Is AI denying your dental claims? What insurers actually do with it, and what a solo practice controls

By Profit Smiles · Published October 24, 2026

A claim comes back paid as a cheaper procedure than the one you submitted. The explanation of benefits gives a code and not much else. Someone on your team pulls the chart, finds the X-ray, writes a narrative and sends it all back, and the patient gets a bill for a difference they were not expecting.

It is tempting to blame a computer. Dental insurers do use artificial intelligence on claims, and some have said so publicly for years. But what they describe is narrower than the stories about AI denials, the best-known of which come from medical insurance, and the difference changes what a practice should do about it.

This guide covers what insurers and their vendors have actually said, what the American Dental Association is asking for, and four things a solo practice controls: the claim it sends, what it does when one comes back, what each plan really costs, and how much it depends on insurance at all.

• What dental insurers say they do with AI
• Who decides a denial
• What the software reads
• Downcoding: the problem dentists report
• Why one denial costs more than the claim
• Send a claim that is hard to misread
• Decide in advance what you appeal
• Count what each plan really costs
• Lean on insurance less
• How one practice did it
• Run your own numbers
• Sources

What dental insurers say they do with AI#

The most detailed public account comes from Delta Dental of Michigan. In 2022 the insurer and its software vendor, NovoDynamics, announced that they had added real-time AI analysis to the insurer's claim processing to speed up payment. The insurer's chief science officer described the division of labor: "When claims require human review, NovoHealth Dental annotates the associated radiograph (x-ray) images and automatically routes them to our analysts."

The vendor's 2024 announcement shows what the software looks for. By then it had been screening claims for scaling and root planing, submitted to Delta Dental of Michigan and its affiliates in two other states, since 2023, and, in the vendor's words, "a claim may be denied when the procedure does not appear to meet payer clinical guidelines, such as when insufficient bone loss to warrant an SRP procedure is detected on the radiographic (x-ray) image."

Another vendor, Overjet, said in 2024 that its customers include the majority of the ten largest US dental insurers; Guardian, it said in 2021, was the first national carrier to put its AI into claims processing. Overjet describes a similar split: a claim that meets the insurer's criteria is approved automatically, one missing information can trigger an automated request to the dentist, and the rest go to the insurer's clinical review staff or to Overjet's own dental consultants. In the dental plans' trade association's report on 2022, four of the fourteen companies that answered were already using AI to review radiographs.

Who decides a denial#

Every insurer and vendor account cited here says the software can approve a claim on its own but does not make the final call on a denial. The vendor that screens Delta Dental of Michigan's claims writes that dental insurers "are required to have a credentialed clinician review a claim before it can be denied for not meeting their clinical guidelines." In its ten-month pilot, the insurer's clinicians agreed with the software's denial recommendations more than 86% of the time. Overjet's vice president of legal wrote in 2025 that its AI "is never used to deny claims."

The American Dental Association wants that rule written down rather than taken on trust. In September 2026 it told a House subcommittee that "insurers should not use AI as the sole basis for claim denials or prior authorization decisions," and in March it asked the Centers for Medicare & Medicaid Services to require that payers using AI in claims not use it to make final decisions on claim denials or prior authorizations. Some states have already written it into law. Maryland's 2025 law says an AI or software tool "may not deny, delay or modify health care services," and it covers dental plan organizations. California's, in force since January 2025, leaves medical-necessity decisions to licensed professionals and reaches both dental plans and dental-only insurance policies.

Profit Smiles found no published evidence that dental denials are rising because of AI. The best-known stories about automated denials come from medical insurance: in 2023, ProPublica reported that Cigna doctors, working through claims its system had flagged, denied more than 300,000 requests for payment over two months, spending an average of 1.2 seconds on each. Read those as a warning about where automation can go, not as a description of your dental plans.

What the software reads#

The screening described in public reads the claim and its attachments: it checks the claim for completeness against the plan's rules and measures the radiographs against the insurer's clinical guidelines for the code. A claim whose films are clear and whose charting supports the code is the kind the vendors say is approved without a person looking at it. A claim missing information can be sent straight back to the office, and one whose images or record do not appear to support the code goes to a clinical reviewer; that is where delays and denials happen.

That makes the documentation the part of the process a practice controls most directly. The ADA's own guidance on scaling and root planing claims says that dental plans name radiographs that are not of diagnostic quality as a common reason those claims are denied or sent back for more information.

Downcoding: the problem dentists report#

Downcoding is the ADA's word for a plan paying a claim as if it were a different, cheaper procedure than the one submitted. In October 2025 the ADA described a case. A dentist reported a two-surface posterior composite, code D2392, and a Delta Dental member company paid it as a single-surface restoration. The plan called it a national policy of the Delta Dental Plans Association. The ADA said it knew of other cases too: three-surface restorations paid as two-surface ones, posterior composites paid as amalgams, and the adult cleaning code rejected for a 12-year-old with adult teeth.

Nothing in that report blames software, and the ADA's answer would be the same either way. In June 2026 the chair of its coding subcommittee wrote that a dentist "should report the code that accurately reflects the procedure performed and should not be required to alter clinical reporting to conform to a payer's payment preference."

Why one denial costs more than the claim#

A denied or downcoded claim costs its own amount, then the front-desk time to appeal it and follow it until it is paid or dropped, and then a conversation: the patient who expected the plan to pay now has a bill and wants to know why. A team that can say exactly what the plan did, and what the practice is doing about it, can keep that patient's trust.

This guide uses no figure for what a denial costs to rework, or for how often dental claims are denied. The estimates Profit Smiles found come from medical billing or from vendor surveys, and none of them describes your plans.

Send a claim that is hard to misread#

Four habits help, and every one of them is in the ADA's own guidance:

1. Code what you did. "The only proper action is for the dentist to code for what they have done," as the ADA puts it. A code chosen to fit what a plan prefers to pay is a problem of its own.
2. Send images that show what the code claims. For the procedures your plans review most closely, check the film before the claim goes out.
3. Chart what supports the code. For scaling and root planing, the ADA says proper charting typically covers at least six sites around each affected tooth.
4. Write the narrative even when it seems obvious. The ADA's appeal guidance asks for radiographs, photographs, charting and "a narrative description providing as much information as possible (even if this appears obvious to you)"; the same material can go with the first claim.

Decide in advance what you appeal#

When a claim comes back short, whether to fight it should not be decided from scratch by whoever opens the mail. A written routine settles it ahead of time:

• Which claims get appealed. For example: every downcode on a procedure you documented, and every denial that asks for an attachment you have.
• How. A proper appeal, in the ADA's words, is "a written request to reconsider the claim," and "a phone call is not acceptable." When the explanation of benefits does not explain a downcode, which the ADA says is often the case, appeal in writing, ask the plan for its rationale, and keep the clinical record that supports the code.
• By when. Appeal windows vary by plan. The ADA notes that some plans require appeals within six months of the original denial, and some allow up to three appeals with different consultants.
• What gets written down. Keep a log of each payer's denials and downcodes, by code: the record you will want when you decide which plans to keep.

ADA members can also take a payer problem to the ADA's free Third Party Payer Concierge, which, the ADA says, may not be able to get a claim paid but can help with the appeals process.

Count what each plan really costs#

Every plan you take already costs you its contracted write-off, the gap between your office fee and the fee the plan allows. Across a PPO-heavy practice, write-offs take 30–50% of gross production, the range Profit Smiles uses. Denials, downcodes and the hours spent on appeals come on top, and the log from your appeal routine will show which payers produce them.

The guide to dropping a PPO walks through scoring each plan and running the break-even before you leave one. Put your denial log beside that score. A plan that pays a poor fee and also downcodes what it does pay is a different decision from a plan that pays a poor fee cleanly.

Lean on insurance less#

Two moves cut the number of claims that decide what you collect, without turning insured patients away.

Leaving a network is not refusing insurance. Out of network, the practice still sees the plan's patients and still files their claims, but it collects its own office fee: the plan pays whatever out-of-network benefit it offers, and the patient pays the balance. A downcode then changes what the plan pays toward the visit, not what the practice may collect for it.

Patients with no insurance need no claims at all. About 27% of US adults have no dental insurance, according to the CareQuest Institute. An in-house membership plan gives them predictable care for an annual fee and a member discount, and the practice collects directly, with no claim for anyone's software to screen. The guide to starting a membership plan covers how to build one, and the guide to its legal requirements covers the five checks to make before the first member joins.

How one practice did it#

Dr. Prachi Deore runs Coppell Smiles, a solo practice in Coppell, Texas, and hers was the first practice on Profit Smiles — the tools were proven there before they were offered to anyone else.

She started with her own plans: what each one actually paid, what it wrote off, and what would happen if she left it. Then she left the plans that lost money, about 80% of her plans by count of contracts, and kept one large plan deliberately because it carried a big share of her patients. Six months after dropping the unprofitable plans, her practice's monthly production was up $20,000.

She also runs a membership plan for her uninsured patients, which enrolled 48 members in its first ninety days.

As she puts it in the protocol's own training, the first step out of the squeeze of rising costs and lagging reimbursements "is knowing exactly which plans are doing the damage."

Her results are one practice's results, measured in the platform, and individual results vary.

Run your own numbers#

Three free calculators on this site do this guide's arithmetic: what your PPO plans write off each year, how many of a plan's patients you could lose by leaving its network and still collect the same production, and what a membership plan could bring in from the uninsured adults around your practice. Each opens with an example practice's figures; nothing you enter leaves your browser.

Sources#

• NovoDynamics and Delta Dental of Michigan, "NovoDynamics Accelerates Delta Dental of Michigan Workflow with Real-time AI Analysis of Streaming Insurance Claims" (Business Wire, April 12, 2022); the quotation is the insurer's chief science officer's.
• NovoDynamics, "Delta Dental of Michigan Clinicians Confirm NovoHealth Dental AI Achieves Exceptional Accuracy" (Business Wire, September 12, 2024), a vendor announcement: the screening since 2023, the ten-month pilot (more than 120,000 claim line items; 86%) and the credentialed-clinician statement.
• Overjet, "Overjet Launches the Next Evolution of Insurance Intelligence Platform" (May 7, 2024), "Using Dental AI to Strengthen the Payer-Provider Connection" (April 19, 2023) and its Series A announcement (August 26, 2021), vendor statements: the majority of the ten largest US dental insurers; Guardian the first national carrier. Josh Macfarlane, Overjet, on the National Association of Dental Plans' site (July 28, 2025): "Our AI is never used to deny claims."
• National Association of Dental Plans (May 2, 2023), from its 2022 Claims Metrics report: four of 14 responding companies using AI in radiograph review.
• American Dental Association, letter to the House Judiciary Subcommittee on the Administrative State, Regulatory Reform, and Antitrust (September 14, 2026); comments to the Centers for Medicare & Medicaid Services on its CRUSH request for information (March 27, 2026).
• ADA News, "ADA pushes back against payer downcoding on multisurface restorations" (October 7, 2025) and "Dear ADA: Downcoding" (June 18, 2026); ADA, "Downcoding."
• ADA, "How to File an Appeal"; "Claims Submission: Scaling and Root Planing (SRP)" (updated January 2023); "Dental Insurance Frequently Asked Questions"; ADA News, "Third Party Payer Concierge program comes back to life" (December 22, 2021).
• Patrick Rucker, Maya Miller and David Armstrong, "How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them" (ProPublica and The Capitol Forum, March 25, 2023): medical claims, not dental.
• Maryland Laws 2025, ch. 747 (H.B. 820), Insurance § 15-10B-05.1, in effect October 1, 2025, whose carriers include dental plan organizations; California S.B. 1120 (Stats. 2024, ch. 879), in effect January 1, 2025: Health and Safety Code § 1367.01(k), which reaches specialized health care service plans, dental plans among them, and Insurance Code § 10123.135(j), which reaches specialized health insurers, dental-only policies among them (§ 106(c)).
• CareQuest Institute for Oral Health, State of Oral Health Equity in America (2024 survey of more than 9,000 adults): 27% of US adults without dental insurance.
• Write-offs of 30–50% of gross production is the range Profit Smiles uses across all of its materials. This guide is not legal advice. Dr. Prachi Deore's results are those of one practice, measured in the platform; individual results vary.