What Does It Actually Take to Get a Dental Claim Paid?

September 14, 2023

Updated 6/26/26

Getting a dental claim paid sounds simple: complete the treatment, submit the claim, receive payment. In practice, there are at least six places where that process can break down — and any one of them can result in a denial, a delay, or lost revenue.

Here’s what it actually takes.

Credentialing 

Before a new doctor can bill insurance claims, they need to be properly credentialed with each carrier. Many insurers won’t process out-of-network claims at all — and within the same carrier, some plans may behave differently than others. When a carrier doesn’t process out-of-network, the claim is denied with no avenue for appeal.

Credentialing is time-consuming, but skipping or delaying it costs more than the effort to do it right. For practices working with PPO providers, outsourcing to a credentialing specialist like Unitas can protect revenue while keeping staff focused on other priorities.

Insurance Verification

Verifying a patient’s insurance before treatment isn’t just a courtesy — it’s a billing requirement. Each plan has its own effective dates, deductible amounts, annual maximums, coverage percentages, frequency limitations, age limits, missing tooth clauses, and downgrade provisions.

Every patient, every plan, every time. Skipping or rushing verification is one of the most preventable causes of delayed or denied claims.

CDT Codes

The ADA updates CDT codes every January — adding new codes, revising existing ones, and retiring others. Incorrect coding is one of the leading causes of claim denials, and the changes aren’t always obvious.

Staying current requires ongoing education. Dental Coding with Confidence from Practice Booster is a widely used resource, updated annually to reflect the latest changes.

Submitting the Claim

Once credentialing, verification, and coding are in order, the claim goes out — but there’s still room for error. A complete ADA claim form requires accurate patient and provider information, correct CDT codes, and all necessary attachments.

Depending on the claim, that may include:

• X-rays and intraoral photos
• Clinical narratives
• Periodontal charts or chart notes
• Lab reports
• For HMO plans: referrals for specialty treatment
• For secondary plans: the primary EOB

An incomplete submission delays payment or triggers a denial — even when the treatment itself was covered.

Insurance Appeals 

Denials happen even on well-prepared claims. Appealing isn’t simply resubmitting — once a carrier has denied a claim, they need a concrete reason to reverse that decision.

That means following each carrier’s specific appeals process (some require paper; some require a particular form), providing more detailed documentation than the original submission, and often including enlarged X-rays and a comprehensive narrative from the treating doctor. A well-executed appeal takes more time and attention than the original claim.

Medical Insurance Billing

Medical-dental integration is no longer the exception. Oral surgery is regularly covered by medical plans, and some dental carriers now require a medical claim to be submitted and processed before they’ll consider the dental claim at all.

Billing medical insurance uses a different form (CMS 1500 instead of the ADA form) and different code sets — CPT and ICD-10 rather than CDT. Working with billers who are experienced in both dental and medical coding is the most reliable way to navigate these claims accurately.

Most In-House Teams Are Already at Capacity

Every step in the billing process has a failure point. When any one of them is missed — an unverified plan, an outdated code, an incomplete attachment — the claim stalls or gets denied, and revenue that should have come in doesn’t.

eAssist works with dental practices to handle billing accurately, so claims go out right the first time and get followed through to resolution.

Schedule a free consultation to talk through where your billing stands and what more consistent results could look like.