Most dentists file claims directly. For out-of-network or self-filing, complete a claim form with procedure codes, dates, and costs. Submit with itemized receipt.
Standard claims processing takes 10-30 days. Clean claims with complete information process faster. Complex claims or those requiring review take longer.
An Explanation of Benefits (EOB) shows what was billed, what insurance paid, adjustments made, and your remaining responsibility. It is not a bill.
Common denial reasons: service not covered, waiting period not met, annual maximum reached, missing information, procedure deemed not necessary, or out-of-network provider.
Request denial reason in writing, gather supporting documents (X-rays, dentist notes), write appeal letter explaining medical necessity, submit within deadline (usually 60-180 days).
Pre-authorization (predetermination) is advance approval from insurance showing covered amount before treatment. Recommended for work over $200-300.
Predetermination is a detailed estimate from your insurer showing exactly what they will pay for proposed treatment. It helps avoid surprise costs.
With in-network dentists, they bill insurance directly and you pay your share. Out-of-network, you may pay upfront then submit for reimbursement.
Check claim status online through your insurance portal, call member services, or use the insurance company mobile app for real-time claim tracking.
Assignment of benefits authorizes your insurance to pay the dentist directly rather than reimbursing you, simplifying payment and reducing your upfront costs.