Claims Denial

What should you do about an INSURANCE DENIAL?

Believe it or not, you and your employer are the best advocates in problems related to insurance coverage. Our business office staff spends a great deal of time getting insurance companies to honor their obligations to you, but we have very, very little “pull” in the process. 

When we offer to help you by filing your insurance, it is simply a courtesy because we know how complex and time-consuming it can be to manage as a lay person. Very often the insurance companies do not respond or defer to our professional judgment, even when multiple X-rays, photos and letters have passed between us. There are times when you have the power to hold the insurance companies accountable.  If you have a legitimate complaint, your human resources person should know about it, in detail and they should help you as an advocate. The insurance companies will want their business contract renewed next year, so it behooves them to be responsive to your employer’s inquiries.

If all else fails, ERISA (the Employee Retirement Income Security Act) is a federal law that protects employees by setting standards for those who are administering insurance plans. It requires that insurance companies have a fair and reasonable process for handling claims.

If you have a dental problem that should be covered, but has been rejected, here are the steps to take:

1.    Obtain a copy of your SPD (Summary Plan Description). This gives you a detailed summary of your plan and rules the insurance company must follow about how long they can tie up a claim without decisions. It also tells you how you can appeal if your claim is denied. If you would like to come in and have our office manager “translate” the complex document for you, we are happy to help.

2.    Appeal the claim.  Again, a prescribed time period must be adhered to.

For further information on patients' rights you can call the Benefits Administration toll free hotline at 866-444-3272.

Bottom-line: When certain insurance companies are involved, the squeaky wheel really is the one that gets the grease. Our influence with your insurance company is very limited. In the end, the insurance company cares a lot more about keeping you and your employer happy, than they care about working things out with the dentist.