Dental Insurance Questions and Answers
BenefitsAll
Below is a list of 15 common dental insurance questions and answers. They were developed with the help of a Washington, DC-based dental practice. Dentists and their billing administrators work closely with dental insurers to get claims paid. They are uniquely positioned to know what insurance coverage is needed, what insurers pay for claims, and which claims they often deny.
Dr. Bridgette Rhodes, DDS
Click the tabs on the left side of the page to view the dental insurance questions and answers.
- Do I Need Dental Insurance?
- What are different types of dental insurance plans?
- Which dental insurance plan should I choose?
- What is maximum allowable charge and usual and customary fee?
- What is difference between twice per year versus every 6 months cleanings?
- Is it a dental or medical claim?
- If I have coverage under my own
plan and a spouse's plan, is my dental
care covered at 100%? - My dentist said she accepted my insurance, but does not. Am I responsible for paying the additional costs?
- Why is my dental care bill larger than expected?
- What are the most frequently denied dental insurance claims?
- How can I prevent my dental claims from being denied?
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You may need dental insurance if you answer "yes" to two (2) or more of the questions below.
Other things to consider when deciding if you need dental insurance.
If your employer pays part of your dental insurance premium, you and your covered family members may receive more benefits than you contribute in premiums (if any).
If you are responsible for paying 100% of the dental insurance premium, determine if what you pay in premiums will be greater than what you expect to receive from the plan. Remember that if you are participating in an employer-sponsored plan, you are probably paying premiums with tax-free dollars, reducing dental insurance costs even more (see Example).
For example, suppose your annual dental insurance premium is $480 ($40/mo.), and you anticipate receiving two regular dental cleanings at $150 each ($300 per year). In that case, it may seem like you would save $180 if you paid for the cleanings out of pocket instead of purchasing insurance. However, if your dental insurance premium is tax-free, the $480 per year is closer to $336 (assuming a 30% tax savings). For an additional $36, you can have insurance coverage for the remainder of the year to cover unplanned dental care expenses.
You can maintain this coverage for as long as necessary and terminate the coverage when needed and allowed by the plan. Work with your dentist to create a treatment plan for your dental care needs.
The final question you need to answer is:
Can you afford to cover expected or unexpected dental care expenses ranging from a few hundred to a few thousand dollars without insurance?
Affordable Care Act (aka Obamacare). As of January 1, 2014, plans on the Exchanges have to provide child dental coverage as part of a medical or stand-alone dental plan. Adult dental coverage is not required but may be purchased on the federal and some state Exchanges.
- Was your last dental cleaning more than 18 months ago?
- Do you have broken or missing teeth?
- Do you have bleeding or painful gums?
Other things to consider when deciding if you need dental insurance.
If your employer pays part of your dental insurance premium, you and your covered family members may receive more benefits than you contribute in premiums (if any).
If you are responsible for paying 100% of the dental insurance premium, determine if what you pay in premiums will be greater than what you expect to receive from the plan. Remember that if you are participating in an employer-sponsored plan, you are probably paying premiums with tax-free dollars, reducing dental insurance costs even more (see Example).
For example, suppose your annual dental insurance premium is $480 ($40/mo.), and you anticipate receiving two regular dental cleanings at $150 each ($300 per year). In that case, it may seem like you would save $180 if you paid for the cleanings out of pocket instead of purchasing insurance. However, if your dental insurance premium is tax-free, the $480 per year is closer to $336 (assuming a 30% tax savings). For an additional $36, you can have insurance coverage for the remainder of the year to cover unplanned dental care expenses.
You can maintain this coverage for as long as necessary and terminate the coverage when needed and allowed by the plan. Work with your dentist to create a treatment plan for your dental care needs.
The final question you need to answer is:
Can you afford to cover expected or unexpected dental care expenses ranging from a few hundred to a few thousand dollars without insurance?
Affordable Care Act (aka Obamacare). As of January 1, 2014, plans on the Exchanges have to provide child dental coverage as part of a medical or stand-alone dental plan. Adult dental coverage is not required but may be purchased on the federal and some state Exchanges.
Dental insurance plan types are similar to medical insurance plan types. The different dental insurance plan types include traditional indemnity, HMO, PPO, and EPO plans. There are also dental plan discount programs that are not insurance but offer discounts for dental care services.
HMO or DHMO plan - insurer provides a fixed monthly payment to dentists who contract with them to provide dental services to participants enrolled in the plan. Exams, x-rays, and cleanings are typically covered at 100% by the plan. All other dental services usually require payment of a flat dollar co-pay. The plan participant usually must designate a primary care dentist when they enroll in the plan or before receiving benefits. The plan may require referrals to specialists
PPO plan - insurer contracts with dentists who agree to provide care at negotiated rates less than out-of-network dentists would charge for the same procedure. The plan typically pays 50% to 80% of the contracted amount, and the participant is responsible for the balance. This group of contracting dentists is referred to as preferred or participating providers. Plan participants may have to pay higher out-of-pocket costs for services received from out-of-network dentists. Plan participants can visit any dentists in the network of participating providers without a referral
EPO plan - insurer contracts with dentists who agree to discount their fees to participants enrolled in the plan. However, there is no option to receive benefits outside the network (like the dental HMO). No referrals needed to visit an in-network specialist
- Traditional indemnity plan - insurer provides payment on a fee-for-service basis, usually at 50% to 80% of the cost of treatment. The payment by the insurer is based on their usual, customary, and reasonable (UCR) fee or table of allowance (list of covered services with assigned dollar amount). The plan participant can
There are many different types of dental insurance plans. Dental HMOs and PPOs are two of the most popular types of plans. Also, your employer may design the dental plan to have a high or low option (e.g., high and low option PPO). A high and low option PPO dental plan design allows you to choose between different benefit levels that have different premium rates. Your employer may refer to high and low option dental plans as two different plans because of the differences in benefits levels and costs; however, they are usually one plan from the point of the insurer and provider.
Consider choosing a dental plan based on:
Dental HMOs typically have lower monthly premiums and pay 100% of the cost for preventive dental care services such as exams, x-rays and cleanings. They also have fewer participating dentists accepting new patients, provide lower reimbursements for basic and major dental care services, and limit which dentists you can visit. You may pay more out-of-pocket for non-preventive dental care services with a dental HMO plan.
Dental PPOs typically have higher monthly premiums than dental HMOs, and most pay 100% of the cost for preventive services. PPO plans have more extensive networks of participating providers and allow enrolled participants to visit dentists outside their network. If you receive care from an out-of-network dentist, your out-of-pocket costs will be greater than if you visited an in-network dentist.
For example, if your current dentist participates in your dental HMO plan and you only anticipate receiving two routine cleanings in a year, the lower-cost dental HMO may meet your needs. If you anticipate dental care beyond your twice-a-year cleanings, or cannot locate a suitable dentist accepting new patients, consider enrolling in a dental PPO plan.
Consider choosing a dental plan based on:
- anticipated dental care needs for the upcoming 12 months
- how much you are willing to spend in monthly premiums and for services that are not covered by the plan
- flexibility in choosing a dentist and getting timely appointments
Dental HMOs typically have lower monthly premiums and pay 100% of the cost for preventive dental care services such as exams, x-rays and cleanings. They also have fewer participating dentists accepting new patients, provide lower reimbursements for basic and major dental care services, and limit which dentists you can visit. You may pay more out-of-pocket for non-preventive dental care services with a dental HMO plan.
Dental PPOs typically have higher monthly premiums than dental HMOs, and most pay 100% of the cost for preventive services. PPO plans have more extensive networks of participating providers and allow enrolled participants to visit dentists outside their network. If you receive care from an out-of-network dentist, your out-of-pocket costs will be greater than if you visited an in-network dentist.
For example, if your current dentist participates in your dental HMO plan and you only anticipate receiving two routine cleanings in a year, the lower-cost dental HMO may meet your needs. If you anticipate dental care beyond your twice-a-year cleanings, or cannot locate a suitable dentist accepting new patients, consider enrolling in a dental PPO plan.
The terms maximum allowable charge (MAC) and usual and customary (UCR) are often used interchangeably and are also called Maximum Fee Allowance.
The MAC or UCR is the maximum amount the insurer will pay for a particular procedure, regardless of the amount the dentist submits.
Example of Maximum Allowable Charge for Out-of-network services:
Assume your dental plan pays 50% of major dental services (e.g., crown or cap). You visit an out-of-network dentist who bills the insurer $1,500 for the crown, and the insurer's maximum allowable charge is $1,000. The plan will reimburse the dentist $500 (50% of $1,000, the maximum allowable charge). You would be responsible for paying the remaining $1,000. An out-of-network dentist will bill you for charges not paid by your insurance.
An important note about allowance methods (MAC/UCR) used by dental insurers: in-network or participating dentists have a fee schedule of what the insurer considers reasonable fees for service. Out-of-network or non-participating dentists do not have these schedules and will bill their usual fees, which may be significantly higher than what the insurer will pay. If you plan to visit an out-of-network dentist, call your insurer or ask your dentist to request a pretreatment estimate before services are performed.
The MAC or UCR is the maximum amount the insurer will pay for a particular procedure, regardless of the amount the dentist submits.
Example of Maximum Allowable Charge for Out-of-network services:
Assume your dental plan pays 50% of major dental services (e.g., crown or cap). You visit an out-of-network dentist who bills the insurer $1,500 for the crown, and the insurer's maximum allowable charge is $1,000. The plan will reimburse the dentist $500 (50% of $1,000, the maximum allowable charge). You would be responsible for paying the remaining $1,000. An out-of-network dentist will bill you for charges not paid by your insurance.
An important note about allowance methods (MAC/UCR) used by dental insurers: in-network or participating dentists have a fee schedule of what the insurer considers reasonable fees for service. Out-of-network or non-participating dentists do not have these schedules and will bill their usual fees, which may be significantly higher than what the insurer will pay. If you plan to visit an out-of-network dentist, call your insurer or ask your dentist to request a pretreatment estimate before services are performed.
A dental insurance plan that allows for paid cleanings twice per year allows you to get two cleanings at any time within the Plan Year. Most Plan Years are calendar years (Jan.-Dec.) but could be any 12-month period, as determined by your employer (e.g., Aug-July).
A dental insurance plan that allows for paid cleanings every six months allows you to get two cleanings once every six months (to the day). For example, if you receive a cleaning on October 16, you will not be eligible for another paid cleaning until April 16 of the following year. If your second cleaning is before April 16th, you will be responsible for 100% of the cost of that cleaning.
A dental insurance plan that allows for paid cleanings every six months allows you to get two cleanings once every six months (to the day). For example, if you receive a cleaning on October 16, you will not be eligible for another paid cleaning until April 16 of the following year. If your second cleaning is before April 16th, you will be responsible for 100% of the cost of that cleaning.
A healthcare flexible spending account (FSA) allows you to set aside tax-free money to pay for anticipated health care expenses (medical, dental, and vision care) that are not paid for by your health insurance. If you anticipate incurring dental care expenses that exceed your dental plans maximum annual benefit allowance, you should consider enrolling in a healthcare FSA in the year you will receive the dental care services.
It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will insure that you set aside a reasonable amount in your FSA.
Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.
Change to healthcare FSA annual limit. As of the January 1, 2015 plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)
New FSA Carryover rule. As of the January 1, 2014 plan year, employers may allow participants to carry over up to $500 in unused FSA funds. This new carryover rule must be adopted by the plan--it is not automatic. Also, employers who currently have a FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will insure that you set aside a reasonable amount in your FSA.
Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.
Change to healthcare FSA annual limit. As of the January 1, 2015 plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)
New FSA Carryover rule. As of the January 1, 2014 plan year, employers may allow participants to carry over up to $500 in unused FSA funds. This new carryover rule must be adopted by the plan--it is not automatic. Also, employers who currently have a FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
Maybe. It depends on the treatment. For example, if you had fillings started under one insurance plan and changed plans during open enrollment, your new insurance would cover any additional fillings you needed. The only time an insurance company would not continue dental coverage for work in progress is when the policy has a missing tooth clause. For example, if you had a tooth removed under one insurance plan and changed plans during open enrollment to a new plan with a missing tooth clause; the new plan would not pay to replace the tooth. The missing tooth would be considered a pre-existing condition.
Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Dual coverage is not the same as double benefits, and it does not mean that combining both plan's benefits would cover 100% of the cost of a particular dental procedure. For example, if your primary dental plan pays 50% of the cost of a crown (up to a maximum dollar amount), and your secondary plan pays 60% for a crown, you would likely receive a total benefit of 60% and would be responsible for the balance. This is because most plans have non-duplication rules that state that they will only pay the difference between what the primary carrier paid and what the secondary carrier would have paid if they were primary.
Consequently, enrolling in more than one dental plan makes sense if:
one plan provides a greater reimbursement for dental services that you plan to use, and the percentage difference is greater than the cost of the premium of the second plan
enrollment is free
Consequently, enrolling in more than one dental plan makes sense if:
- one plan provides benefits you need that
Unfortunately, this situation happens more often than it should... However, you are responsible for any charges incurred and not covered by the insurer if you "mistakenly" visit a non-participating dentist. Even if the dental office provided you with incorrect information... It is always the patients' responsibility to make sure that their dentist participates in their plan's network, if they want to take advantage of in-network benefits.
How to avoid this issue:
You should plan to do all of the above, not one or the other…
You can also request that the dentist accept the in-network reimbursement as payment in full, if they mistakenly informed you that they accepted your plan. Of course, they are under no obligation to do so, but if they want to keep you as a patient, they might.
How to avoid this issue:
- Know which plan you are enrolled in and the plan's network. For example, if you are enrolled in the Delta Dental PPO Plus Premier plan, you would know by reading your plan summary that you have access to two dental networks (Delta Dental PPO and Delta Dental Premier). Both networks provide discounts and no balance billing.
Also, a dentist may accept a different Delta Dental plan and just say "yes" if you ask if they accept Delta Dental. It is important to be specific when asking if a dentist participates in a certain plan and network - Visit your plan's web site to find participating provider information online. You must still select the correct plan and, sometimes, network when using these tools.
Remember that contracts between dentists and insurers may end at anytime; make sure the dentist is participating as of the date you receive services. Never assume that an online database of participating providers is up-to-date - Call the insurer to confirm that the dentist is a participating provider and which network they participate in, so that you can get the maximum benefits from your plan
You should plan to do all of the above, not one or the other…
You can also request that the dentist accept the in-network reimbursement as payment in full, if they mistakenly informed you that they accepted your plan. Of course, they are under no obligation to do so, but if they want to keep you as a patient, they might.
Even if you did not change dental insurance plans during your annual open enrollment period, your plan's benefits may have changed. Insurers, with the approval of employers, make changes to dental benefits that are not always obvious to plan participants. Always review your dental plan information before visiting the dentist. Never assume, because you did nothing, that your dental plan benefits have not changed from year to year.
Reviewing your plan documents fully and working with your dentist and insurer, before you receive care, can reduce unexpected dental expenses.
- Insurance companies may reduce dental care benefits through frequency limitations:
- reducing fluoride treatments for minors from twice per year to once per year
- replacing crowns every 10 years instead of every five years
- reducing fluoride treatments for minors from twice per year to once per year
- Dental insurance plan documentation may not be completely clear. For example, your benefit plan summary may state that crowns are covered, but leave for the small print that metal (silver) crowns, not porcelain (white) crowns are covered. Or the plans will pay for porcelain crowns for front teeth only. If your dental insurer only covers metal crowns, you may be responsible for paying the difference between the cost of the porcelain and metal crown. Some dental insurance policies provide benefits for the least expensive alternative treatment (LEAT), also called downgrading. With the LEAT provision, insurers may cover a percentage of a silver filling and the patient pays the difference between this amount and what the white filling cost. Some insurers may not pay anything for white fillings. Review your plan documents carefully
- Plan reimbursements are based on maximum allowable charges or usual and customary fees; it is almost impossible to accurately determine what the insurer will pay and what you will owe
- You may need more work than previously thought and the dentist may need to address these prior unknown issues while they have you in their chair
Reviewing your plan documents fully and working with your dentist and insurer, before you receive care, can reduce unexpected dental expenses.
- Deep cleanings (also known as scaling or root planing). Deep cleanings are needed when there is tartar beneath the gum line, separation of the gum tissue from the root of the tooth and inflammation of the gingival tissues. Deep cleanings are performed to prevent further loss of bone and gingival attachment that sometimes cannot be determined by x-rays alone. Therefore, a thorough periodontal evaluation by your dentist is required to determine the need for a deep cleaning.
Dental insurers often use consultants to approve or deny claims for deep cleanings, and may not always have the best interests of the patient in mind. - Transitional partial dentures. A dentist may provide a transitional partial denture (also known as a flipper) after removing teeth so that the patient does not have to walk around with a space in the mouth while awaiting a more permanent solution
This is when you learn just how far your dentist is willing to assist you in getting your “eligible” claims paid by the insurer. The dentist may have to appeal the denial several times before the insurer will pay the claim.
If you have dental insurance, you can prevent denial of dental care claims by following a few simple rules:
Work with your dental care provider(s) to create a treatment plan and submit it to your insurer for a benefits review before the work is performed. Also, make sure your dentist obtained preauthorization, if required, and submitted all necessary and accurate paperwork to the insurer
Make sure your dentist is willing to advocate on your behalf should a claim be denied (e.g., submit a letter of appeal or provide additional documentation).
- Read plan documents, and not just the two-page summaries provided during the annual enrollment period. Ask for a copy of the plan's full summary plan description. These documents are often available in electronic format, making it easy to review only those sections related to your needs
- Review the benefits exclusions or (frequency) limitations section of your plan. This section will list which dental care services your plan will not cover, even if you want or need them, and it will state under what circumstances your plan may or may not cover other services
For example, dental plans typically
- What are the different types of oral examinations?
- What are the different types of cleanings?
- Should I enroll in a healthcare flexible spending account (FSA)?
- Does my plan cover work in progress under a recent dental plan?
- Is it a dental or medical claim?
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Periodic (Routine) Oral Exam: typically performed every six months or twice yearly when the patient visits the dentist for routine cleaning. It falls under the preventive and diagnostic services category and is usually paid at 100%. The insurer may not cover additional exams/cleanings beyond the two
Limited (Problem Focused/Emergency) Exam: typically performed on patients with a specific oral problem or dental emergencies, such as an infection or pain. It may require diagnostic procedures such as X-rays. The exam and x-rays fall under the preventive and diagnostic services category and are usually paid 100%. Suppose emergency treatment is required at the time of evaluation. In that case, these services usually fall under the basic or restorative services categories and are usually subject to a deductible and coinsurance (%) amount. Review your plan documents to see if limited exams are covered separately or in place of routine exams
Full mouth debridement (FMD): typically performed on a patient with extensive plaque, tartar buildup, and stains on their teeth. The patient has probably not visited a dentist in several years and needs more extensive cleaning. With FMD, two cleanings are done--the first to remove most of the tartar and the second (2-3 weeks later) to remove any remaining tartar. If covered, it falls under the basic services category and is usually subject to a deductible and coinsurance (%) amount. This type of cleaning is usually allowed only once in a lifetime.
Deep Cleaning or Scaling: recommended by your dentist to treat periodontal disease. Periodontal disease is an infection of the gingival tissues caused by plaque left on the teeth and gums for an extended period of time and caused bone loss. Every patient should have a periodontal evaluation as part of their comprehensive oral exam. This service falls under the basic services category and is usually subject to a deductible and coinsurance (%) amount
Review your plan documentation to determine what cleanings your plan will pay for and how often.
A healthcare flexible spending account (FSA) allows you to set aside tax-free money to pay for anticipated health care expenses (medical, dental, and vision care) not paid for by your health insurance. Suppose you anticipate incurring dental care expenses that exceed your dental plan's maximum annual benefit allowance. In that case, you should consider enrolling in a healthcare FSA in the year you will receive dental care services.
It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will ensure that you set aside a reasonable amount in your FSA.
Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.
Change to healthcare FSA annual limit. As of the January 1, 2015, plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)
New FSA Carryover rule. As of January 1, 2014, plan year, employers may allow participants to carry over up to $500 in unused FSA funds. The plan must adopt this new carryover rule—it is not automatic. Also, employers with an FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
It is important to work with your dentist to create a treatment plan to determine what work you will need for the upcoming year and estimate how much of the cost you will be responsible for paying. This will ensure that you set aside a reasonable amount in your FSA.
Using a healthcare FSA for orthodontia care: Because orthodontia care typically lasts more than one year, special IRS guidelines state that these services are considered incurred at the time of payment. Read your FSA plan documents for a breakdown of how orthodontia claims may be reimbursed.
Change to healthcare FSA annual limit. As of the January 1, 2015, plan year, the maximum amount a single individual may contribute to a healthcare FSA is $2,550. You and your spouse may each contribute $2,550 even if you work for the same employer. (Your employer sets the maximum amount you can contribute to a healthcare FSA, which may be lower than the legal maximum of $2,550.)
New FSA Carryover rule. As of January 1, 2014, plan year, employers may allow participants to carry over up to $500 in unused FSA funds. The plan must adopt this new carryover rule—it is not automatic. Also, employers with an FSA plan with a 2 1/2 month grace period cannot offer both the grace period and the carryover option--they have to choose one or the other.
Maybe. It depends on the treatment. For example, if you had fillings started under one insurance plan and changed plans during open enrollment, your new insurance would cover any additional fillings you needed. The only time an insurance company would not continue dental coverage for work in progress is when the policy has a missing tooth clause. For example, if you had a tooth removed under one insurance plan and changed plans during open enrollment to a new plan with a missing tooth clause, the new plan would not pay to replace the tooth. The missing tooth would be considered a pre-existing condition.
Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Check your plan documentation and call your new insurer's customer service number for verification. Also, speak with the dentist who performed the procedure and check with your former insurer to determine if you are entitled to coverage under the former plan.
Determining when treatment of the mouth is a dental or medical claim can be complex. In general, dental claims cover services performed by dentists (cleanings, exams, tooth extractions, etc.). Medical claims cover services performed by medical doctors.
So, for the most part, determining if your claim is a dental or medical claim usually depends on the type of provider providing the services.
Reviewing the oral care benefits limitations/exclusions sections of both your medical and dental plan policies is extremely important to determine if an oral surgery or other complex dental care claim will be paid and by whom. These sections of your policies are extremely detailed. Also, contact your dental and medical plan insurer if you have specific questions about coverage not outlined clearly in the plan documents.
So, for the most part, determining if your claim is a dental or medical claim usually depends on the type of provider providing the services.
Reviewing the oral care benefits limitations/exclusions sections of both your medical and dental plan policies is extremely important to determine if an oral surgery or other complex dental care claim will be paid and by whom. These sections of your policies are extremely detailed. Also, contact your dental and medical plan insurer if you have specific questions about coverage not outlined clearly in the plan documents.
- If I have coverage under my own
plan and a spouse's plan, is my dental
care covered at 100%? - My dentist said she accepted my insurance, but does not. Am I responsible for paying the additional costs?
- Why is my dental care bill larger than expected?
- What are the most frequently denied dental insurance claims?
- How can I prevent my dental claims from being denied?
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Dual coverage is not the same as double benefits, and it does not mean that combining both plans' benefits would cover 100% of the cost of a particular dental procedure. For example, if your primary dental plan pays 50% of the cost of a crown (up to a maximum dollar amount), and your secondary plan pays 60% for a crown, you would likely receive a total benefit of 60% and would be responsible for the balance. This is because most plans have non-duplication rules that state that they will only pay the difference between what the primary carrier paid and what the secondary carrier would have paid if they were primary.
Consequently, enrolling in more than one dental plan makes sense if:
one plan provides a greater reimbursement for dental services that you plan to use, and the percentage difference is greater than the cost of the premium of the second plan
enrollment is free
Consequently, enrolling in more than one dental plan makes sense if:
- one plan provides benefits you need that
Unfortunately, this situation happens more often than it should... However, you are responsible for any charges incurred and not covered by the insurer if you "mistakenly" visit a non-participating dentist. Even if the dental office provided you with incorrect information... The patient must always ensure their dentist participates in their plan's network if they want to take advantage of in-network benefits.
How to avoid this issue:
You should plan to do all of the above, not one or the other…
You can also request that the dentist accept the in-network reimbursement as payment in full if they mistakenly informed you that they accepted your plan. Of course, they are not obligated to do so, but they might if they want to keep you as a patient.
How to avoid this issue:
- Know which plan you are enrolled in and the plan's network. For example, if you are enrolled in the Delta Dental PPO Plus Premier plan, you would know by reading your plan summary that you can access two dental networks (Delta Dental PPO and Delta Dental Premier). Both networks provide discounts and no balance billing.
Also, a dentist may accept a different Delta Dental plan and just say "yes" if you ask if they accept Delta Dental. When asking if a dentist participates in a particular plan and network, it is important to be specific. - Visit your plan's website to find participating provider information online. You must still select the right plan and, sometimes, network when using these tools.
Remember that contracts between dentists and insurers may end anytime; make sure the dentist is participating as of the date you receive services. Never assume that an online database of participating providers is up-to-date. - Call the insurer to confirm that the dentist is a participating provider and which network they participate in so that you can get the maximum benefits from your plan
You should plan to do all of the above, not one or the other…
You can also request that the dentist accept the in-network reimbursement as payment in full if they mistakenly informed you that they accepted your plan. Of course, they are not obligated to do so, but they might if they want to keep you as a patient.
Even if you did not change dental insurance plans during your annual open enrollment period, your plan's benefits may have changed. With the approval of employers, insurers make changes to dental benefits that are not always obvious to plan participants. Always review your dental plan information before visiting the dentist. Never assume, because you did nothing, that your dental plan benefits have not changed from year to year.
Reviewing your plan documents thoroughly and working with your dentist and insurer before you receive care can reduce unexpected dental expenses.
- Insurance companies may reduce dental care benefits through frequency limitations:
- reducing fluoride treatments for minors from twice per year to once per year
- replacing crowns every ten years instead of every five years
- reducing fluoride treatments for minors from twice per year to once per year
- Dental insurance plan documentation may not be completely clear. For example, your benefit plan summary may state that crowns are covered, but leave for the small print that metal (silver) crowns, not porcelain (white) crowns, are covered. Or the plans will pay for porcelain crowns for front teeth only. If your dental insurer only covers metal crowns, you may be responsible for paying the difference between the porcelain and metal crown costs. Some dental insurance policies provide benefits for the least expensive alternative treatment (LEAT), also called downgrading. With the LEAT provision, insurers may cover a percentage of a silver filling, and the patient pays the difference between this amount and the white filling cost. Some insurers may not pay anything for white fillings. Review your plan documents carefully.
- Plan reimbursements are based on maximum allowable charges or usual and customary fees; it is almost impossible to accurately determine what the insurer will pay and what you will owe
- You may need more work than previously thought, and the dentist may need to address these prior unknown issues while they have you in their chair
Reviewing your plan documents thoroughly and working with your dentist and insurer before you receive care can reduce unexpected dental expenses.
- Deep cleanings (also known as scaling or root planing). Deep cleanings are needed when there is tartar beneath the gum line, separation of the gum tissue from the root of the tooth, and inflammation of the gingival tissues. Deep cleanings are performed to prevent further loss of bone and gingival attachment that sometimes cannot be determined by X-rays alone. Therefore, a thorough periodontal evaluation by your dentist is required to determine the need for a deep cleaning.
Dental insurers often use consultants to approve or deny claims for deep cleanings and may not always have the patient's best interests in mind. - Transitional partial dentures. A dentist may provide a transitional partial denture (also known as a flipper) after removing teeth so that the patient does not have to walk around with a space in the mouth while awaiting a more permanent solution
This is when you learn how far your dentist is willing to assist you in getting your “eligible” claims paid by the insurer. The dentist may have to appeal the denial several times before the insurer will pay the claim.
If you have dental insurance, you can prevent denial of dental care claims by following a few simple rules:
Work with your dental care provider(s) to create a treatment plan and submit it to your insurer for a benefits review before the work is performed. Also, make sure your dentist obtained preauthorization, if required, and submitted all necessary and accurate paperwork to the insurer
Make sure your dentist is willing to advocate on your behalf should a claim be denied (e.g., submit a letter of appeal or provide additional documentation).
- Read plan documents, not just the two-page summaries provided during the annual enrollment period. Ask for a copy of the plan's full summary plan description. These documents are often available in electronic format, making it easy to review only those sections related to your needs
- Review your plan's benefits exclusions or (frequency) limitations section. This section will list which dental care services your plan will not cover, even if you want or need them, and it will state under what circumstances your plan may or may not cover other services
For example, dental plans typically
THIS TOOL DOES NOT PROVIDE INSURANCE ADVICE. It is for general informational purposes and does not address individual circumstances.