Delta Dental is one of the leading dental insurance providers in the country, offering coverage for a wide range of dental procedures. However, there are instances when they may reject claims, leaving policyholders wondering why. This article aims to explore ten possible reasons for Delta Dental rejecting a claim for a crown and provide insights into each one. Let's delve into the details:
Lack of Pre-authorization
One common reason for claim rejection is the absence of pre-authorization. Delta Dental requires pre-approval for certain procedures, such as crowns, to ensure the necessity of the treatment and determine coverage limits. It is essential to consult with your dentist and obtain pre-authorization before proceeding with the crown placement to avoid claim rejection.
For eligible crown procedures, Delta Dental typically covers an average of 50-80% of the cost, depending on the policy. However, it is important to note that actual coverage percentages and costs vary based on the individual's plan and the specifics of the treatment.
Missing Documentation
An incomplete or improperly filled claim form is another reason for claim rejection. Delta Dental requires specific documentation, such as a dentist's statement, X-rays, and treatment records, to support the claim. Ensure that all necessary documents are provided accurately to increase the chances of claim approval.
Limited Coverage
Another possibility is that the crown procedure may not be fully covered under your policy. Some Delta Dental plans have limitations on coverage for certain procedures, including crowns. Review your policy carefully to understand the extent of coverage for crown treatments.
The average price of a crown without insurance ranges from $800 to $1,500 per tooth. With insurance coverage, the out-of-pocket cost can be significantly reduced, typically ranging from $200 to $700 per tooth, depending on the plan and coverage percentage.
Frequency Limitations
Delta Dental may have frequency limitations on crown procedures. This means that if you have already received a crown within a certain time frame, your claim for a new crown may be rejected. Check your policy to understand if there are any restrictions on the frequency of crown placements.
Waiting Period
Some Delta Dental plans impose waiting periods, which require policyholders to wait for a specific duration before receiving coverage for certain procedures, including crowns. Claims submitted within the waiting period may be rejected. Review your policy to determine if you are within the waiting period for crown placements.
Excluded Services
Certain dental treatments, including cosmetic procedures, may be excluded from coverage under your Delta Dental plan. If the crown is deemed solely for aesthetic purposes, rather than for restoring function, it may not be covered by insurance. Verify the coverage details in your policy to understand if the crown qualifies for insurance reimbursement.
Alternative Treatment Options
Delta Dental may reject a crown claim if there are alternative treatment options available. For instance, if a dental filling or a less expensive procedure can adequately restore the tooth, a crown may not be considered necessary. Your dentist's recommended treatment plan and its necessity play a significant role in claim approval.
Improper Diagnosis
An incorrect or insufficient diagnosis from your dentist can lead to a claim rejection. Delta Dental reviews the diagnosis to determine the necessity and appropriateness of the recommended treatment, including crowns. Ensure your dentist provides accurate diagnosis information to support the claim.
Policy Exclusions
Each Delta Dental plan has specific exclusions listed in the policy. These exclusions outline the treatments or conditions that are not covered under the policy. If the need for a crown falls under one of these exclusions, the claim is likely to be rejected. Familiarize yourself with the exclusions in your policy to understand the coverage limitations.
Policy Termination
If your Delta Dental policy is terminated or expired at the time of the crown placement, the claim will be rejected. It is crucial to ensure that your policy is in effect and up to date during any dental procedures to avoid claim denials.
Frequently Asked Questions
Q: Can I appeal a rejected claim for a crown with Delta Dental?
A: Yes, you can appeal a rejected claim by submitting an appeal letter along with any additional supporting documents or explanations from your dentist. Visit Delta Dental's website or contact their customer service for the specific appeal process.
Q: How long does it take to receive a decision on an appeal?
A: Delta Dental typically provides a decision on the appeal within 30-60 days from the receipt of the appeal request and all necessary information.
Q: Will Delta Dental cover the cost of a crown replacement?
A: Delta Dental may cover the cost of crown replacement if it meets the necessary criteria, such as natural wear or tear, accidental damage, or if there were any issues with the initial placement. Review your policy to understand the replacement coverage details.
References:
1. Delta Dental. Retrieved from
2. American Dental Association. Retrieved from
3. WebMD. Retrieved from
