Since a major population of America has their dental healthcare covered under dental insurance plans, it has become a common practice for most dental practitioners/ clinics to send in dental claims to the insurance carriers for every service they provide.
Is that mandatory for dental practitioners/clinics to send in claims for every service they provide?
Well, there’s no straight answer to this question discovered yet. Though the answer could be positive in most cases, there are several conditions where sending dental claims isn’t necessary.
Wondering what situations could lead to the submission of service claims being non-mandatory? We’ve put together the most common such situations in this blog post for your understanding!
When Isn’t Mandatory To Send In Service Claims To The Insurance Carriers
Dive in to burst your curiosity!
1. Service Is Not Covered Under Insurance
There’s a massive variety of dental health care services that patients avail from a dental clinic or practitioner. And not all of those services are covered under every insurance plan.
Whether or not a dental practitioner/clinic has to submit the service claim to a patient’s insurance carrier clearly depends on the coverage. If the service is covered, they sure have to submit a claim and vice-versa.
Successful dental billers always check insurance coverage thoroughly before sending in the dental claims.
2. Insurance Limit Has Ended
Another situation where a dental practitioner or clinic does not have to send in service claims is when the patient’s insurance limit has ended. It is case-sensitive and requires thorough research, so ideally, a dental biller is responsible for doing a backcheck and determining if the patient’s treatment could be claimed or not.
The right way is to conduct prior-to-treatment research and inform the patient if their insurance limit has ended.
3. Dental Clinic Is Out-Of-Network
A very clear situation where the dental practitioner or clinic does not have to submit service claims is when their office is out of the patient’s insurance network. Not all insurance companies are entertained at every clinic, and so patients have to look through clinics that fall under their network.
In case a patient’s insurance does not fall into your offered networks, there’s no need to claim the services.
3. Dental Clinic Is In-Network, But The Service Fee Is Too Low For A Claim
When your office is in-network, it’s almost mandatory for the practitioner or clinic to claim the service. However, if the service fee is too low to be claimed, you must check through the patient agreement to know if you can easily avoid claiming for the service.
If there’s a good reason for not paying but the patient agreement says otherwise, you can always take help from HIPPA and amend the agreement in compliance with its policies.
HIPPA is a federal obligation for all medical matters, and it is always superior to the contractual agreement that a doctor has with insurance companies. It really comes into play when the practice aims at protecting the plan’s limitation period.
To put it all condensed, it is somehow mandatory for a dental practitioner/clinic to send each service’s claim to the insurance carriers. However, an exception could be made based on the specified conditions described above.