Does my dental insurance work same way as my medical insurance? Dental insurance is not like health insurance. Dental insurance is based on a contract between the employer (or plan sponsor), the insurance company and you, who bears full responsibility for settlement of your financial obligation to our office. Most contracts have limits and/or various degrees of co-payment.
What is my maximum coverage per year? The maximum cumulative coverage for a “benefit year” for most dental plans is between $1,000 to $1,500. Dental insurance is rarely a “pay-all”; it is only an aid. This is often a surprise to the patients, because regardless of how much dental treatment they may need, the dental insurance company’s responsibility is usually capped at a relatively low amount.
What is a deductible? A deductible is the set amount you must pay before your insurance coverage begins. Most dental insurance has deductibles between $50 and $100. Please check with your insurance carrier to determine your deductible amount.
What is the percentage that my insurance will pay for your services? We will make every effort to provide you with a reasonable estimate of what your plan is likely to pay. Unfortunately, because of such things as maximums, deductibles, non-covered procedures, etc. calculating the exact coverage is often impossible.
Why was my benefit different than what I expected? Many plans tell their participants that they will be covered “up to 80 percent or up to 100 percent,” but do not clearly specify plan fee schedule allowances, annual maximums or limitations (such as only 2 exams per year). It is more realistic to expect dental insurance to cover 45% to 80% of our services. The amount a plan pays is determined by how much the employer has paid for the plan.
In addition, your dental benefit may vary for a number of reasons, such as:
You have already used some or all of the benefits available from your dental insurance.
Your insurance plan will pay only a percentage of the fee charged by your endodontist.
The treatment you needed was not a covered benefit.
You have not yet met your deductible.
You have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
Why can’t you tell me exactly how much I will owe you for the treatment? At the time of service, your portion of the payment responsibility is only an estimate. Our office will perform a benefit check to assess your benefits under your plan as well as complete the dental portion of your claim form and submit it on your behalf. The amount of the precise financial responsibility is determined by your dental insurance company after the claim has been filed. A final statement is then issued to you. If there is an overpayment, we will issue you a refund check. We recommend directing questions about your claim to your insurance company.
Why isn’t the recommended treatment a covered benefit? Your treatment plan is individually tailored, and is not based on your dental insurance benefits or lack of benefits. Some employers or insurance plans exclude coverage for necessary treatment as a way to reduce their costs. Therefore, not all endodontic treatment will be covered through your insurance plan. Some endodontic services (such as CBCT imaging for most dental plans) may be excluded. While we want to provide you with the highest possible quality of care, your dental insurance may cover only very basic services. The type of care you receive from our office is based upon our professional judgment and years of experience and not the coverage you receive from a dental benefit plan. We do not believe it is in your best interest to compromise any recommended care in order to accommodate your insurance program..
“In-Network” vs. “Out-of-Network:” If we are “in network” with your insurance company, this simply means we have a contractual agreement with that insurance to only charge an agreed fee for the procedures that they cover. The insurance company will then pay the appropriate percentage of that fee. If we are “out of network” with your insurance company, we do not have a contract with that insurance and your insurance will pay a percentage of our normal fees. You are fully responsible for all fees not covered by your insurance.
What happens if I used all of my benefits on my insurance? Once your annual maximum has been reached, the insurance company will not provide additional benefits for any dental service until the renewal period. Each insurance policy is different. Please read your policy so that you are aware of your benefits and limitations.
Your claim will be filed once your treatment is completed. North Carolina law requires insurance companies to take action on a claim within 30 days. If your claim is not paid by your carrier within 45 days, the unpaid portion will become your responsibility. You are responsible for any amounts your insurance company chooses not to pay, for whatever reason. Should questions arise regarding your dental insurance benefits, it is best for you to contact your employer or insurance company directly. We will gladly provide all pertinent information to you at no charge.
What is a “UCR” and how is it determined? “UCR” is the term used by insurance companies to describe the amount they are willing to pay for a particular dental procedure. There is no standard fee or accepted method for determining the UCR and the UCR has no relationship to the fee charged by our office. The administrator of each dental benefit plan determines the fees that the plan will pay, often based on many factors including region of the country, number of procedures performed and cost of living.
Why was my benefit different from what I expected? Your dental benefit may vary because: you have already used some or all of the benefits available; your insurance plan paid only a percentage of the fee charged by our office; the treatment you needed was not a covered benefit; you have not yet met your deductible; or you have not reached the end of your plan’s waiting period and are currently ineligible for coverage.
How do I understand my Explanation of Benefits (EOB)? Your Explanation of Benefits (EOB) contains a wealth of information. The EOB identifies the benefits, the amount your insurance carrier is willing to pay and charges that are and are not covered by your plan. The statement includes the following information: UCR, co-payment amount/patient portion, remaining benefits, deductible and benefit paid.
What if I still have questions? Many questions that you have may be best answered by calling your insurance company directly. While we will do our best to answer all your insurance question, please keep in mind that there are many insurance plans available and that your employer chooses your plan and your benefits. If you believe your benefits are inadequate, you may want to discuss the matter with your plan administrator and explore appropriate alternatives.