Don't let missing tooth clauses sink your dental insurance claims

Dental insurance policies often contain fine-print clauses that can affect benefit determinations. Without experienced billers to identify and interpret these clauses, your practice may be losing revenue without even realizing it. Let's look at two real-world scenarios that show how understanding contract fine print can protect your revenue

Scenario No. 1: The missing tooth clause

A patient comes in needing a dental bridge. The treatment goes smoothly and you file the claim. However, when the explanation of benefits comes back, the insurance company denies it because of a missing tooth clause. That clause says they won't cover teeth that were missing before the patient's policy began.

Julia Nevodcikova

Frustrating, right? But here's the kicker: Even if they refuse to pay for the pontic (the false tooth), you might still be able to secure coverage for the retainer teeth (depending on the policy) if they require treatment for issues like fractures, decay, or other qualifying conditions based on the guidelines for coverage. This reimbursement could mean $500 to $1,000 or more for the two retainer teeth.

Scenario No. 2: The replacement clause

A claim for a bridge replacement is rejected under the missing tooth clause. The patient is confused -- the bridge has been there for years. What's going on?

Do you think the patient understands this denial? Most often, he or she blames the office for not knowing about his or her coverage. Sound familiar?

Here's what you need to know: Since the bridge was already in place when the policy began, the missing tooth clause doesn't apply. Instead, it falls under the replacement clause, which typically allows a new bridge after a set period of time, like five to 10 years.

If the patient's original bridge is older than that, the insurance should cover the new one. Knowing this difference can be the key to winning an appeal and getting the insurance to pay their share for the treatment performed.

Why does this matter?

If these details slip by, your practice could lose thousands of dollars while patients face financial stress, lose trust in your office, refuse to pay, or leave your practice unhappy. It happens all the time, and guess what? The dental office ends up being the bad guy, not the carrier or the employer that selected the plan. Have you ever tried explaining to a patient that you're not the bad guy? How did that go? 

What can you do?

• Don't give up on denied claims. Look closely at the policy again before closing a denied claim.
• Appeal strategically. Use clear, policy-specific arguments backed by strong documentation. Use artificial intelligence tools to help create a strong argument for your appeal.
• Ask the experts. There are many resources online that offer solid advice at no cost. Surround yourself with a community of knowledgeable people who are willing to share what they know.

Not sure where to start? I've created two detailed appeal letters that walk you through these exact scenarios to help dental teams fight for reimbursements. Download your copy here. Need additional guidance? Let's talk about how Stellar Dental Solutions can make your claims work for your practice.

Julia Nevodcikova is the founder and CEO of Stellar Dental Solutions, a dental billing company serving dental offices across the U.S. She holds a master's degree in accounting from SUNY Polytechnic Institute in Utica, NY. Nevodcikova is passionate about helping practices streamline their billing systems to prevent revenue loss while supporting healthy, sustainable growth.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.