Question 1

What is a dental claim narrative?

Accepted Answer

A dental claim narrative is a brief clinical explanation submitted with an insurance claim to justify the medical necessity of a procedure. It connects clinical findings to the treatment rendered and helps the insurance carrier understand why the procedure was needed for that specific patient.

Question 2

When is a dental narrative required for insurance claims?

Accepted Answer

Narratives are typically required for major procedures such as crowns, root canals, scaling and root planing, extractions, bridges, implants, and periodontal surgery. They are also required for any CDT code that includes 'by report' in its description. Routine preventive services like cleanings and exams generally do not require a narrative.

Question 3

How do I appeal a denied dental insurance claim?

Accepted Answer

To appeal a denied dental claim: (1) Review the EOB to understand the denial reason, (2) Determine if it is a clinical or contractual denial, (3) Gather supporting documentation including updated radiographs and intraoral photos, (4) Write a formal appeal letter on practice letterhead with stronger clinical justification, (5) Submit as a formal appeal -not a new claim, and (6) Track the appeal deadline, which is typically 30-180 days depending on the carrier.

Question 4

What is the difference between a clinical denial and a contractual denial?

Accepted Answer

A clinical denial means the carrier determined the procedure was not medically necessary based on the documentation provided -these can often be successfully appealed with stronger evidence. A contractual denial means the procedure is not covered under the patient's specific plan terms (frequency limits, benefit maximums, waiting periods, exclusions) -these are rarely overturned through appeal.

Question 5

What words should I avoid in a dental narrative?

Accepted Answer

Avoid words like 'cosmetic', 'esthetic', 'patient desires', 'patient wants' (implies elective treatment), 'normal attrition', 'normal wear' (carriers consider this age-related), vague descriptions like 'tooth is bad' or 'large decay', and emotional appeals like 'severe pain'. Instead, use clinical and objective language that describes functional impairment and structural compromise.

Question 6

What should strong dental clinical notes include?

Accepted Answer

Strong clinical notes should include: tooth number and surfaces involved, chief complaint in the patient's own words, clinical findings (decay extent, fracture description, probing depths), radiographic findings, diagnosis, medical necessity statement, treatment rendered, materials used, and post-operative instructions. Notes should be signed by the treating provider and documented contemporaneously.

Question 7

How often can dental crowns be replaced under insurance?

Accepted Answer

Most dental insurance plans allow crown replacement once every 5 to 10 years per tooth. If replacement is needed sooner due to premature failure (fracture, recurrent decay), an appeal with clinical documentation explaining the early failure is typically required. The specific frequency limit varies by carrier and plan.

Question 8

What is pre-authorization in dental insurance?

Accepted Answer

Pre-authorization (or prior authorization) is a process where the dental office submits a treatment plan to the insurance carrier for approval before performing the procedure. It is commonly required for major services like crowns, implants, and orthodontics. Important: pre-authorization is NOT a guarantee of payment -coverage is always subject to plan terms at the time of service.

Question 9

What are CDT codes?

Accepted Answer

CDT (Current Dental Terminology) codes are standardized 5-character alphanumeric codes maintained by the American Dental Association (ADA). They start with 'D' followed by four digits (e.g., D2740) and are used to identify dental procedures on insurance claims. CDT codes are updated annually -the current version is CDT 2026.

Question 10

How can I reduce dental claim denial rates?

Accepted Answer

To reduce denial rates: (1) Verify eligibility and benefits before treatment, (2) Obtain pre-authorization when required, (3) Write strong clinical notes with medical necessity language, (4) Include all required supporting documentation (radiographs, photos, charting), (5) Use the correct CDT code for the procedure performed, (6) Submit claims promptly within the carrier's timely filing deadline, and (7) Review claims for errors before submission.