Tired of dealing with claim denials and delayed payments? Every rejected claim is lost revenue for your practice. Here are the top reasons dental claims get denied—and how you can avoid costly mistakes to keep your cash flow healthy.
1. Incomplete or Incorrect Patient Information
- Errors in the patient’s name, date of birth, insurance ID, or policy details.
- Mismatch between patient details on the claim and what is on file with the insurance provider.
2. Eligibility & Coverage Issues
- The patient’s insurance is inactive or has lapsed.
- The procedure is not covered under the patient’s plan.
- Frequency limitations (e.g., exams covered only twice per year).
3. Missing or Incorrect CDT Codes
- Incorrect or outdated Current Dental Terminology (CDT) codes.
- Incorrect combinations of procedure codes.
- Failure to use proper codes for multi-step procedures.
4. Lack of Necessary Attachments
- Missing X-rays, perio charts, narratives, or intraoral images for certain procedures.
- Not submitting required documentation for claims requiring prior authorization.
5. Coordination of Benefits (COB) Issues
- Incorrect primary and secondary insurance order.
- Failure to include EOB (Explanation of Benefits) from the primary payer when submitting to secondary insurance.Each insurance provider has a time limit for claim submissions (e.g., 90 days, 180 days, or one year).
- Failure to submit within the allowed timeframe results in claim denial.
6. Pre-Authorization Required but Not Obtained
- Some procedures (e.g., crowns, implants, orthodontics) require pre-authorization from the insurance provider.
- Submitting claims for treatments that require prior approval without obtaining it first.
7. Coding and Bundling Issues
- Upcoding or unbundling procedures improperly.
- Submitting multiple procedures separately when they should be combined under a bundled code.
8. Duplicate Claims
- Submitting the same claim multiple times without justification.
- Not waiting for processing before resubmitting, leading to automatic denial.
9. Timely Filing Limit Exceeded
10. Out-of-Network Provider Issues
- The dental provider is out-of-network, and the patient’s insurance does not cover services.
- Lack of proper credentialing with the insurance company.
11. Insufficient Medical Necessity Explanation
- Insurance denies claims that lack supporting documentation proving medical necessity.
- Failure to include clear treatment rationale in the claim submission.
12. Wrong Provider Information or NPI Errors
- Mismatched provider name, address, or NPI (National Provider Identifier).
- Billing under the wrong provider’s NPI, especially in multi-dentist offices.
13. Incorrect Fee Schedule or Overbilling
- Charges exceeding the insurance company’s allowed amount.
- Billing a patient’s plan for services not covered or deemed excessive.