Have you ever experienced claim denials due to procedures “exceeding frequency”? It’s a common issue in dental insurance when insurance companies deny claims for some procedures that exceed their frequency limitations.
The frequency limitation rules determine how often insurance companies pay for a certain procedure. By knowing these rules, you can effectively reduce claim denials, keep your patients happy, and ensure a smooth dental revenue cycle management for your practice.
Want to know how these rules impact your dental claims, and which best practices help you submit clean claims? Let’s discuss in detail.
What is Frequency Limitation?
Frequency limitation is a rule from insurance companies that limits how often they cover a dental procedure within a certain timeframe. Maybe it’s two cleanings a year, or maybe it’s once every five years for a crown.
These rules usually affect preventive and diagnostic services like cleanings, exams, X-rays, and fluoride treatments. But they also apply to bigger procedures, like crowns, bridges, and even periodontal maintenance.
The tricky part? Every plan is different. One insurer might cover two root canal treatments a year, while another payer might allow only once a year. This is exactly why claims get denied.
Understanding these rules is important for your dental revenue cycle. It saves you hours of inquiring details on the phone with insurance reps and helps maximize your reimbursements.
Why Do Insurance Companies Use Frequency Limitations?
Insurers use frequency limitations to control costs. These limitations help them avoid paying for treatments, which they consider unnecessary.
For example, most patients don’t need more than two cleanings per year. If you bill for three or four cleanings per patient within a year, insurance may ask if it’s really needed, and deny the claim.
Some patients genuinely need extra care and treatment for periodontal disease, high cavity risk, or other health issues. But insurers create policies according to the general population, instead of individual patient needs.
So, you should know the frequency limitation rules to:
- Guide your patients on time
- Prevent unexpected costs
- Protect your practice revenue
Common Procedures with Limited Coverage by Insurers
While each dental procedure doesn’t have limits, some procedures including routine services by your practice may do. It depends on each insurance company’s policies.
But, let’s have a quick look at some procedures commonly covered by insurers:
- Cleanings (Prophylaxis): Usually two per year or one every six months. Insurance may cover a third cleaning if medical necessity is proven.
- Exams: Usually limited to twice a year for periodic exams. Comprehensive exams might only be covered once every three years.
- Bitewing X-Rays: Usually once or twice a year. Full mouth X-rays have stricter limits, mainly once every three to five years.
- Fluoride Treatments: Most pediatric plans cover it once or twice a year. Adult coverage is rare.
- Periodontal Maintenance: After active treatment, quarterly maintenance is sometimes covered. Some plans separate it from regular cleanings.
- Crowns and Bridges: Usually once every five to seven years per tooth. Replacing a crown too soon requires clinical documentation for evidence.
- Sealants: Mainly limited to once per tooth every three to five years, and is available mainly for children.
With a strong front office management, you can identify these procedures easily and communicate that to patients before treatment begins, so they’re prepared to expect costs and make decisions.
How Frequency Limitations Are Calculated?
Each insurance plan defines its own criteria to calculate frequency limitations. Below are some ways through which coverage for procedures is calculated and limited:
| Limitation Criteria | Description | Example |
|---|---|---|
| Calendar Year | Limitation resets at the start of the year and is valid throughout the 365 days. | If a patient has two cleanings in the year 2025, the limit resets on January 1, and the patient can get two cleanings in 2026. |
| Benefit Year | Starts on the patient’s insurance enrollment year. | Instead of January 1, the coverage limitations start from the date when the patient enrolls with insurance (e.g. July 1). |
| Rolling Periods | A rolling period starts from the last date of the previous dental treatment. | If a patient has a root canal treatment on a tooth dated September 10, further treatment can’t be covered within the next six months, e.g. March 10. |
| Per Tooth | Coverage for treatment on a particular tooth is limited for the specific timeframe. | If tooth #3 has a crown treated five years ago, it might be eligible for replacement, but other teeth are subject to different rules. |
| Age-Based | Some treatments cover only certain ages. | Fluoride or sealants may be covered for patients under 19, and adults may not get coverage at all. |
Above are just examples. Each patient’s coverage plan is different, and you have to verify benefits and limitations according to the plan, and proceed with the treatment.
Frequency Limitations vs. Waiting Periods: What’s the Difference?
The two terms, frequency limitations and waiting periods, might seem confusing. It’s important to understand the differences. With that, treatments are planned accurately, and claims are submitted without risking denials.
So, frequency limitations define how often a covered procedure can be performed and reimbursed within a set timeframe. If treatment is within the timeframe, there is no need to wait.
Speaking of waiting period, it’s a set amount of time during which a patient must wait before certain benefits begin.
Example: A patient switches to a new plan. They have to wait six months before a filling is covered. But even after that waiting period is over, frequency limits still apply. If they got a crown on the same tooth three years ago under a different plan, they might not be eligible for a replacement because of the frequency rules.
The key difference? Waiting periods usually apply just once when a patient first enrolls in an insurance plan, while frequency limitations are ongoing and apply throughout the plan.
How to Verify Frequency Limitations Before Treatment?
The best way to prevent claim denials is to catch issues before treatment. Verifying frequency limits timely makes it easier to explain coverage to patients instead of presenting them with surprise bills after treatment.
These following actions help verify coverage limitations on time:
Contact the Insurer
Get the patient’s ID number, date of birth, and procedure codes ready. Ask directly about frequency limits for the planned treatment.
Check Explanation of Benefits
Whether paper or electronic, an Explanation of Benefits (EOB) statement shows what’s been covered and when. This helps you figure out when the next service will be eligible.
Use Payer Portals
Many insurers have portals where you can check benefits in real time. They show the last date of service for specific procedures and when the next one will be covered.
Review Plan Documents
If the patient has a benefits booklet, it should outline frequency limits. But be careful! These documents can be outdated. Always verify on time by contacting the insurer.
Document Your Conversation
When you verify benefits, note who you spoke with, the date, time, and what they said. This documentation legally protects you if there’s ever a dispute.
Update Patient Records
Once verified, record frequency limits in the patient’s chart. This keeps your whole team informed and avoids scheduling conflicts.
Automate Insurance Verification
Verifying frequency limitations might sound like a lengthy process, which requires staff’s time and effort. Automating insurance eligibility verification is the right solution for that. It helps check frequency limitations from insurance plans in real-time, so you can inform the patients about what insurance covers and costs they need to pay.
What Happens If Treatments Exceed Frequency Limitations?
Insurers deny claims for procedures which exceed their set frequency limitations.
Denials can lead to many issues for your staff and patients, such as:
- Patient Responsibility: If insurance doesn’t pay, the patient owes the full cost. If they aren’t expecting it, this leads to frustration and even disputes.
- Administrative Burden: Your billing team now has to explain the denial to the patients, discuss options, and possibly file appeals. That’s hours of work that could’ve gone elsewhere.
- Revenue Delays: Even if the patient eventually pays, your cash flow takes a hit.
- Appeals and Documentation: Appealing requires detailed notes, supporting documentation, and sometimes peer-to-peer reviews. It’s a lot of work with no guarantee of success.
- Compliance Risks: Repeatedly billing for services that exceed limits can lead to external investigations.
Strategies for Handling Frequency Limitation Denials
You can manage frequency limitation denials with effective strategies:
- Review the Denial Carefully: Make sure the denial is really due to frequency limits and not a coding error or missing info.
- Check Your Records: Look at when the last service is performed and compare it to the plan’s rules. If there’s a discrepancy, you have some strong points to appeal.
- File an Appeal with Documentation: If a service is medically necessary despite exceeding the limit, file an appeal with detailed clinical notes, radiographs, periodontal charts, or other diagnostic records.
- Submit a Predetermination: For future cases, consider submitting a predetermination before treatment. The insurance company reviews it and gives a clear answer upfront.
- Offer Alternative Payment Options: If the appeal fails, work with the patient. Offer payment plans, alternative treatment timing, or discounts if appropriate.
- Educate the Patient: Explain the insurance limitations upfront. Patients who understand their plan are more likely to accept financial responsibility without frustration.
- Track Patterns: If a certain insurer continues to deny claims, review if your staff is unable to understand their rules or if codes are inaccurate. Identifying patterns helps prevent repeated issues.
This denial management helps you reduce financial loss and maintain good relationships with your patients, even when insurance plans don’t cover certain treatments.
How to Explain Frequency Limitations to Patients?
Dealing with patients and explaining frequency limitation rules to them is very tough. After all, most patients don’t truly understand their dental insurance.
And frequency limitations? That usually just adds to their confusion.
Now, it’s up to your staff to explain that to patients in a way that they can easily understand these limitations and are convinced to pay for the costs. Here are a few tips for you to do it smoothly:
Communicate Clearly
Instead of using technical and insurance-specific terms, explain limitations to the patients in a simple and clear way.
Example: If an insurance plan allows two prophylaxis procedures per calendar year, explain this to them in an easy way: “insurance covers two cleanings a year”.
Patients also want to know when they can expect to be back for a procedure. Now, if their cleaning is in March and their insurance plan doesn’t allow the next cleaning for the next six months, explain to them that their coverage covers the next one starting in September.
Explaining everything clearly builds trust and allows patients to make the right decision according to their budget and health needs.
Explain the Rule’s Purpose
Patients can question you why insurance companies offer limited coverage on some treatments. If you explain the reason, they can be more understanding and cooperative.
You might explain that in this way: “Insurance companies set these limits to control costs and encourage routine care without performing more treatments than needed.”
Offer Flexible Treatment and Payment Options
Your front-end staff should handle the situation smartly. Instead of just telling patients what insurance doesn’t cover, offer them alternative options.
For example, you can advise them to wait for the coverage plan to reset, or move forward with the treatment, but they’ll have to pay for the charges. And if patients can’t afford the expenses, offer them flexible payment options.
Create payment plans for 6 months, 1 year, or 2 years, depending on treatment costs, making it easier for patients to pay in monthly installments for the set timeframe.
Provide Written Estimates to Patients
After the conversation, provide a written estimate that clearly shows what insurance pays and what the patient is responsible for. This avoids confusion later.
Set Early Expectations
Ideally, these conversations start at the first visit. When patients understand how their insurance works from the beginning, there are fewer surprises down the road.
When patients know what to expect upfront, they’re much less likely to get upset when insurance doesn’t cover something.
Exceptions to Frequency Limitation Rules
Here is the good news: Insurance companies make exceptions to their frequency limitation rules in some situations. Let’s discuss them below.
Medical Necessity
If a patient needs more frequent treatment due to a medical or dental condition, insurance may approve it. For example, someone with advanced periodontal disease might genuinely need cleanings every three months.
Changes in Oral Health
If a patient’s condition has clearly worsened since their last visit, that can justify additional treatment. Provide strong documentation to the insurers to strengthen your claim.
Emergency Situations
Insurers may provide coverage when an emergency treatment is required. For example, insurance may approve a broken crown that needs immediate attention, even if the five-year limit hasn’t passed yet.
Appeals with Solid Documentation
Denied claims can be appealed when there is strong clinical justification. Peer-to-peer reviews, where the dentist speaks directly with the insurance consultant, can be especially effective.
Coding for Procedures
Sometimes, coverage issues are not due to frequency limitations. These can also be due to coding errors.
For example, a patient who needs more frequent cleanings due to gum disease may qualify for periodontal maintenance (CDT D4910) instead of a standard cleaning (CDT D1110). So, if you know the right code for a procedure according to the patient’s dental condition, you can bill that to get claims approved.
If you notice all the above situations, providing correct documentation is common. Detailed notes, X-rays, periodontal charts, and clear explanations can improve chances of claim approvals.
Coding Considerations and Frequency Limitations
Good dental coding isn’t just about getting paid. It also helps you avoid unnecessary denials and compliance issues.
So, follow these instructions to submit claims according to frequency limitations.
- Use the correct code every time: Coding errors are one of the top reasons claims get denied. Make sure the code matches the service provided.
- Know the difference between similar procedures: An example is that adult cleanings and periodontal maintenance aren’t the same thing and don’t follow the same frequency rules. Using the wrong code can lead to claim denial.
- Support your codes with documentation: If a service exceeds frequency limits, your clinical notes should clearly explain why the treatment is necessary.
- Never upcode or downcode: Using the wrong code just to get around frequency rules is a serious compliance issue. If treatment is needed more than the limitations, document the reason and submit an appeal instead.
- Follow CDT updates regularly: CDT codes change each year. Make sure your staff uses the latest codes and understands how changes impact coverage rules.
Accurate dental billing and coding protects your practice, reduces denials, and keeps your billing smooth.
Conclusion
Frequency limitation rules set the number of times an insurance covers certain dental procedures during a certain timeframe, and exceeding them can lead to claim denials and patient frustration. Plans vary, and some allow exceptions for medical necessity or emergencies. It’s important to know these limitations. Partnering with a reliable billing company like TransDental, helps your practice master these rules, stay compliant, and prevent denied claims.
Frequently Asked Questions (FAQs)
What is frequency limitation denial code in dental billing?
A frequency limitation denial code is a number which indicates that the insurance denies the claim because the procedure is done very frequently or too soon based on the plan’s rules.
What is frequency limitation in dental insurance?
Frequency limitation is the rule that controls how often a dental service is covered, such as cleanings every 6 months, X-rays once a year, or crowns every 5 years.
What are Medicare frequency limits in dental billing?
Original Medicare generally doesn’t cover routine dental care, so frequency limits usually don’t apply. Dental services are only covered in rare, medically necessary situations (like dental work tied to a covered surgery). Medicare Advantage plans may offer dental benefits, and those plans set their own frequency limits.
What does “no frequency” mean on dental insurance?
“No frequency” means the dental plan doesn’t set a time limit on how often that specific service can be covered. Coverage still depends on medical necessity and plan rules.
How often does dental insurance cover X-rays?
It depends on the plan, but most dental insurance covers bitewings once every 6-12 months and full-mouth or panoramic X-rays once every 3-5 years.
Why is a dental claim denied due to frequency?
A claim is denied due to frequency when the procedure is performed before plan is renewed. The insurance records show the service is already paid for within that specific duration.
