Expenses incurred prior to coverage

Why this happens on dental claims

• Multi-visit work such as crowns and orthodontics started before the plan's effective date, where the payer counts the prep or banding date rather than the seat date
• New hires treated during an employer waiting period before dental benefits activated
• Enrollment lag where the employer added the employee late and the payer's effective date on file is simply wrong

How to appeal CO-26

1. Confirm the actual effective date with both the payer and the employer's benefits administrator, since payer files lag enrollment
2. For multi-visit procedures, check which date the plan treats as the incurred date and appeal if your dates qualify under the plan's own rule
3. If the payer's effective date is wrong, have the subscriber or employer push a corrected enrollment file, then request reprocessing
4. If coverage genuinely had not started, bill the patient promptly with a clear explanation

How to prevent it

• Verify effective dates, not just active status, before starting multi-visit treatment
• Document the plan's incurred-date rule for crowns and orthodontics when a patient's coverage is new