Dental Insurance Refused, Medical Insurance Paid

Sometimes a claim is rejected. However, that’s no reason to give up.

In 2011, 59 percent of health insurance appeals were decided in favor of the patient.

In this example, a patient needed immediate help with a fractured tooth. Emergency Dental Care did an exam and took x-rays, then extracted the tooth.

The patient’s dental insurance paid the claim for the exam and x-rays, but denied the claim for the fractured tooth. However, that part of the claim was transferred to the patient’s regular health insurance, where it was paid in full.

The patient received a two-page Explanation of Benefit (EOB) form. The important parts have been outlined in the image below:

Dental insurance denied claim, medical insurance paid claim

  1. The claim for extracting the broken tooth was denied.
  2. This was noted under the heading See Remarks.
  3. Then explained in the Remarks section.
  4. The second (bottom) page shows that the claim was submitted to the patient’s health insurance. The claim was then paid in full, as shown in the sections Payable Amount.
  5. The Issued Amount.