Dec 20, 2023 4 min read

Understanding the Missing Tooth Clause

Most people who have dental insurance think that all essential procedures will be covered under their insurance. This myth gets busted when they receive rejections from insurance companies for services, for what they might consider trivial reasons. One such reason or clause that confuses the dental industry is the missing tooth clause. This clause, which is included in a lot of policies, states that any dental procedure to replace a tooth that was pulled or lost before the insurance coverage began would not be covered. Therefore, if your patient has a tooth pulled out or lost before their insurance coverage began, such policies typically would not pay for any procedure to replace the missing tooth. This could include services like implants, fixed partial dentures, or removable partials. This clause results in the patient having to spend significantly more than anticipated. This makes it necessary to check your patient's coverage thoroughly for missing tooth clauses.

Key Points to Note While Looking for a Missing Tooth Clause:

In some instances, after a waiting period, the insurance coverage may pay for tooth replacement expenses. However, the plan may not pay for the tooth replacement if the tooth was lost within the waiting period specified in the missing tooth clause. Remember, insurance companies have different waiting periods, which typically range from a few months to a year. Some insurance plans may also include waiting periods of up to five years.

What Can Your Practice Do About Missing Tooth Clauses?


Insurance companies may reject claims based on a missing tooth clause when your practice least expects it. In such cases, a predetermination can help guarantee that your patient receives the information they need to make an economically sensible decision on their treatment. It can be a useful strategy for your practice when working with patients, to secure their consent for desired treatment plans. This helps them gain a better understanding of their out-of-pocket expenses following any coinsurance, deductibles, and policy maximums. Dental practices may have to perform predeterminations for several reasons, including potential missing tooth clause-related rejections.

Detailed Treatment Plan

Giving your patients a treatment plan following the diagnostic appointment is another step your practice can take. This will encourage your patient to open a dialogue their insurance company and help them better understand their course of treatment and the clauses included in their coverage.

Send Appeals

Make sure that you send appeals for rejected claims due to missing tooth clauses, for which you have necessary documentation as proof or support. Sometimes the first decision is reversed by the first appeal, and benefits are paid out. There are times a second appeal is required, or a peer review is asked for. Having an appeal template for the missing tooth clause can be a good idea. The appeal also helps inform your insurance provider that the patient would not have accepted the service if payment was not going to be provided. Your documentation can serve as evidence that shows your practice has conducted the required research on reimbursement for the procedure.

Educate Your Patients

The most important thing to remember is to inform and educate your patients about missing tooth provisions in their insurance coverage before starting a treatment. Make sure you have completed a pretreatment estimate and have the necessary documentation on the policy on-hand in case you need to file an appeal. By taking these actions, your practice will at least be able to keep your patients from being taken by surprise by huge out-of-pocket expenses. Building a financially sustainable dental care plan for your patient's dental care and gaining patients who trust you and your team can depend on this step.

How Does Ignoring Missing Tooth Clauses Affect the Practice?

Ignoring missing tooth clauses can lead to your patients losing trust in our practice and can also result in revenue loss. If the claim is rejected after replacing a patient's missing tooth, you lose money. Further more, the practice's reputation may suffer if the claims get denied. It is natural for a patient to expect that your practice has done the necessary verifications with the insurance company. Not doing so will result in the patient inconvenienced with a sizable amount that will have to come out of their pocket. Remember, a practice's value is greatly enhanced by their patients’ trust. The development and success of a practice depends on its reputation. Understanding the missing tooth clause and assisting patients in using their insurance benefits helps your practice avoid denials due to a missing tooth clause.

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