Why is my claim getting denied or only partially covered?

Sometimes, in order to control costs, insurance companies may reduce your benefits using the following methods:

  • bundling: two different procedures were performed on the same tooth, but the insurance company combines it into one procedure
  • downcoding: the dental plan changes the procedure code to a less complex or lower cost procedure than was actually performed (for example, a white filling was performed but they changed the code to a silver filling)
  • least expensive alternative treatment: if there is more than one way to treat a condition, the plan will pay only for the least expensive treatment. For example, your dentist recommended an implant, but the plan may only cover less costly dentures.
  • delaying payment: the insurance company may not pay your claim for many months, and ask for additional information multiple times
  • not medically necessary: the insurance company may deny payment stating that they did not receive enough proof of necessity. You can appeal this process with a letter from your dentist, including supporting photos and x-rays to explain the treatment decision.