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Unpaid claims disrupt cash flow, delay collections, and create unnecessary rework for staff. Each denied claim represents time, supplies, and clinical work that the practice has already absorbed without reimbursement. The impact shows up quickly in the aging report and slows down day-to-day operations. Most denials stem from simple, preventable issues like coding mismatches, incomplete documentation, or policy misunderstandings. These issues are rarely difficult to fix, but they require consistent attention and clear internal processes. This guide outlines six common causes of unpaid claims. Each section includes a practical correction your team can apply immediately to reduce denials, shorten payment cycles, and protect revenue.
Aug 6, 2025
1. Incorrect or Missing Patient / Plan Information
Most claim denials start with basic data entry mistakes. Carriers reject incomplete or mismatched information before reviewing codes or documentation. The most common issues include:
Misspelled names or transposed birth dates
Subscriber IDs or group numbers from an outdated plan
Missing payer ID, tax ID, or treating provider details
These errors usually originate at the front desk during intake or when coverage isn’t re-verified before the visit. To catch them early, build a two-point check into your scheduling workflow: once at booking, again 24–48 hours ahead of the appointment. Request a clear image of both sides of the patient’s insurance card and compare it directly to the record—not notes, not memory.
Run weekly audits in your practice management system. Sort by blank fields or known problem inputs like group numbers with expired effective dates. Flag and correct discrepancies before claims are submitted. Getting patient and plan details right won’t guarantee payment—but getting them wrong guarantees delays.
2. Coding Mistakes
Incorrect or outdated CDT codes remain one of the most common reasons claims get denied. The risk rises early in the year when code changes take effect and systems haven’t fully updated. Submitting an obsolete extraction code or failing to follow payer bundling guidelines sends a claim straight to rejection.
This is about applying the codebook with precision. Each CDT update includes small adjustments that can affect reimbursement. Using the wrong version, mismatching the code to the clinical notes, or separating procedures that should be bundled under a single code will all trigger denials or downgrades.
Start with a standardized review process:
Confirm the code matches the most recent CDT update
Cross-check against payer-specific bundling rules
Attach required documentation (X-rays, narratives, perio charting) before submitting
Align submitted fees with the plan’s allowable schedule to avoid automatic adjustments
Review quarterly code changes as a team, and flag high-risk codes that historically cause problems. Solid documentation and a current code set protect claims from easy rejections and reduce the need for follow-up calls or appeals.
3. Missing, Unreadable, or Insufficient Documentation
Payers reject claims that lack clear, complete, and legible documentation. Procedures like crowns, root canals, and scaling and root planing typically require pre-op and post-op images, diagnostic detail, and a concise note explaining medical necessity. If any of those pieces are missing or unreadable, the claim gets denied without review.
Most documentation failures trace back to process gaps. Common issues include:
Blurry or low-resolution images exported from imaging software
Handwritten notes that don’t scan clearly
Narratives that omit clinical justification or timing of treatment
Missing patient IDs or unsupported dates of service
Build standard documentation packets by procedure type. Use high-resolution JPEGs (200–300 dpi) and export directly from your imaging software to avoid compression. Create drag-and-drop templates for common codes so your team doesn’t have to hunt down requirements each time.
Before submission, zoom in on every image and narrative. If you can't confirm margins or see decay clearly, assume the payer can’t either. Add a final check for matching codes, clear clinical notes, and visible patient information on every page. Fast, full documentation keeps claims moving and avoids delays caused by preventable rework.
4. Late or Incomplete Claim Submission
Most payers enforce a strict filing window, typically between 90 and 180 days from the date of service. Miss that deadline, and reimbursement is no longer an option. The remaining balance often shifts to the patient, creating uncomfortable conversations and avoidable write-offs.
Delayed submissions usually trace back to disjointed workflows. Draft claims get stuck in review folders, stall during transmission, or route to the wrong payer due to incorrect plan data. These breakdowns aren’t always obvious. You might not notice the issue until the denial arrives months later, stamped “claim not on file.”
To prevent missed deadlines, use a shared tracking board with four fields:
Date of service
Date claim sent
Follow-up date
Filing deadline
Color-code overdue claims and review the board during daily or weekly billing check-ins. Set a non-negotiable rule: all claims leave your system within five business days of treatment. If a payer sends the claim back requesting signatures, clinical notes, or additional attachments, don’t wait. Most filing windows do not reset; resubmitting within the original timeframe is your only shot at payment.
Clean claims filed on time protect your revenue and reduce the need for manual appeals. Still, even the best-timed claim can be denied if the patient wasn’t eligible at the time of service. That’s the next piece to lock down.
5. Contractual and Policy Limitations
Some claims get denied even when everything looks correct on your end. Payers use contractual rules to block reimbursement based on plan terms, not errors. These include frequency limits, waiting periods, plan downgrades, and exclusions like the Missing Tooth Clause, which denies prosthetics for teeth lost before the policy took effect.
Common limitations to watch for:
Frequency caps (e.g. two prophys per year, one panoramic film every five years)
Waiting periods for major services like crowns or bridges
Annual maximums already met by earlier treatment
Missing Tooth Clause, often buried deep in plan documents
Out-of-network restrictions, which reduce or eliminate coverage
Coordination of Benefits (COB) adds another layer. If the primary insurer’s Explanation of Benefits isn’t attached or the COB box isn’t checked, the secondary payer won’t process the claim. To reduce denials tied to policy terms:
Verify benefits in detail, not just eligibility, before every visit
Flag charts with known frequency caps, missing tooth exclusions, or waiting periods before presenting treatment
Attach the primary EOB and note “COB” when submitting to a secondary insurer
Review payer contracts and fee schedules annually to catch updates to coverage, downgrades, or reimbursement rates
Many of these denials stem from workload pressure and fragmented systems. When front desk teams are managing phones, check-ins, and last-minute cancellations, there’s little time left for deep benefit reviews or contract lookups. Without clear protocols and shared accountability, policy-level denials slip through—even in well-run practices. That operational gap is just as important to address as the claim itself.
6. Staff Overload and Workflow Gaps
When administrative staff juggle phones, patient check-ins, scheduling, and claims all at once, accuracy drops. Small mistakes like missing attachments, unchecked eligibility, and skipped narratives turn into denials. These aren’t knowledge gaps. They’re workflow failures caused by unrealistic workloads and fragmented responsibilities.
Understaffing compounds the problem. Many front desks are stretched thin due to open positions or inconsistent clinical support. As claim volume builds, tasks get delayed or rushed, increasing the risk of rejections tied to timing, coding, or incomplete documentation.
Set clear boundaries around claim work:
Block a dedicated hour each day for uninterrupted submission and follow-up
Assign a single point person to oversee claim workflows from verification to payment
Cross-train a secondary staff member to prevent coverage gaps during absences
If internal capacity is still tight, consider temporary or fractional staffing support. Offloading time-consuming tasks like eligibility checks or attachment prep gives your team room to focus on claim quality and resolution, not just staying afloat.
Keep Claims Clean With Teero
When your team runs lean, insurance details slip through the cracks. A majority of practices report serious challenges recruiting clinical staff, a gap that pushes administrators to juggle too many roles and fuels claim errors. Teero steps in with the right hands at the right moment, so you can send every claim out the door complete and on time.
Teero's platform connects you with qualified professionals through instant fill-ins for same-day cancellations, temp-to-perm matches when you need stability, and app-based scheduling that shows real-time availability.
When coverage is handled, your front desk can focus on verifying benefits, attaching clear X-rays, and following up before deadlines. Less stress for your team means fewer resubmissions and stronger cash flow for your practice. Sign up Teero to see how extra hands make all the difference.