, dispute, and formally appeal a denied claim and what to do if the appeal doesn’t succeed.
Denied claims can often be reversed with persistence and documentation. And if coverage can’t be recovered, there are still ways to save on the care you need like exploring a dental savings plan to reduce your out-of-pocket costs.
Step 1: Understand Why Your Claim Was Denied
Start by carefully reviewing the Explanation of Benefits (EOB) that your dental insurance provider sent when you purchased the plan (the EOB may also be available online, on your provider’s web site. Check your account section). This document outlines what is covered, what isn’t and any restrictions that impact your coverage.
Look for the denial reason code or a short explanation of why the claim was denied. Common reasons for denial include:
- Services not covered under your current dental plan.
- Missing, incorrect, or incomplete documentation.
- Claim submitted outside the allowed time frame.
- Pre-authorization required but not obtained prior to treatment.
Understanding Insurance denial codes
Also called claim adjustment reason codes (CARCs) or explanation codes—are generally standardized to a degree, but they can also vary by insurer and plan.
1. Standardized Codes (e.g., CARCs):
Most insurance providers use standard codes established by theCenters for Medicare & Medicaid Services (CMS) and managed by the Washington Publishing Company (WPC). These codes are part of the HIPAA transaction standards and are typically used in electronic claims processing. Examples include:
Common Dental Insurance Claim Denial Codes
| Code | Meaning | Common Cause | What You Can Do |
|---|---|---|---|
| CO-16 | Claim/service lacks information or has billing errors. | Missing tooth numbers, dates, or documentation like X-rays. | Ask your dental office to correct and resubmit the claim with complete info. |
| CO-50 | Not deemed medically necessary. | The insurer believes the procedure was cosmetic or elective. | Submit a letter of medical necessity from your dentist with clinical evidence. |
| CO-96 | Non-covered charge(s). | The service isn’t covered under your specific dental plan. | Confirm coverage in your benefits handbook; consider appeal or DSPs. |
| CO-97 | Payment adjusted because this procedure is included in another procedure. | The insurer sees the procedure as part of a bundled service. | Ask the dentist to itemize services or appeal if both should be billed separately. |
| CO-109 | Claim/service not covered by this payer/contractor. | You may have sent the claim to the wrong insurer. | Confirm correct insurer for your plan and resubmit if needed. |
| CO-119 | Benefit maximum for this time period or occurrence has been reached. | You hit the annual dollar limit or frequency limit (e.g., 2 cleanings/year). | Wait until the next benefit period or consider a dental savings plan. |
| CO-125 | Submission/billing error. | Incorrect CPT or CDT code, mismatched patient info. | Have your dental office review and fix the submission. |
| CO-B10 | Allowed amount has been reduced because a more appropriate code was billed. | The insurer “downcoded” to a less expensive procedure. | Appeal with detailed clinical notes and original coding rationale. |
| CO-A1 | Claim denied for lack of authorization. | Pre-authorization required but wasn’t obtained before treatment. | Request retroactive authorization or appeal with a letter of explanation. |
| DENY-PRAUTH (proprietary) | Pre-authorization not obtained. | Internal code used by many insurers for unapproved pre-treatment. | Contact insurer to see if retroactive review is possible. |
| EXC-FREQ (proprietary) | Frequency limitation exceeded. | Too many visits in a calendar period (e.g., fluoride or X-rays). | Confirm your plan’s limits and appeal if medically justified. |
It’s important for patients to:
- Read the full description next to the code in the EOB.
- Call the insurance provider if the code or reason isn’t clear.
- Request clarification in writing when preparing an appeal.
Understanding the specific reason for the denial will help you decide whether it can be resolved quickly or if a formal appeal is required.
Contact Your Dental Office and Insurance Company
If the denial seems confusing or potentially incorrect, your next step is to reach out to both your dental provider and insurance company.
Start with your dental office’s billing department. Ask them to:
- Double-check the claim submission for accuracy.
- Resubmit the claim if a coding or clerical error occurred.
- Provide any documentation that may have been missing the first time.
Next, call your insurance provider’s customer service team. Be prepared to ask:
- What specifically triggered the denial.
- Whether new or corrected documentation can resolve the issue.
- If the claim can be reprocessed without filing a formal appeal.
This step often clears up minor issues and prevents the need for a more time-consuming appeal process.
Prepare to File a Formal Appeal (If needed)
If the informal review doesn’t resolve the issue and your claim remains denied, it’s time to formally appeal. This involves submitting a written request to your insurance company asking them to reconsider.
Start gathering the following documentation:
- A copy of your denial letter or EOB.
- Dental records related to the denied treatment.
- A letter of medical necessity from your dentist explaining why the procedure was important for your health.
- Any other correspondence or supporting materials.
Review your dental insurance policy or member handbook to check:
- How long you have to file an appeal (usually between 30 and 180 days).
- What forms or documents are required.
- Where and how the appeal should be submitted (by mail, online, or fax).
Write and Submit Your Appeal Letter
The appeal letter is your opportunity to clearly and professionally make your case. It should include:
- Your name and policy ID number.
- The date of service and treatment codes.
- A detailed explanation of why you believe the claim should be approved.
- Supporting documents such as provider notes, X-rays, and any pre-approvals if applicable.
Make sure to follow your insurer’s appeal instructions exactly. Send your appeal via certified mail or through your provider’s designated online portal, and always keep copies of what you submit.
Follow Up and Track the Appeal Status
Most insurers must respond to a formal appeal within a set period—typically 30 to 60 days. Stay proactive and check on your appeal by:
- Logging into your insurer’s online portal.
- Calling the member services line and asking for updates.
- Documenting all interactions and follow-up communications.
If the appeal is denied again, don’t give up. Some policies allow for a second-level internal appeal, and many states permit an independent external review conducted by a third party. If your plan is employer-sponsored, you may also have extended rights under ERISA (the Employee Retirement Income Security Act).
Special Considerations and Alternative Options
There are additional strategies that can improve your chances of a successful appeal—or help you manage costs if your appeal is denied:
- Enlist your dental provider’s support. They can submit extra documentation or participate in peer-to-peer reviews with your insurer to clarify the medical necessity of your treatment.
- Check your appeal rights under federal and state laws. Employer-sponsored plans may have additional protections and review procedures.
- Consider a dental savings plan. These plans offer discounts of 10% to 60% on dental services at a nationwide network of participating providers, with no waiting periods or annual spending caps. There are no claims to file, you simply pay the discounted rate directly to the dentist.
Winning Dental Insurance Claim Denials
Claim denials can be frustrating but they don’t have to be final. By understanding your denial, gathering the right information, and communicating clearly with both your dental office and insurance company, you may be able to reverse the decision. And if your appeal is ultimately unsuccessful, you’re not out of options.
Dental savings plans offer an immediate, flexible alternative for patients facing uncovered costs. You don’t have to postpone or skip care because of a denied claim. And – as noted above – you’ll never have to fight a claim denial with a dental savings plan, since you never need to file claims. Explore dental savings plans on DentalPlans.com to find immediate discounts that can help manage your dental care costs. Plan members report an average savings of 50% on their annual dental costs. Use the calculator below to see how much you can save with a dental savings plan.
