Dental insurance claims denied? Here are 10 reasons why


50% of the revenue for in-network private practice dental comes from dental insurance claims, says Ontario Academy of General Dentistry. So when claims are consistently denied, that’s half of your revenue put at risk. With your cash flow on the line, you need to know why claims are denied, so you can take action, get paid, and enjoy steady revenue month after month.
Almost every dental professional we’ve spoken to says the same thing: Dental insurance claims work is their least favorite part of the job. And we get it — you try to create clean claims, yet you still see denials. You may even be stuck appealing half of your submissions.
According to Dentistry IQ:
Insurance claim submissions is repetitive work — not only to re-create each denied claim, but to follow-up with insurance until it is paid. That’s time taken away from patient care, but if you’re in-network, likely half your revenue depends on it.
At DCS, dental insurance billing is our most popular solution. Dental business owners gravitate toward our insurance billing services because of our proven expertise doing insurance claims work. Since 2012, successful dental businesses have relied on our services so their in-house team can spend more time focused on patients — and spend less time on repetitive paperwork.
The key to unlocking the insurance denials dilemma is to submit squeaky-clean claims. To help you accomplish that, our insurance billing team listed the mistakes they see most often. They also offered their expert advice to help you get more claims accepted the first time.
So, let’s take a close look at why claims are denied so frequently by dental insurance, starting with Ontario Academy of General Dentistry, who shared their perspective on the role of insurance companies:
We’ll add that insurance companies profit from unpaid claims — the more claims they deny, the more cash they keep. They will use any excuse to refuse reimbursement, and these 10 reasons dental insurance claims are denied are the most common.
When you understand why your claims are denied and apply these experts’ tips, you can confidently avoid these errors, see fewer denials, and enjoy more revenue with a consistent cash flow.
Key takeaways about why your dental insurance claims are denied:
- Even the smallest error, like getting a patient’s birthdate wrong by one number, can negatively impact your claim acceptance
- Insurance verification is an essential step to avoiding dental insurance claim denials
- Half your revenue depends on niche expertise in insurance claim submission, follow-up, and appeals
1. Incorrect dental codes
For a dental claim to be processed properly, it’s necessary to identify the diagnosis, services rendered, and procedures performed with the correct code set, whether a CDT (Current Dental Terminology) or an ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) code.
Coding errors are probably the easiest mistakes to make because the current codes are hard to keep up with — they update and change every year. Coding mistakes are especially frequent when both medical and dental codes are involved, as with oral surgery. Ontario Academy of General Dentistry explains:
“Dental and medical insurance are complicated. Frequent policy changes, regulatory complexity and insurance-specific jargon are also difficult for healthcare providers to navigate.”
So, how can you keep up?
Try this:
Make learning dental codes your priority. Invest in your education of the CDT and ICD-10-CM codes to avoid making mistakes that cost time and money — and could also lead to accusations of fraud. Your team should review the 2025 CDT Code book every year to keep up with the annual updates and revisions.
2. Outdated or incorrect insurance claim forms
Dental insurance companies will occasionally update their claim forms by changing the information needed to complete them. It’s important to use the current form so you’re not sending claims on outdated forms, which is a short, quick path to claim denials.
Try this:
For a smoother process that will also be quicker, always use the most recent version of claim forms. If you’re in doubt about which version of a claim form to use, call the insurance company and double-check. You can also get the most up-to-date ADA insurance claim form here.
Verifying which form to use when sending a claim will take you a few minutes, but that’s nothing when compared to hours spent redoing the paperwork to file an appeal, and then following up with insurance until it’s paid — all because you used last year’s form.
3. Incomplete or inaccurate information on the dental insurance claim
This might seem like a no-brainer, but it’s one of the more common reasons that dental insurance claims are denied because even the smallest error is a reason for payers to reject the claims.
It’s easy to misspell someone’s name, input the wrong insurance number, or any other everyday input error. It might not even been an input error — maybe the patient’s information has changed, and they haven’t told you.
Therapy Brands shares:
Accuracy for every detail on the claim form is crucial for acceptance. And it’s important to recognize error descriptions so you’ll where the error is and exactly how to correct it.
Try this:
Make sure whoever is responsible for creating and sending claims is not distracted from this vital work by other responsibilities. Your billing specialist should have time dedicated daily to filling out claims, with sufficient time to create, correct, batch, and send claims — which includes double-checking that all the form fields and blanks have been accurately completed.
Related: 4 things your dental insurance claim needs for reimbursement
4. Not verifying patient insurance benefits before their appointment
As you read through this article, you’ll find this mentioned often: It’s a best practice to have your administrative team ask for a run-down of the patient’s benefits before their visit. So much can change between scheduling an appointment and showing up for it — patients move across town, get married, etc.
Or they may have a different insurance company or group number, or their policy is the same, but the benefits have changed. If they made the appointment 6 months ago, there’s a good chance their insurance has changed or been updated.
Try this:
Always review a patient’s benefits a few days before they enter the office. Use this time to verify all the patient’s personal information is up-to-date (such as their name and address), their benefits are still active, and how much of the procedure their insurance will cover.
This early check also shields your patient from a longer wait time or even a surprise bill. Therapy Brands shares this tip:
“Make a copy of both the back and front of the insurance cards. While you might not use patients’ medical insurance for most dental procedures, it does not hurt to have this information on file (as some medical insurance companies will cover specific dental procedures). Having the cards on file ensures that you have the correct insurance information for the patient.”
5. No student verification
Inadequate documentation of a student’s status often leads to denied or delayed claims. You guessed it, this is another example of proper insurance verification.
If the patient’s student enrollment status is going to affect their insurance coverage, it’s important you review the patient’s benefit plan to fully understand it before the procedure, and also collect proof of their attendance.
Try this:
Ask the patient’s insurance carrier what information you’ll need regarding the patient’s status as a student. It only takes a few minutes to call insurance and ask how student status will impact their benefits. This is a small, quick task compared to waiting to receive a denied claim and then resubmitting a new one — and then waiting weeks for payment.
6. Unreadable procedure attachments and/or insufficient documentation
As insurance companies and dentist offices transition to electronic information, a common problem is unreadable information or files. Outsource Strategies International states:
For example, most preventative services such as cleanings, radiographs, and fluoride treatments don’t require attachments, but more major services like crowns, bridges, implants, and dentures do require attachments to explain why the treatment was needed.
While you’re less likely to submit illegible handwriting in these days of digital documentation, there’s still a chance of submitting unclear photos, blurry x-rays, or inadequate narratives (which we’ll get to below!).
It’s always better to over explain on an insurance claim rather than risk leaving off valuable information. Remember—insurance wants clear and unquestionable proof of why a treatment was necessary.
Read more: Why attachments are important in dental insurance claims
Try this:
Ensure your claims aren’t denied by having great quality images and x-rays attached to your claim. This means investing in high-quality clinical equipment — both intraoral camera and x-ray machines — and taking your time when gathering these images to guarantee a crisp, color representation.
When you clearly convey the condition of the patient’s mouth, you increase your chances of claim acceptance on first submission. As with the claim form, details matter. When submitting x-rays or charts, confirm you’re sending the correct imagery, and that the images are mounted, labeled (such as Right or Left), and easy to read.
7. The missing tooth clause guidelines
The missing tooth clause is a statement that the dental insurance plan will not cover any treatment that replaces a tooth which was extracted or missing before the patient’s insurance coverage started.
Family Choice Dental shares this example:
“If someone loses a tooth on June 1 and the insurance policy goes into effect on June 2, the policy will not cover the restoration. The missing tooth clause can also include a waiting period. When that is the case, the policy will not cover a tooth replacement if the tooth was lost during this waiting period. Waiting periods differ from one insurance company to the next. However, waiting periods can be as long as five years.”
The date the tooth was removed or lost could make a paramount difference in a patient’s bill — the procedure could have full coverage, partial coverage, or no coverage at all. This is another strong case for verifying patient insurance 2 or 3 days before their procedure. So…
Try this:
Verify the patient’s benefits before complex procedures. Confirm you and the patient aren’t missing any “fine print” information that will impact their coverage — in this case, the date when their tooth was extracted.
Related: 3 tips to successfully communicate your patient's dental treatment plan presentation
We can’t emphasize enough how important it is to verify insurance before any procedure is performed. It saves more time than it takes, as it helps your team avoid confusion, claim denials, and explaining surprise bills to your patient.
8. Clinical and non-clinical contractual limitations
Contractual denials occur because some contracts don’t cover certain services, or they set limitations for waiting periods. They’re stipulated per insurance policy and per patient, and they only allow benefits for certain procedures after a specified amount of time has passed.
There are two types of contractual denials: Clinical and non-clinical.
Clinical contractual limitations
Dr. Bicuspid breaks it down simply: Some dental contracts don’t cover specific services. For some services, this make sense, such as cosmetic services like bleaching or veneers that are just for show.
However, sometimes the lack of coverage doesn’t make clinical sense. Dr. Bicuspid specifies splinting as a good example.
Either way, non-covered services are just that: services outside the scope of the insurance policy, whether or not it makes sense.
Non-clinical contractual limitations
Dr. Bicuspid also helps us understand non-clinical reasons for limitations. They include:
- Waiting periods: Some plans require months, or even years, between gaining coverage and eligibility for benefits for specific services.
- Age: Many insurance contracts do not allow certain procedures on patients — such as crowns, sealants, endodontics, and removable/fixed prosthesis and periodontal work — based on their age.
- Frequency: Dental contracts may limit how much time must pass before procedures can be repeated on the same tooth.
These contractual limitations will vary, so you need to be aware of them — for each patient and for each procedure — to avoid denials.
Try this:
Verify the patient’s insurance benefits before the procedure to make sure they’re active, and also to confirm whether the scheduled specific procedure is covered by their plan.
Once again, insurance verification is the key. For example, if the patient wants a whitening procedure done, you need to see if their benefits will cover this cosmetic procedure. You also need to fully grasp the rules of their benefits, particularly frequency and waiting periods, to explain them to the patient. It’s your team’s responsibility to know the ins and outs of the patient’s benefits for the treatment presentation, when you will also need to answer a patient’s questions about their coverage.
Read more: 3 steps to explain dental insurance coverage to a patient successfully
9. No narrative or incomplete narrative on the claim form
You must always include a detailed explanation that’s personalized to each patient for why a procedure was performed. This is called a narrative — think of it as your patient’s clinical story.
The ADA says:
Remember, the narrative has to be specific to each patient. We’ve seen offices have claims denied, and even get into legal trouble, because their claim forms used stock narratives — pre-written, default explanations of why a treatment was needed.
Try this:
Another good reason to ensure at least one person has time dedicated to processing insurance claims. To avoid a quick denial because there’s a boilerplate explanation, or no explanation at all, time is needed to compose a detailed, individualized narrative that justifies the procedure.
Dental Economics advises on the level of detail that insurance companies expect and require:
“Document, document, document. For example: For crowns, detail the extent of decay or damage (e.g., “50% of tooth structure compromised”). For SRP (scaling and root planing), include evidence of bone loss, pocket depths, and bleeding points from periodontal charting. Be specific in narratives. Generic phrases like “crown required due to decay” won’t cut it. Provide precise details, such as the location and severity of decay.”
Documentation is time-consuming, but it’s vital for first-submission claim acceptance. Make sure the person(s) responsible for insurance claims isn’t leaving out key information simply because their time is spread too thin across a variety of office tasks. If they don’t make the time to file claims correctly, they’ll have to find time later to do them over for the appeals.
10. Trying to juggle too many tasks
Finally, claims are denied because whoever is responsible for sending claims is juggling too many responsibilities. In fact, this could be considered the root of every claims error detailed in this article.
Mistakes happen, and everyone is human, but we can spot errors before submission when we have enough time and focus. Filling out claim forms is tedious, and making sure they are accurate, batched, and sent is a time-consuming process — but your cash flow and half your revenue depend on it being done well
And when you’re also trying to check in patients, answer phones, and keep your schedule booked, it’s too easy to make the small mistakes that cause big problems.
Try this:
There are two options for bringing a single-minded approach to your claims submissions. You can either:
- Hire an insurance coordinator whose only job is managing your insurance billing — they have no other pressing responsibilities
- Outsource dental insurance billing to a dental revenue cycle management company like DCS, where an Account Specialist will be dedicated to getting your office’s claims submitted accurately and paid swiftly.
To avoid additional overhead costs, we recommend partnering with RCM experts, like our team at DCS.
Turn dental insurance claims into consistent cash flow when you use our insurance billing service.
Submit your dental insurance claims without fear of denials
To recap, here are 10 reasons your dental insurance claims are denied:
- Incorrect dental codes
- Outdated or incorrect insurance claim forms
- No student verification
- Incomplete or inaccurate information on the dental insurance claim
- Not verifying patient insurance benefits before their appointment
- Unreadable procedure attachments and/or insufficient documentation
- The missing tooth clause guidelines
- Clinical and non-clinical contractual limitations
- No narrative or incomplete narrative on the claim form
- Trying to juggle too many tasks
We know sending in clean claims is time-consuming, but getting prompt payments is preferable to resubmitting claims for appeals. That’s why our Insurance Billing service is so popular!
Why stress about claim denials when an insurance billing expert will make sure your claims are ready for submission, then send them in and do all the follow-up work for you?
With our support, your in-house team can focus on creating an incredible patient experience while reaping the benefits of consistent cash flow.
Our client-partner, Tom Touhey’s office manager, explained their experience with DCS:
“I am the office manager and only person at the front, and having DCS take over all our insurance claims, payment posting, and working on any insurance errors has been life altering! We are very busy and needed help, but we just weren't sure that we needed another whole person. DCS is the best employee you don't have. Make the call!”
Don’t let insurance claims take up your entire day, and get the revenue you’ve earned from each and every claim: Book a free 30-minute consult today.
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Dental revenue resources from Dental Cashflow Solutions (formerly Dental Claim Support)