Roy Shelburne

Dental Consultant

Is a dental practice obligated to send a claim to the insurance carrier?

There may be several reasons a practice would rather not submit a claim to the dental insurance carrier for services provided to a patient: the service is not a covered service, the patient has reached their maximum, the office is in-network and the network fee is extremely low — so much so that the reimbursement will not even cover the lab fee — and the practice will lose money by providing the service, limitation period concerns, etc, etc.  So, is a dental practice obligated to send a claim to the insurance carrier?  

The answer is: maybe

If the doctor is out of network, most likely there is no obligation to send a claim to the carrier for the services provided.  If the doctor is in-network, there is a great possibility that the doctor is contractually obligated to send claims for all services provided for the patient.  Check the participation agreement to determine this obligation and follow the contract if it states that all services must be submitted. This being said, in the event there is a good reason not to submit the claim to the carrier, HIPAA may come into play and the HIPAA rules can circumvent the contractual obligation to submit all services.  

HIPAA always has the final say

If the patient signs an agreement directing the dental practice not to submit the claim for the service(s) to the carrier, the practice cannot submit the service or the practice will violate the HIPAA regulations.  HIPPA is a Federal mandate and supersedes the contractual agreement the plan has with the doctor.  This is particularly helpful in situations where the practice would like to protect the plan’s limitation period. 

Here’s an example. A patient presents having evolved tooth #9 in an accident and would like a replacement (flipper) placed until an implant can be provided to replace #9.  If a flipper is completed as an interim replacement, the claim is submitted to the carrier and the claim is paid for the replacement of #9, a more definitive implant replacement will not be covered for another 5-7 years (depending on the plan’s limitation period).  The less expensive flipper will be paid rather than the more expensive implant. Saving the higher reimbursement for the implant would benefit the patient and is a situation where having the patient sign the HIPAA form and not submitting the claim for the flipper would be in the patient’s best interest.  

So, check your participation contracts and be aware if there is a requirement to submit all services to the plan, and follow that requirement unless the patient signs a do not submit form.


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