Why Insurance Sometimes Requests ‘Narratives’ From Dentists Before Paying Claims

Dental insurance companies ask for a dentist's 'narrative' when the treatment appears to be unusual or expensive, or not covered under guidelines. A narrative is the oral health clinical explanation, written by your dentist, that explains the need for a specific procedure for your oral health. Common causes include many crowns, bone graft, implants, or therapies that coincide with cosmetic therapies.

Key Takeaways

• A dental narrative is a written clinical statement you’d have to your dental insurance company, explaining a therapy.
• When a procedure seems complicated, expensive or not covered by routine coverage, insurers ask for narratives, not to imply there's something wrong.
• These are usually associated with crowns, implants, bone grafts, periodontal therapy, or procedures which may be considered cosmetic.
• Clove Dental works on your patient's behalf to submit narratives to get claims approved and lower out of pocket expenses.

Have you ever been told by your dentist's office that your dental insurance company is requesting a 'narrative' before they'll process your claim? If so, you're probably wondering, what does that mean, why does it happen, and will it affect whether your treatment gets covered?

You're not alone. Patients often are taken aback when their dental insurance company requires further documentation before it will approve payment. The positive side: It does not necessarily mean that your claim will be rejected. It simply means that the insurance company requires additional information to make its decision.

What are narratives, why do insurance companies ask for them and how your dental team can guide you through.

What Is a Dental Narrative?

A dental narrative is a written clinical statement from your dentist that is sent to your dental insurance provider. It provides a medical explanation for the need of a particular treatment or procedure for your oral health and not only for cosmetic reasons.

Having a good story when applying for a dental insurance claim can increase the likelihood that you will get your claim paid in full.

Why Do Dental Insurance Companies Ask for Narratives?

Narratives are used by insurance companies to help them verify a treatment was medically necessary and not simply elective or cosmetic.

Narratives are requested when-

• The procedure is expensive or beyond standard routine care.
• The treatment falls in a 'gray area' between medically necessary and cosmetic.
• Multiple procedures were performed in the same visit or on the same tooth.
• The claim is for a service that requires clinical documentation according to policy guidelines.

Please note: the request for a narrative is not a red flag or denial. It is just the insurer's diligence prior to payments.

Which Dental Procedures Most Often Trigger a Narrative Request?

Some treatments may be more likely to be met with a narrative request by your dental insurance provider. These include:

Crowns

Especially if the tooth hasn't had a root canal or prior restoration. Insurers want to know the existing structure is compromised enough to justify the cost.

Dental implants

Many plans categorize implants differently from standard tooth replacement, so clinical justification is often required.

Bone grafts

Because these can relate to both functional and cosmetic needs, insurers frequently request documentation showing why the bone was deficient.

Periodontal (gum) treatments

Deep cleanings and surgical gum procedures need to show evidence of active disease rather than preventive care.

Orthodontics for adults

Adult braces or adult aligners are not just for looks; there are other reasons to consider them, like bite correction or jaw alignment.

What Goes Into a Strong Dental Narrative?

A strong narrative does more than describe what was done; it tells the story of why it had to be done. Your dentist will include-

• The patient's clinical findings (symptoms, measurements, X-ray results).
• The diagnosis and how it was reached.
• What happens if the condition is left untreated?
• Why is the selected treatment the most suitable and economical treatment?
• Supporting documentation, including photos, X-rays and periodontal charting.

Additionally, if a narrative is requested and not submitted or if the submitted narrative doesn't contain clinical information, then the insurance company might slow, limit, or refuse the claim. That is then your responsibility as a patient.

What Happens If the Narrative Isn't Submitted or Is Too Vague?

If a narrative is requested and not provided or if it's submitted but lacks clinical detail, the insurance company may delay, reduce, or deny the claim. That cost then falls to you, the patient.

This is exactly why it matters who writes your narrative. Your dentist can help if your claim is still rejected after a compelling story; they may be able to provide more evidence or even ask the insurer to conduct a clinical review.

Does a Narrative Guarantee That My Claim Will Be Approved?

Sometimes not but it will help you to increase your chances. The final decision on insurance approval will be based on the conditions of your particular plan. A narrative may not impose any annual benefit limits, waiting period, or exclusions that are not present in the policy.

But with a complete and well-documented story, you're sure to communicate the clinical need for your treatment well. Even with a compelling story, in case of a continued denial, your dentist can help you through the appeals process, provide more information or ask for a clinical review from the insurance company.

Should You Be Worried When Your Insurance Asks for a Narrative?

No. For some procedures, a narrative request is a normal part of the dental insurance claim process. This does not mean that your dentist has “failed” to do the right thing or that your claim will be denied.

It does not mean that the insurance company cannot process your application. The most important thing you can do is ensure that your dental office is responsive, detailed and has experience with these requests, which is what Clove Dental takes seriously for all patients.

How Clove Dental Handles Dental Insurance Narratives for Patients

Dealing with dental insurance may seem like a daunting task, particularly if you're facing a dental problem. We at Clove Dental will communicate with the insurance company for you.

We do the following on your behalf-

• Determine whether a story is required prior to making a claim.
• Include supporting documentation such as X-rays, photos and periodontal records.
• Contact the insurance company to follow up for prompt processing.
• Help with a follow-up appeal when a claim is originally rejected.

We can help you secure the most from your dental insurance plan, and that's all we want to do. For more information on our insurance services, check out clovedds.com.

Conclusion

Don't panic if your dental insurance provider requires a narrative; it's a typical aspect of the process that’s used by insurance companies to ensure that complicated, costly procedures meet clinical needs. The key here is that your dental office is responsive, comprehensive and properly documented.

At Clove Dental, we keep abreast of all the insurance processes to let you focus on your health. Contact our team at clovedds.com today with any questions or concerns about your dental insurance coverage or upcoming treatments.

FAQs

What is a dental narrative in insurance terms?

A dental narrative is a clinical writing report from your dentist sent to your dental plan. It justifies medical necessity for a particular treatment to be performed based on your oral health condition.

Will my claim be denied if a narrative is requested?

Not necessarily. A narrative request is just a request from the insurance company for additional information prior to making a decision. A strong narrative from the dentist will greatly increase the odds of approval.

Does my dentist write the narrative, or do I have to?

Your dentist composes the story. Requires clinical terminology, diagnosis codes and supporting documentation that can only be provided by a licensed dental professional.

How long does it take for dental insurance to process a claim after receiving a narrative?

There are various factors that can affect the processing time depending on the insurance company that is handling the claim, however, most insurance companies will respond within 30 days after receiving a complete narrative and supporting documents. If there are any delays, your dental office can follow up.

What can I do if my dental insurance denies my claim even after a narrative is submitted?

An appeal can be made. Your dentist may provide more clinical information, or ask for a review by the insurance company's clinical staff. Appeals cases are a way to have initially denied claims approved.