Short Description
Insurance company guidelines that determine how claims are evaluated, approved, or denied based on plan rules.
Long Description
Processing policies are internal rules and guidelines used by dental insurance companies to evaluate claims, pre-treatment estimates, and reimbursements. These policies ensure consistency in determining coverage eligibility, payment amounts, and service limitations.
Factors considered in claim processing include:
Frequency limitations (e.g., two cleanings per year)
Waiting periods for specific procedures
Exclusions (non-covered treatments like cosmetic procedures)
Plan maximums and deductibles
Understanding an insurance company’s processing policies helps patients and providers avoid denied claims or unexpected costs. Dentists may submit a pre-treatment estimate to check whether a procedure meets policy guidelines before proceeding.