Many patients’ dental insurance doesn’t cover all the care they need. Submitting claims to medical insurance, when appropriate, can stretch their coverage and make essential care more affordable — and more procedures qualify than many practices realize. Not submitting them means missed reimbursements for patients and lost revenue for the practice.
Since the process can be unfamiliar for teams accustomed to dental billing, this guide breaks it down with practical tips to simplify claims, improve collections, and avoid common mistakes.
Why Dental Medical Billing Matters
To submit medical claims for dental work successfully, it is essential to understand the difference between medical and dental billing.
“Medical insurance pays for medically necessary treatment, meaning a medical condition is either manifesting itself in the oral cavity, or the condition of your oral cavity is making your medical condition worse,” says Kimberly Pajak, CPB, Director of Internal Education/ Global Operations Project Manager/ Medical SME at eAssist Dental Solutions.
Dental insurance generally covers preventative care, such as cleanings, exams, and X-rays; basic care, including fillings and extractions; and restorative care, including crowns, root canals, and dentures. In some cases, dental plans cover orthodontics or implants.
A good rule of thumb is to save dental insurance for things that medical insurance won’t pay for, says Pajak. Let’s say a college student needs to have impacted wisdom teeth pulled. “If you send their entire claim to dental, that’s going to wipe out their dental for the whole year,” says Pajak. “How likely are they going to be to come back for exams and cleanings? If that patient has medical coverage for those impacted wisdom teeth and the IV sedation, then medical pays for that service, and dental gets saved for the things medical wouldn’t pay for.”
Despite the advantages, many practices fail to capture revenue from what could be successful medical claims due to the complexity of billing.
Dental Billing vs Medical Billing: Key Differences
| Dental Billing | Medical Billing | |
|---|---|---|
| Code set | CDT codes | CPT codes + ICD-10 diagnosis codes |
| Claim form | 2024 ADA Dental Claim Form | CMS-1500 |
| Documentation | Clinical notes (SOAP format recommended) | Medical-quality chart notes (SOAP format required) |
| Primary diagnosis code | Not required | Required on every claim |
| Pre-authorization | Plan-specific — must be obtained before treatment | Plan-specific — must be obtained before treatment |
Common Mistakes in Dental Billing
By avoiding common mistakes, it’s possible to increase reimbursement rates for medical billing.
Incorrect Coding
Dental billing uses CDT codes. Medical billing requires both CPT codes and ICD-10 codes. A dental medical claim must include a primary diagnosis code. “The primary code is always going to be the main reason the patient comes to you,” says Pajak.
Insufficient Documentation
Medical billing requires detailed written explanations of medical necessity. “When you get into medical billing for dentistry, you are following medical rules,” Pajak explains. “Your chart notes must be medical quality, which most dental chart notes are not.”
The SOAP format is a useful framework:
- Subjective — the patient’s chief complaint
- Objective — what the dentist observes in the patient’s mouth
- Assessment — connecting the patient’s complaints to the diagnosis
- Plan — typically includes three options for care
For example, when treating a diabetic patient, document whether the diabetes is controlled or uncontrolled and whether the patient takes insulin. “If a diabetic patient with periodontal disease needs scaling and root planing, there is a specific diagnosis code for Type 1 and Type 2 diabetes with periodontal disease,” says Pajak.
Not Verifying Medical Benefits
Many practices assume dental coverage is the only route to reimbursement and don’t verify procedures with the patient’s medical insurance upfront — resulting in missed reimbursements.
Missing Pre-Authorization
“For medical claims, if a pre-authorization is required, you must do it before you perform the service, or they’ll deny your service,” says Pajak. “There’s often no retroactive authorization.”
Using the Wrong Claim Form
Medical claims must be submitted on the CMS-1500 form. Using a dental claim form will result in denial.
Best Practices to Maximize Reimbursement
To ensure the best possible reimbursement rate, here are some best practices to embrace:
Verify medical eligibility upfront. Train staff to verify medical benefits as part of the check-in process. Confirm whether a treatment is covered, whether it requires pre-authorization, and whether there are any plan exclusions.
Standardize documentation. Keep detailed notes on the patient’s complaints, diagnosis, and treatment plan, along with clear reasons why the treatment is medically necessary. As Pajak says: “With medical billing, it’s not what you’re billing, it’s why you’re billing it.”
Track authorizations and follow up on denials. “My recommendation is using a spreadsheet and checking it daily or at least twice a week,” says Pajak. “Be consistent with your follow-up dates and have somebody responsible for the follow-up process.”
Use correct CPT and ICD-10 codes with detailed narratives. Accurate coding paired with strong documentation is the foundation of successful medical claims.
How eAssist Supports Dental Medical Billing
eAssist supports practices with two specialized services: Advanced Medical Billing and OMS Specialty Billing. Both provide access to specialists trained in CPT, ICD-10, and cross-coding, using proven processes to minimize denials and maximize reimbursement. eAssist also helps register dental practices with medical providers so insurance companies can recognize them properly.
“Most practices are not necessarily equipped to follow up on their dental claims,” says Pajak. “Then the follow-up process for medical billing can make that problem more difficult. By outsourcing medical billing, they could have a dedicated team that does their pre-authorizations and follows up on their claims.”
Frequently Asked Questions
Dental billing uses CDT codes and is submitted on the 2024 ADA Dental Claim Form. Medical billing uses CPT codes and ICD-10 diagnosis codes and is submitted on the CMS-1500 form. Medical billing also requires medical-quality documentation, a primary diagnosis code on every claim, and more frequent pre-authorization.
Many procedures may qualify, including treatment for traumatic injuries, extractions of impacted teeth, biopsies, oral appliances for sleep apnea and TMD, periodontal surgery, bone grafts, and diagnostic radiographs. Coverage depends on the patient’s specific medical plan and the medical necessity of the procedure.
Medical claims require medical-quality chart notes that establish medical necessity. The SOAP format — subjective, objective, assessment, and plan — is a useful framework. Notes should document the patient’s chief complaint, clinical findings, diagnosis, and treatment plan, along with the medical reasons supporting the need for treatment.
If the medical plan requires pre-authorization and it is not obtained before treatment begins, the claim will be denied. Retroactive authorization is generally not available, so it is critical to confirm pre-authorization requirements during the benefits verification process.
Ready to Start Billing Medical Insurance?
Dental medical billing doesn’t have to be a source of lost revenue. With the right systems — or the right partner — practices can unlock new revenue streams, help patients afford treatment, and strengthen their financial stability. To learn more about how eAssist can support your dental medical billing, schedule a free consultation.
