Emergency Dental Care USA's Guide to Explanation of Benefits: What happens if a Claim is Denied?

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If an insurance claim is rejected, don't give up. Review your Explanation of Benefits, then contact your insurance company if there's a problem.

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

When a patient is treated by a dentist, physician or other medical professional, the patient's health insurance company will send them an Explanation of Benefits (EOB) form. This statement summarizes the dates and types of treatment received, and costs the insurance company will pay.

Sometimes the news isn't good: 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, according to a survey by the Government Accountability Office (GAO). And 40 percent of external appeals that were reviewed by a third party were reversed in the patient's favor.

In recognition of Health Literacy Month in October, Emergency Dental Care USA has created a six-page guide that makes it easier to review and understand an EOB. In addition, they also have published a case study of a claim that was originally refused, then paid later.

"Getting a claim paid doesn't always work the first time," said Michael Obeng, DDS, of Emergency Dental Care USA. "That's why patients need to look over their EOBs carefully, and contact their insurance company if there's a problem with payment."

He cited the example of a patient who was visiting from out of town and needed immediate help with a fractured tooth. Emergency Dental Care did an exam and took x-rays, then repaired the tooth.

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

More details and examples of the patient's EOBs can be found on the Emergency Dental Care USA website:


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Michael Obeng, DDS
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