We would like you to understand that dental insurance works differently than medical insurance.
Employers offer dental benefits to help employees pay for a portion of the cost of their dental care.
Dental plans are designed to share in the cost of your dental care, not completely pay for those costs.
Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually the insurance company). The amount your plan pays is determined by the agreement negotiated by your employer with the insurer.
You are responsible for any remaining balance of your treatment that your insurance does not cover.
UCR amounts are the maximum amounts that will be covered by the plan for eligible services.
This means the dental insurance plan pays an established percentage of the dentist’s fees based on the plans “customary” or “reasonable” fee limit. Although these limits are called “customary”, they may or may not reflect the fees that we charge.
In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.
The allowance is established under the optional service provision in the dental plan. We have NO control over the allowance they choose.
Most dental programs have an annual dollar amount maximum. This is the maximum dollar amount a dental plan will pay toward the cost of dental care within a specific benefit period, usually the plan year. The plan purchaser/employer makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. The patient is usually responsible for paying costs above the annual maximum.
Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for teeth cleanings only twice a year even though the patient requires cleaning every three months. Limitations may vary depending on the contract purchased. Limitations in coverage are the result of the financial commitment the plan sponsor has agreed to make and the benefits the third-party payer will offer for that commitment.
A dental plan may not cover certain procedures or preventative treatments. This does not mean that these treatments are unnecessary. You need to be aware of the exclusions and limitations in your dental plan but should not let those factors determine their treatment decisions.
Just like medical insurance, a dental plan may not cover conditions that existed before the patient enrolled in the plan. This includes plans that have a “missing tooth” exclusion. Benefits will not paid for replacing a tooth that was missing prior to the effective date of coverage. Even though your plan may not cover certain conditions, treatment may still be necessary.
Down-coding- This is the practice of third-party payers in which the procedure code has been changed to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.
Least Expensive Alternative Treatment- The dental plan may only allow benefits for the least expensive treatment for a condition. As in the case of exclusions, patients should base treatment decisions on their dental needs, not on the dental benefit coverage.
We can ESTIMATE your out of pocket expense, but there WILL be an additional amount that will be billed to you after your insurance pays.
Pre-treatment estimates are NOT a guarantee of payment because we cannot predict exactly what your insurance will contribute to your dental care.
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Coordination of benefits (COB) is a method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
Nonduplication of benefits is a term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid.
Even though you may have two or more dental benefit plans in place, there is no guarantee that any other the plans will pay for your services. Please consult with your own plan for further details regarding coordination of benefits and nonduplication of benefits.
And EOB is a written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charge covered or not covered by the dental benefit plan. In those instances where the plan makes a partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the EOB. Any difference between the fee charges and the benefit paid may be due to limitations in the dental plan contract.
Typical information reported on an EOB includes:
1) the treatment reported on the submitted claim by ADA procedure code numbers and nomenclature; and
2) the ADA procedure code numbers and nomenclature on which benefits were determined.