Dental Claims Denied After Treatment
I’ll start by saying I’m not well-versed in insurance matters. Until last year, I hadn’t experienced any major issues. That changed when I had a root canal and two crowns done, with the dental office providing a total estimate that included what my insurance was expected to cover. I paid my portion at the time of service, and these procedures took place over several appointments in August and September 2024.
Then, around the start of the new year, I was surprised to receive a bill from the dentist for over $2,000. When I reached out, they informed me that three claims were still pending and they intended to resubmit them to insurance. A month later, I received another bill, this time totaling close to $4,000, with all three claims denied. The two largest claims consisted of one for the crowns and the other related to an out-of-network dentist claim, even though both dentists worked at the same location. I initiated a three-way call with the dentist and the insurance company, where we discussed what should be covered, and they agreed to resubmit the claims.
Today, I followed up with both parties. The smallest claim remains denied, the crowns claim was partially rejected—insurance issued a payment, but it was less than half of the total cost—and the claim for the out-of-network dentist is still pending, amounting to around $1,500 on its own.
This situation is weighing heavily on me financially, and I now recognize that I could have taken more proactive steps before the treatment, but I was in pain and relied on the dental office’s pricing. Is there a way to appeal these denials, or am I stuck paying for services that insurance insists aren’t covered? I feel like I’m caught in a frustrating loop where neither side provides clear answers, and it’s becoming increasingly difficult to navigate this process.
I’m sorry to hear about the challenges you’re facing with your dental claims. It sounds incredibly frustrating, especially since you were following the guidance of your dental office. Here are some steps you can take to address this situation:
Request an Explanation of Benefits (EOB): Contact your insurance provider and ask for a detailed EOB for each denied claim. This document will clarify why your claims were denied or underpaid and provide codes associated with the dental procedures.
Clarify Network Status: Reach out to your insurance provider again to confirm the network status of both dentists. If both dentists are indeed part of the same dental practice, you may be able to argue that the claim should be covered.
Ask for a Detailed Bill: Request an itemized bill from your dental office that clearly outlines all services provided and their corresponding codes. This can help in the appeals process.
File an Appeal: You have the right to appeal any denied claims. Your insurance company should have a process for this. Prepare a letter explaining your situation, including any supporting documentation (like your EOB, itemized bills, and any communication with the dental office and insurance).
Contact a Consumer Assistance Program: Depending on your state, there may be consumer assistance programs that can help you navigate disputes with insurance companies. They can provide guidance on your rights and may even assist in the appeals process.
Seek Help from Your Dentist’s Office: Encourage your dental office to assist you with the appeals process. They may have encountered similar issues with insurance before and can provide valuable support.
Consider Mediation: If both sides continue to avoid responsibility, look into mediation services that specialize in healthcare disputes.
Stay Organized: Keep track of all communications, dates, notes from calls, and any documents you receive or send. This will help if you escalate the matter.
It’s understandable to feel stressed about the financial impact of these claims, but being proactive and persistent can help you resolve the situation. Good luck!