Disclaimer: Insurance administration and dental billing recommendations, as well as interpretations of the CDT codes, represent the opinions of our experts. For the latest CDT codes and official interpretations, contact the American Dental Association or visit ADA.org. You are responsible for your own use of the CDT Codes, insurance administration, and dental billing.

The Dreaded “No”: How to Turn Claim Denials into Wins

Imagine that it’s 4:25pm on a Friday. You can already taste the weekend when the latest batch of EOBs hits your desk. You open the first one, and there it is in black and white: CLAIM DENIED. Your blood pressure spikes. You know ‘Dr. Spent-Two-Hours-On-That-Bridge’ did flawless work. The patient needed it. So why is the insurance company acting like you billed them for a sports car instead of a bridge?

Claim denials are the ultimate vibe killer in a dental practice. They frustrate patients, stall your cash flow, and leave your front office team drowning in paperwork and question marks. But here’s the good news: A denial is not the end of the road. By tightening up your front-end submissions and fine-tuning the art of a proper clinical narrative, you can dramatically slash your denial rate.

Why do claims get rejected?

Before we dive into the complexity of claim denials, let’s address the silly mistakes that tank clean claims. Insurance payors love to reject claims for formatting technicalities. To keep your claims moving smoothly, ensure your front office team is checking these boxes every single time:

• Double-check the insurance card: Don’t just type in what the patient writes down. Scan the front and back of the card. Compare your system’s data with the payor’s portal to catch inaccuracies in patient names, ID numbers, birthdates, etc.
• Confirm the anatomy: Always ensure that tooth numbers, quadrants, and surfaces match the clinical notes perfectly. A mismatch in information will cause an unnecessary denial.
• Fill in the missing details: In the event the claim is for replacement crowns, onlays, veneers, bridges, or dentures, you must include the date of initial placement. Leaving that blank is an automatic ticket to the denial pile.

When a radiograph doesn’t show the whole story, your clinical narrative has to do the heavy lifting. Remember, while crafting a compelling narrative can be essential to getting paid, never embellish or invent symptoms. Only write exactly what was diagnosed and documented during the patient’s appointment. 

Many dental claims are denied in error.

A classic example of this is core buildups. Many payor computer systems routinely deny buildup claims, stating the service is “inclusive” to the crown procedure. Do not accept this! Appeal these by providing clear documentation showing that there was insufficient tooth structure to retain the crown (e.g., “More than 50% of tooth structure missing due to fracture” or “Tooth was endodontically treated”).

Implant restorations are another frequent victim of denials. If the patient has the benefits available, and no missing tooth or alternative treatment clauses apply, restorations on implants should be covered. If they deny it, look closely at the contract language. Unless the policy explicitly states “restorations are only payable on natural teeth,” fight back and request a second review.

What about attrition, abrasion, and erosion?

This is where things get tricky, and where patient expectations often collide with reality.

Many employers buy dental plans that explicitly exclude treatment for damage caused by attrition (tooth-on-tooth grinding/bruxism), abrasion (mechanical external wear from things like incorrect brushing or certain foods), or erosion (chemical wear from GERD or acidic drinks). When a patient has severe wear, they often assume insurance will cover the crowns to fix it because it’s “medically necessary.” But insurance consultants look at it through a strict contractual lens: If there is no other underlying pathology on that tooth, the claim is denied.

If you submit a claim for a worn tooth and simply note “severe attrition,” expect a denial. However, most insurance benefits consultants agree that if an additional, coverable condition exists on that same tooth, the coverable condition overrides the wear exclusion.

To get these claims paid, you must document and highlight the other pathology in your narrative:

• Is there a visible cavity?
• Is there a fractured incisal edge or cusp?
• Is there a failing existing restoration?
• Is the patient experiencing thermal pain from exposed dentin?

Make sure these clinical realities are front and center in your chart notes and your claim remarks.

Don’t Leave Money on the Table

It can be frustrating when a dental plan contractually excludes a service and denies a claim. In these cases, coach your patient to chat with their HR or Employee Benefits Manager. If enough employees complain, the company might choose better coverage during its next renewal cycle. However, for the administrative typos, the vague narratives, and the auto-generated system errors… the power is in your hands! Treat denied claims like a puzzle, not a brick wall. Pull the EOB, look at what’s missing, write a fabulous narrative, attach those crystal-clear images, and require that second review. Your bottom line — and your patients — will thank you!

To expand your understanding, please review the specific chapter on denied claims in our Dental Administration with Confidence publication.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 232-236). 2025 eAssist Publishing, LLC.