Below are some general information items to help you better understand many elements of your dental insurance plan and how it relates to any potential dental benefit reimbursements.  The process can be confusing as it may be different for each carrier.  We work very hard to try and obtain for you any dental benefit to which you are entitled.  As always, the most current information regarding your coverage can be obtained directly from your dental insurance carrier. Often, plans do not provide for full reimbursement for your care, depending on one or more of the many factors explained below:

General Items:   Generally speaking, dental insurance coverage is tilted toward preventative care for reimbursement.  Nearly all dental insurances have some type of deductible as well as a percentage or copayment for restorative care (fillings), crowns and dentures.  Dental insurance is typically only an assistive measure in paying for your dental care and is not intended to cover all your needs.  We will seek to obtain all benefits you are entitled to receive under your plan for your care but we cannot create benefits that do not exist.

Coverage year: Standard coverage years are calendar or fiscal. Some unions and schools, for example, set the coverage year fiscally from April 1 to March 31.  Most insurances run on a calendar year but it is important to be sure which type of year your coverage runs.

Maximums: Yearly maximum dollars allowed each year can vary from $750 to $1000 and possibly more.  Annual maximum benefit allowances do not rollover each year if they are unused.  If not used, they simply disappear at the end of the contract term and the next year starts out with the same amount.   Once your annual maximum is reached, any further care provided that plan year will not be reimbursed by your carrier.

Effective coverage date: Knowing the effective date of coverage is important because it coincides with any waiting periods on dental treatment.  Care provided before the starting date or after the termination date of a plan will not be reimbursed by your carrier.

Key Information: There are certain items that must match exactly in order for an insurance carrier to recognize and pay a dental care claim.  Both the policy subscriber as well as the patient’s legal name including middle initial, date of birth, address and gender.  These items must all match exactly.  We also need to have their accurate patient ID number and insurance group number.  If any one of these items is wrong, the entire claim will be rejected.   When a claim is rejected due to one or more of these items being incorrect, the error most often resides in the carrier’s database and not ours.  Only the patient can call the carrier and correct their personal information data.  Insurance carriers will not accept calls correcting any patient information from our office.  This is for your insurance security purposes. 

Waiting periods: Knowing the waiting period for certain procedures is important so that the patient has a more accurate determination of out of pocket expenses. For example, if the patient has a crown diagnosed but there is a 12-month wait for major dentistry then, the patient’s out of pocket would be 100% for the first 12 months instead of the policies 50% after the 12 month period has elapsed. 

Frequency limitations: It’s good to know frequency limitations for certain procedures. The standard frequency limitations written on most contracts are preventive frequency. The most common preventive frequency is: preventive visits covered two times per year or each six months. It is vital to clarify when the coverage frequency limit is listed as two times per year. Does this mean two times in a calendar year or two times in a 12 month period?  Do cleanings have to be at least 6 months apart or is then any allowed time variance.   Another area that can be tricky is radiographs (x-rays).  It is important you communicate to us if you have seen any other dental care providers within the last 12 months as this may impact any potential dental coverage expectations. 

Percentage of the carriers’ allowance for Dental Insurance: A insurance may list it covers care at 100% but that only means 100% of their defined allowance and not 100% of the actual fee.  Often, their defined allowance is lower than a typical fee and a co-payment would then still be required.   We try to provide our best guess as to what your carrier may pay but due to the variety of allowance schedules, sometimes a difference is found only after we receive insurance payment.  All differences are considered the patients responsibility

Percentage or fee schedule?: Typically, there are two types of dental plans  Percentage plan are ones that are designed to pay a percentage of an allowable fee determined by the insurance carrier.  The other type, fee schedules, are designed to pay solely according to a predetermined fee schedule regardless of what fee was charged.  Percentage plans are only for that specific insurance carriers table of allowances and these allowance tables vary widely between carriers.  They can even vary significantly within the same insurance carrier depending upon the level of dental insurance plan you have purchased. 

Assignment of Dental Benefits:  Most insurance plans allow for you to assign benefits to our office.  However, in Pennsylvania there are two carriers, United Concordia and Delta Dental, PA which typically do not allow you to assign your dental benefits here.  This means these two dental insurance companies will not send your dental benefit check to our office but will only send your dental benefits payments directly to the plan subscriber.  These two carriers will only send dental insurance payments to a dentist if that dentist is participating within their network of dental care providers. For many reasons including my fundamental desire to allow patients the right to choose their care provider and to not have your treatment choices influenced by a for profit insurance carrier, I do not participate with any dental insurance carrier network.  The good news is there is active, pending legislation that would outlaw this practice and provide patients the right to choose their provider without interference by insurance carriers.  The majority of US states have already adopted such laws and hopefully PA will soon join the majority and support patients’ rights. 

Pre-Determinations (Pre-D) of Dental Insurance benefits: In order to better predict dental coverage levels, our office can submit a pre-determination to your carrier.  It typically takes about 3 weeks to get back and it will tell us if the planned care is covered and if so, to what extent.  All pre-D’s carry the disclaimer that this is not a guarantee of benefits as the annual maximum may have been reached, the plan may have been terminated prior to the care being done or some other change may have occurred that would cause your policy to now no longer allow for payment.  Typically, pre-determinations are quite accurate and provide a better understanding of your expected dental benefit allowances prior to treatment.

Missing tooth clause:  When planning to replace a missing tooth, sometimes a dental policy has a missing tooth clause.  Essentially, this states that any tooth missing prior to the effective date of coverage will not be entitled to any benefit reimbursement for the cost to replace the missing tooth. 

Primary and Secondary Dental Insurance: If you have coverage under two dental insurance policies, one policy will be your primary insurance and the other will be your secondary.  We must submit to your primary insurance first prior to submitting to your secondary, even if we know the primary will provide little to no benefits.  Your secondary carrier will typically require a copy of the primary insurance EOB (explanation of benefits) in order to determine your benefits payable under your secondary policy.  We appreciate this can be frustrating but it is something we are unable to alter.  We must follow the required format or your claim will be rejected.

Birthday Rule for Dental Insurance: If you have two dental policies, insurance companies direct which one will be your primary.  Currently, it is not an option to choose which plan will be considered your primary coverage.  The primary is determined by the earliest birthday of the policy holder.

Non-Duplication Clauses: The standard definition of “non-duplication clause” is this: If a patient is covered under two plans and primary pays 80% of the claim, the secondary will not duplicate the benefit.  So, if the secondary benefit is also 80%, the secondary plan will pay nothing or only 80% of the remaining 20% (after the secondary deductible is met)..

Non-covered dental care services: Too often a patient will have a clear care need and will have an active insurance policy but still receive no dental insurance dollar benefit.  This is usually due to a specific exclusion in their dental policy which does not provide coverage for a type of treatment.  No matter how clear the need, there will be no insurance reimbursement benefit for that care.  Implant care is often not covered but is slowly being covered by more carriers.  Typically, cosmetic care is not covered.

Minimal alternative treatment: When a space is present from a missing tooth, there are different options available to replace that tooth.  Typically they are a partial denture, a bridge or an implant.  Some plans will only pay their percentage based upon the cheapest alternative, the partial denture, regardless of the actual choice of care made by you.  

Appeal of a claim denial:  If a claim is denied, it may be appealed.  Only the patient can file an appeal. We can assist by writing a narrative, submitting copies of radiographs and clarify any coding as needed but the appeal process is not open to the provider, only the patient.