Dealing with Delayed Dental Claims: What Washington Dentists Should Know
Delayed dental claim payments can create unnecessary administrative work and strain practice cash flow. For many private/commercial claims in Washington, prompt-payment standards require carriers to pay 95% of clean claims within 30 days of receipt and pay or deny 95% of all claims within 60 days of receipt. Interest may apply to undenied, unpaid clean claims that are more than 61 days old.
The following WSDA resources can help members and their teams understand these timelines, respond to repeated documentation requests, and raise concerns when payors delay claims that should otherwise be processed.
Personal Support through WSDA’s Dental Benefits Concierge Service
WSDA's Dental Benefits Advocacy Manager Crystal McGaffin is here to provide 1:1 support for WSDA member dentists and any staff in their office.
Crystal can support you with questions on:
- Coding and Reimbursement
- Credentialing & Third-Party Payor Issues
- Dental Benefits Advocacy
- Other Dental Benefits Issues in Your Office
Contact Crystal today at dentalbenefits@wsda.org.
Delayed Claim Payment Letter Templates
Visit wsda.org/dentalbenefits to download letter templates to use in your office to communicate with insurance companies and/or their contractors regarding delayed claim payments or to address disputes about claim adjudication and resolution that exceed the insurer or regulatory standards.
About Washington’s Prompt Payment Requirements for Private Dental Claims
Washington has “prompt pay” standards that most health insurers must follow for timely claims processing. If you’re a participating provider with a contract, the insurer must meet certain minimum timelines:
- 95% of “clean claims” must be paid within 30 days of receipt by the insurer. In practice, many carriers (including dental carriers) strive to process clean claims in about a month or less. For instance, a plan’s policy may be to process all claims within 30 days whenever possible.
- 95% of all claims (clean or not) must be paid or denied within 60 days of receipt. In other words, insurers can’t let a pile of claims linger indefinitely – almost all should be resolved (paid or at least formally denied) within two months. If a claim is not clean and cannot be paid promptly, the insurer should notify you of the denial or request for more information within this timeframe.
- Interest accrues on late payments. For any clean claim that isn’t paid or denied for more than 61 days, the insurer may be required to pay interest. The interest rate is 1% per month (simple interest, prorated per day) on the amount owed. This interest is typically paid to the provider on top of the claim reimbursement and cannot be charged against the patient’s benefits (it doesn’t count toward the patient’s deductible or co-insurance). It is neither standard nor advisable to impose arbitrary interest fees on insurers and any concerns around violations should be reported to the WSDA.
What to Do If a Claim is Delayed
- Confirm the claim and all supporting documentation were received by the carrier.
- Check whether the claim has passed the 30-day or 60-day timeline.
- Save claim reference numbers, portal confirmations, dates, representative names, and documentation submitted.
- Respond promptly to legitimate requests for additional information.
- If the request duplicates information already submitted, consider using WSDA’s template letters to ask the payor to resolve the claim.
- Contact Crystal McGaffin through WSDA’s Dental Benefits Concierge Service at dentalbenefits@wsda.org with reimbursement concerns.
- Use payor escalation channels or provider appeals when appropriate. If concerns remain unresolved, consider contacting the Washington Office of the Insurance Commissioner. Crystal can assist members in filing a complaint with the OIC.
The Importance of Clean Claims (and How to Achieve Them)
One of the best defenses against claim delays is preventing them in the first place. A “clean claim” is a claim submitted correctly with no errors, missing information, or lacking documentation that would prevent timely processing. In other words, it provides the insurer with everything needed on first submission.
Help prevent delays by submitting clean claims:
- Verify patient name, date of birth, member ID, and coverage before submitting.
- Use the correct CDT code and include required documentation.
- Review payor attachment guidelines to identify any specific details needed to process claims.
After claim submission and receipt is confirmed:
- Monitor aging reports regularly.
- Keep proof of submission, receipt, representative names, dates, and reference numbers.
- Respond promptly to legitimate requests for additional information.
When Payors Request the Same Documentation More Than Once
Repeated requests for the same documentation can create unnecessary delays. Washington’s unfair claims settlement practices rule identifies delays caused by requiring substantially duplicative submissions as an unfair practice in certain claim-handling contexts.
Here are some tools and tips for addressing these situations:
- Respond thoroughly – the first time: When an insurer requires additional supporting documentation to determine coverage, respond thoroughly and timely. You may receive letters or requests for additional information embedded in your payment remits.
- Document every contact: Keep notes of phone calls with the insurance representatives, reference numbers for faxed documents, and save copies of emails or portal submissions. If a pattern of delay emerges, this log will be valuable evidence. Let the insurer know you are logging all communications regarding the claim and keep this information within your practice management software.
- Use provider relations or escalation channels: Most insurers have a provider relations department or a supervisory review process. If frontline claim representatives keep asking for the same information, escalate the issue. Ask for a supervisor or a dental consultant review. Sometimes a peer-to-peer discussion between the insurer’s dental director and the treating dentist can resolve a needless documentation loop.
- Invoke the contract’s dispute resolution: If you’re in-network, your provider contract will have a dispute/appeals process for claims. Washington rules require insurers to have a process for provider complaints or disputes and to decide such complaints within 60 days. File a formal provider appeal or grievance about the delayed claim processing. This not only forces a higher-level review but also creates an official record that you challenged the handling of the claim.
- File a complaint with WSDA and the OIC: Report your issues to the WSDA by emailing redacted examples to our Dental Benefit email or calling Crystal McGaffin, who can help you file an OIC complaint when needed.
Contact WSDA with Questions
For questions about delayed payments or other dental benefits issues, contact Crystal McGaffin through WSDA’s Dental Benefits Concierge Service at dentalbenefits@wsda.org. Members may also access WSDA’s delayed payment template letters at wsda.org/dentalbenefits.
This article focuses on private/commercial insurance. Medicare, Medicaid/Apple Health, ERISA/self-funded plans, and other federally regulated benefit programs may be subject to different rules. Practices should follow the terms of applicable provider agreements and program requirements. Other important limitations include those set forth by the Provider Contract.
