Dental insurance claims… explained


Learn how to easily read dental claims and EOBs

Insurance claims can be confusing sometimes. It doesn’t matter if it’s for medical, home & auto, or even dental, understanding insurance claims can seem difficult. However, with a little explanation, we can help you gain a better understanding of how dental insurance claims work, and give you more confidence that you’re getting the most of your insurance benefits.

What is an insurance claim?

Let’s start with the basics. What is an insurance claim? In its simplest form, an insurance claim is simply a “claim” against your insurance policy requesting a benefit payment for covered services that are performed. It’s almost like a notification to the insurance company that you’ve received covered treatments, so they need to make a payment to the provider who performed the services.

What is claims filing?

If an insurance company never receives a claim, then they’ll never know if any covered services are performed for an insured member. This is why a claim needs to be filed so that the carrier can be notified of the insured event.

With dental insurance, most dental offices will file claims directly to the insurance company on behalf of the patient. These claims are often electronically filed, which can speed up the process. Members can also file claims themselves if needed.

What is claims processing?

Once the insurance company receives the filed claim, it will need to be processed. Claims processing is simply reviewing the services or treatments that were performed and making any payments according to the plan benefits. Most benefit payments are made directly to the dentists’ office.

For example, let’s say a member has a dental plan with benefits for general exams covered at 100%. Once the member has their dental exam, the dentist will file the claim with the insurance company. The carrier then processes the claim and makes a payment for 100% of the allowed charges filed by the dentist. The carrier then sends a payment back to the dentist, and also sends an Explanation of Benefits to the member.

What is an Explanation of Benefits?

When a claim has been processed, the insurance carrier will send an Explanation of Benefits or EOB to the covered member. An EOB is a summary of the claim details to show what was filed and how the claim was processed.

The Explanation of Benefits will typically include several key pieces of information. An EOB will show the services and procedures that were performed, the allowed amounts that the carrier applied for each charge, the payments that the carrier made, and the patient responsibility for charges payable by the member.

How to easily read an EOB

Let’s dig in to the components of an EOB to explain how to properly understand it. When you receive an EOB for dental treatments, there are a few things you can check to make sure the claim was processed correctly.

The first thing you can do is to make sure that all the procedures and services that you received are shown on the EOB. Then you can check the charges and allowed amounts for each procedure to see how the carrier paid the claim. Typically most dental plans will pay a percentage for each charge depending on the category the service falls in.

Lastly, you’ll want to make sure the patient responsibility amount that’s listed at the bottom of the EOB matches the amount the provider is billing you. This way you can know that you’re paying the correct amounts to the dentist office.

Be sure to review your dental claims and EOBs

You see, dental claims and EOBs aren’t that difficult to understand after all. With a better view of the entire claims process, you can see how claims are filed, processed, and paid. Then you’ll be able to properly review your EOB to make sure everything was paid correctly. Once you’ve done these things, you can be confident you’re getting the most out of your dental benefits.

Try our “Easy One Step” dental quotes


Leave a Reply

Your email address will not be published.