Key Takeaways
- The Main Culprit: Our internal data shows that Non-Covered Charges account for over 35% of all denials.
- Top Denial Code: The single most frequent denial reason is Code PR-96 (Non-covered charge), impacting thousands of claims annually.
- The AI Solution: In a recent case study, a large DSO used Remit AI automation to reduce "Resubmit/Rebatch" denial volume by 48%.
The Hidden Cost of Denials
The struggle with denied dental claims is the silent enemy of your practice, slowing down cash flow and burying your team in administrative rework. Every denied claim is a setback, a frustrating reminder of time and money lost.
In this guide, we break down the top five reasons claims get denied based on claims data processed through the Remit AI platform. We won't just list the problems; we'll show you how AI-powered Revenue Cycle Management (RCM) tools can turn your most frustrating work into a streamlined process.
Data Spotlight: The Real Top 5 Denial Categories
Based on an analysis of high-volume dental claims from a large multi-location DSO:
- Non-covered charge (Patient Responsibility): 35.24%
- Benefit Maximum (Patient Responsibility): 16.82%
- Resubmit/Rebatch Denied Procedure: 16.25%
- Frequency Limit (Patient Responsibility): 8.20%
- Duplicate Services: 6.14%
1. Incorrect Patient or Insurance Information (Eligibility)
The Problem: Data accuracy is the foundation of getting paid. While industry reports cite general issues, our internal data from a DSO reveals a stark reality: 35.24% of all their denials stem from "Non-Covered Charges" and 16.82% are due to "Benefit Maximum" limits.
This means over 50% of your denials could often be predicted as eligibility issues that occur before the patient even sits in the chair. The most common specific denial code we see is PR-96 (Non-covered charge), which alone accounted for 9.04% of total denial volume in our study.
How AI Solves It: AI moves you from "correction" to "prevention."
- Front-End Defense: Automated eligibility verification tools catch coverage limits and non-covered benefits before submission.
- Back-End Intelligence: For submitted claims, tools like Cavi AR (within Remit AI) instantly flag these specific denials. This allows your team to bill the patient immediately rather than wasting time appealing a valid insurance rejection.
2. Claim Submission Errors (Resubmits & Rebatches)
The Problem: Administrative churn is a major revenue leak. Our data shows that "Resubmit/Rebatch Denied Procedure" is the third most common denial category, accounting for 16.25% of total denials. These are often technical errors, missing fields, or process gaps that force your team to do the same work twice.
How AI Solves It (Case Study): AI doesn't just track these errors; it fixes the workflow.
Success Story: By implementing Remit AI’s automated workflows, a large multi-location DSO achieved a dramatic reduction in administrative rework:
- 48% reduction in "Resubmit/Rebatch" denial volume (dropping from 9,078 to 4,710 claims).
- Result: Staff spent significantly less time chasing paperwork and more time on high-value tasks.
3. Benefit Maximums Exceeded
The Problem: It is frustrating to perform work only to find the patient has no benefits left. In our analysis, Code CO-45 / PR-119 (Benefit Maximum) was a top recurring specific denial code. These denials are "hard" denials—no amount of appealing will get the insurance to pay if the max is met.
How AI Solves It:
- Real-Time Tracking: AI tools monitor utilized benefits against the annual maximum.
- Denial Prioritization: When these denials do come in, AI categorizes them as "Patient Responsibility" immediately, automating the move to patient billing so you can collect faster. In our case study, the DSO reduced the volume of these active denials by 47% (from 9,324 to 4,958) by handling them more efficiently.
4. Duplicate Services
The Problem: Submitting the same claim twice is a common symptom of a disorganized billing process. Our data shows that Duplicate Services account for over 6% of total denials. This often happens when staff don't have visibility into claim status and assume a claim wasn't received.
How AI Solves It:
- Step Tracking: Cavi AR provides full visibility into the claim lifecycle. It tracks "touches" and status updates, ensuring staff know a claim is "In Process" so they can follow up with the payer for remittance updates, if need be.
5. Missing or Incomplete Documentation
The Problem: While "coding" gets the blame, often the proof is simply missing. Denials for "Non-covered charges" often overlap with missing narratives or X-rays that prove necessity. If the payer can't verify the need, they default to "Non-covered."
How AI Solves It:
- Gap Analysis: Cavi AR’s denial intelligence engine scans rejections to identify exactly what is missing.
- Actionable Alerts: Instead of a generic error code, your team receives a plain-text prompt telling them exactly which document to attach for a successful resubmission.
Leveraging AI for Smarter Denial Management
AI-assisted denial management helps practices move from reactive to proactive workflows. With Cavi AR, teams can:
- Focus on what really matters with pre-filtered claims and smart scheduling
- Understand denial reasons clearly with plain-language explanations and take immediate action
- Track all steps on denied claims for complete accountability and audit trails
- Identify problematic codes with high denial rates and flag claims that don't go out clean
- Automate claims-to-payments matching to eliminate manual reconciliation work
- Combine ERA and EOB data for comprehensive insights into payer behavior patterns
This approach reduces administrative workload by up to 50% and accelerates reimbursements by an average of 23%.
Real practices using Cavi AR have reduced their most challenging denial categories by 12-14% within six months, preventing hundreds of denials and recovering significant revenue that would have been lost to manual processing delays.
Ready to Transform Your Revenue Cycle?
You've worked hard for every dollar. Don't let PR-06 or Benefit Maximums dictate your cash flow. See How Practices Reduced Top Denial Categories by 14% in 6 Months – Book Your Demo Today
Frequently Asked Questions
What is the most common reason for dental claim denials?
According to Remit AI internal data, Non-Covered Charges (Patient Responsibility) is the top category, accounting for over 35% of denial volume.
How long do I have to resubmit a denied dental claim?
Most dental insurers allow 90-180 days from the date of service or date of denial to resubmit, but deadlines vary significantly by payer. Some insurers have stricter 60-day windows, while others may allow up to 365 days for corrected claims. Always check your specific payer contracts and use automated tracking to avoid missing deadlines.
Can AI really reduce dental claim denials?
Yes. In a recent case study, a DSO using Cavi AR reduced its volume of "Resubmit/Rebatch" denials by 48% and "Benefit Maximum" denials by 47%.
What does Denial Code PR-06 mean?
PR-06 stands for "Patient Responsibility - Deductible." However, in many contexts, it serves as a catch-all for "Non-covered charge." It was the #1 volume driver in our 2024 analysis.
What's the difference between a claim denial and a claim rejection?
A rejection occurs when the clearinghouse or payer refuses to accept the claim due to errors (wrong format, missing information). Rejections happen quickly and can be corrected and resubmitted. A denial occurs after the payer processes the claim but refuses payment. Denials require appeals or corrected resubmissions and are subject to timely filing limits.
Should I appeal every denied claim?
Not necessarily. Use value-based prioritization: focus on high-dollar denials and those with strong clinical documentation. Claims denied for timely filing or missing information may not be worth appealing.
Why do multi-location practices have higher denial rates?
Multi-location practices face unique challenges: inconsistent coding practices across offices, different staff training levels, varied payer mixes by location, and complex coordination of benefits. Each location may develop its own workflows, leading to systematic errors that multiply across the organization. AI-powered centralized denial management helps standardize processes and provide visibility across all locations, reducing these inconsistencies.
