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Insurance Breakdown & Verification — Smiles N Texas
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1
Verification details▼If out-of-network
COMMON DENIALS & RED FLAGS — VERIFICATION
- No confirmation number recorded. If the insurer denies the claim, you have no proof the verification was done. Always get a ref # and write it down.
- Verifying with the wrong plan type. Always ask "Is this the primary or secondary plan?" before proceeding.
- HMO plans verified as PPO. HMO patients must see in-network providers only. Treating out-of-network means the entire claim gets denied.
- AOB sent to subscriber instead of dentist. The insurance check goes to the patient's house. Always confirm AOB direction.
- Fee schedule not verified. Treating under the wrong fee schedule means you collect less than you're entitled to, or overbill and trigger an audit.
2
Subscriber & policy info▼Dependents on policy
COMMON DENIALS & RED FLAGS — SUBSCRIBER
- Wrong Member ID used on claim. Even one digit off causes an automatic denial. Always read it back to the rep to confirm.
- Claim filed under subscriber name but patient is a dependent. The claim must list the patient's name and relationship.
- Dependent over age limit not flagged. Most plans cut off dependent coverage at 18 or 26. Treating after the cutoff = claim denied, you eat the cost.
- Group number changed mid-year. Employers change carriers at open enrollment. Always re-verify at the start of each calendar year.
- Payor ID wrong on electronic claim. A wrong Payor ID sends the claim to the wrong insurance company. It disappears with no denial and no payment.
- COB not identified. If a patient has two plans and you only bill one, you leave money on the table. If you bill the wrong one first, both may deny.
3
Benefits & deductibles▼COMMON DENIALS & RED FLAGS — BENEFITS
- Annual maximum already exhausted. Always check remaining balance before scheduling treatment.
- Deductible not applied correctly. If you forget the deductible on the first claim of the year, your estimate is wrong and the patient gets a surprise bill.
- Waiting period not flagged before treatment. Treating during a waiting period = full write-off or angry patient who owes the full fee.
- Missing tooth clause triggered. If a tooth was extracted before the plan started, implants, bridges, and partials to replace it are denied forever under that plan.
- Benefit year assumed to be calendar year. Some plans run June-May or Oct-Sep. Always verify the actual benefit year dates.
- Filing deadline missed. Most plans allow 12 months from DOS. Some allow only 90 days. A claim filed one day late is denied with no appeal option.
- Pre-estimate skipped on a plan that requires it. Skipping it = automatic denial regardless of medical necessity.
4
Preventive & diagnostic▼%
Exams (D0120 / D0150)
Prophylaxis / cleaning (D1110 / D1120)
Bitewings (D0272 / D0274)
%
%
CBCT — Cone Beam CT (D0367)
CBCT is denied more than almost any other imaging code. Insurers require medical necessity documentation. Always ask: "What clinical narrative and supporting records are required for D0367, and is pre-authorization required?" Record the rep's exact answer and confirmation number.
%
COMMON DENIALS & RED FLAGS — PREVENTIVE
- Prophy billed too soon. If a patient had a cleaning 5 months ago at another office, it denies as "frequency exceeded." Always check the last date of service.
- D0150 billed more than once per 3 years. Most plans cover D0150 only once per 3-5 years. Bill D0120 (periodic exam) for annual visits.
- Bitewings and FMX billed same year. Many plans will not pay for bitewings AND a full mouth series in the same benefit year.
- Fluoride billed for patient over age limit. Most plans cut fluoride at age 14 or 18. Billing D1206 for a 19-year-old is an automatic denial.
- Sealants billed on a tooth that already has a restoration. Insurers deny sealants on any tooth that has an existing filling or crown.
- D0140 billed same day as D0120. Most plans do not allow two exams on the same date of service. One will deny.
- CBCT (D0367) billed without medical necessity documentation. Missing clinical narrative = automatic denial. Pre-auth is required by many plans.
- CBCT billed when plan only covers limited FOV (D0364). Always verify which CBCT code is covered.
5
Basic restorative▼%
Fillings
Endodontics
%
%
%
Periodontics
COMMON DENIALS & RED FLAGS — BASIC RESTORATIVE
- Posterior composite downgraded without telling the patient. If the plan downgrades and you don't collect the difference upfront, you lose the gap.
- Filling billed on same tooth, same surface within frequency limit. Most plans won't pay for a replacement filling within 2 years on the same surface.
- Root canal billed without supporting X-rays. Missing radiographs = denial pending records request = delayed payment.
- D3330 (molar RCT) billed on a premolar. D3320 is premolar, D3330 is molar. Wrong code = automatic denial.
- SRP billed without perio charting. Insurers require clinical attachment level and pocket depth documentation for D4341. No chart = denial.
- D4910 billed at prophy frequency. If D4910 shares frequency with D1110, you cannot bill both in the same period. One will deny.
- SRP billed on all 4 quads when plan limits to 2 per visit. Some plans cap SRP at 2 quads per visit. Billing 4 on the same date triggers a partial denial.
6
Major restorative▼%
Crowns
Implants
%
%
%
%
%
Dentures & partials
%
%
%
%
Oral surgery
%
%
%
%
%
%
Adjunct services
%
COMMON DENIALS & RED FLAGS — MAJOR RESTORATIVE
- Crown billed before replacement frequency period ends. Most plans require 5 years between crown replacements on the same tooth.
- Crown downgrade not applied. If the plan downgrades porcelain to base metal and you bill full porcelain, the insurer pays only the base metal rate.
- Build-up (D2950) billed same day without confirming coverage. Many plans do not cover D2950 when billed same day as a crown prep.
- Implant billed when plan excludes implants entirely. The majority of basic PPO plans do not cover implants. Assuming coverage without verifying is one of the most expensive mistakes in dental billing.
- Missing tooth clause applied to bridge or partial. If the tooth was extracted before the plan's effective date, the replacement is excluded.
- Denture billed before replacement frequency. Most plans require 5 years between denture replacements.
- Occlusal guard billed without bruxism diagnosis when plan requires it. No diagnosis note = denial.
- D9110 billed same day as definitive treatment. Many plans deny D9110 if any other restorative procedure was done on the same date.
7
Orthodontics & retainers▼Orthodontic benefits
%
REMOVABLE / CLEAR RETAINER COVERAGE
Always ask specifically: "Is D8680 or D8693 a covered benefit, and does it require active ortho treatment on file to qualify?" Record the rep's exact answer and confirmation number.
%
%
FIXED / BONDED RETAINER COVERAGE (D8695 / D8696)
Fixed retainers are almost never listed in plan booklets. Ask specifically: "Is a bonded lingual retainer covered under any benefit category and what documentation is required?"
%
%
COMMON DENIALS & RED FLAGS — ORTHODONTICS & RETAINERS
- Ortho lifetime maximum already used at previous orthodontist. Ortho lifetime max is per patient, not per provider. Always ask "how much of the lifetime max has been used?"
- Ortho treatment started during waiting period. If the plan has a waiting period for ortho, the entire course of treatment may be excluded.
- Patient over age limit for ortho coverage. Many plans cover orthodontics only for patients under 19. Adult ortho is excluded on most basic PPO plans.
- Work-in-progress (WIP) not accepted by new plan. If a patient switches insurance mid-treatment and the new plan doesn't accept WIP, all future claims deny.
- D8680 denied — requires prior ortho on record. Many plans will only cover a retainer if there is documented orthodontic treatment history in the plan's records.
- D8693 billed but plan only recognizes D8680. Older plan documents may not list D8693 as a covered code. Always ask specifically about D8693 by code number.
- Both arches billed same date when plan covers one arch per visit. Billing upper and lower on the same date when the plan limits to one arch triggers a partial denial.
- Fixed retainer assumed covered because ortho was covered. Ortho coverage does not automatically include fixed retainers. Never assume — always verify by code.
- Retainer billed against ortho lifetime max when patient has none remaining. If the ortho lifetime max is exhausted, retainer claims under ortho benefits deny completely.
8
Patient history summary▼Fill in for each patient on this policy. Add rows as needed.
COMMON DENIALS & RED FLAGS — PATIENT HISTORY
- Frequency conflict not caught because last dates weren't checked. If you don't know when the patient last had a prophy, bitewings, or pano at ANY office, you risk billing too soon and getting denied.
- Annual max already spent at another provider this year. Always verify remaining balance, not just the total max.
- Deductible assumed to be met when it isn't. Always confirm exactly how much of the deductible has been met at any provider this year.
- Last pano not recorded — duplicate billed. Pano frequency is typically every 3-5 years. If you don't know the last date, you risk billing a duplicate and getting denied.
9
Notes & red flags▼COMMON DENIALS & RED FLAGS — GENERAL BILLING
- Claim submitted with wrong date of service. A transposed digit in the date causes an automatic denial. Always double-check DOS on every claim before submission.
- Provider NPI number missing or incorrect. Claims missing the treating provider's NPI are rejected at the clearinghouse — they never even reach the insurer.
- Diagnosis code (ICD-10) missing or doesn't support the procedure. Insurers increasingly require ICD-10 codes that match the procedure.
- Bundling — insurer combines two codes into one payment. Some insurers bundle D2950 (build-up) into the crown fee and pay only one rate.
- Coordination of benefits filed in wrong order. Always bill primary insurance first. Filing secondary before primary results in both denying.
- Claim not followed up within 30 days. Insurance companies routinely "lose" claims. The filing deadline keeps running whether they received it or not.
- Appeal deadline missed. Most plans give 90-180 days to appeal a denial. Missing that window means the denial is final.
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