Dental billing and revenue cycle managementDental billing and revenue cycle management

How is dental billing different from medical billing?

Dental runs on its own code set, its own claim form and its own benefit rules, and many practices learn that the hard way after hiring someone with medical billing experience.

• CDT codes, not CPT. Dental procedures are coded with CDT codes from the American Dental Association, for example D0120 for a periodic exam, D1110 for an adult cleaning, D2391 for a one-surface posterior composite, D2740 for a porcelain crown and D4341 or D4342 for scaling and root planing.
• Benefits come with limits that change the math. Annual maximums, deductibles, frequency limits (how often a cleaning, bitewings or a crown replacement is covered), waiting periods for major services, and missing-tooth clauses all decide what the insurance will actually pay.
• Downgrades. Some plans pay for the least expensive alternative treatment, such as paying a composite filling at the amalgam rate. The patient owes the difference, and they need to hear that before treatment.
• Attachments and documentation. Crowns, scaling and root planing, bridges and many other services need radiographs, periodontal charting, narratives or intraoral images attached to the claim. Missing attachments are one of the most common reasons for denial.
• Predetermination. For larger treatment plans, a predetermination (pre-estimate) tells the practice what the plan expects to pay before the work starts. It is not a guarantee of payment, but it removes most of the guessing.
• Coordination of benefits. Patients with two dental plans need the primary and secondary order set correctly, and the secondary claim follows the primary's payment.
• Medical-dental crossover. Some services, like certain oral surgery or sleep apnea appliances, may be billable to medical insurance, which has a completely different process.

What does Medalyze do for dental practices?

1. Benefit verification. We confirm coverage, remaining annual maximum, deductible status, frequency history, waiting periods and downgrade clauses, then summarize them so the team can quote the patient accurately.
2. Dental coding review. Treatment is checked for correct CDT codes, tooth numbers, surfaces and documentation that supports the claim.
3. Claim creation and submission. Claims go out with the required attachments and narratives for the procedure and payer.
4. Payment posting. EOBs and ERAs are posted by line, including write-offs, patient responsibility and any downgrades.
5. Denial management. We correct, resubmit or appeal with the documentation the plan asked for, and track which payers deny which procedures.
6. Accounts receivable follow-up. Unpaid claims and patient balances are worked in order of value and filing deadline.
7. Credentialing and enrollment. We help enroll new dentists with dental plans so they can see insured patients from their start date.

Our existing dental services pages go deeper: dental eligibility and benefits verification, dental coding, dental payment posting, dental AR follow-up and dental denial management.

Which codes and rules matter most in dental?

Who is this for?

General dentistry practices, specialty practices such as periodontics, endodontics and oral surgery, and dental groups with several locations that want one consistent insurance process.

Frequently asked questions

What is the difference between CPT and CDT codes?

CPT codes describe medical services and are maintained by the American Medical Association. CDT codes describe dental procedures and are maintained by the American Dental Association. Dental claims use CDT codes, and a few oral health services can be billed to medical insurance with CPT codes instead.

Why do dental insurance claims get denied?

The usual reasons are a service that exceeds the plan's frequency limit, a waiting period that hasn't ended, missing radiographs or charting, the annual maximum already being used up, and incorrect coordination of benefits. Most of these can be caught at verification or before submission.

What is a predetermination in dental insurance?

It's a request sent to the insurer before treatment to learn what the plan expects to cover. It helps with treatment planning and patient quotes, but it isn't a guarantee of payment, since eligibility and benefits can still change before the work is done.

Do you verify dental benefits before the appointment?

Yes. We check benefits ahead of the visit and record the details your team needs, including remaining maximum, frequency history and any downgrade policy, so the patient hears the estimate before treatment starts.

Can you handle patient balances as well as insurance claims?

Yes. We can post payments, send statements and follow up on patient balances based on your collection policy.

Related services: dental eligibility and benefits verification; dental coding; dental payment posting; dental AR follow-up; dental denial management; provider credentialing and enrollment.

Related reading: why medical claim denials are rising; payer-published denial rates vs your own.