At Dental Illusions we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff. They are well informed and up-to-date.
Please call if you have any questions or concerns regarding your initial visit.
Please bring your insurance information with you to the consultation so that we can expedite reimbursement.
The following information is based on patient education content provided by the ADA.
Understanding Your Insurance
If you employer offers insurance, consider yourself fortunate. This benefit works like a valuable “coupon” that can greatly reduce the cost of your dental care. However, no dental benefit plan is set up to cover all your costs. To avoid surprises on your dental bill, it’s important to understand what your insurance will cover, and what you will need to cover some other way. Dental benefits should not be confused with the dental services you need, which are determined by you and your dentist.
How Dental Plans Work
Almost all dental plans are the result of a contract between your employer and insurance company. The amount your plan pays is agreed upon by your employer with the insurer. Your dental coverage is not based on what you need or what treatment the dentist prescribes. It is based on how much your employer pays into the plan. Employers generally choose to cover some, but not all, of employees’ dental costs. If you are not satisfied with your dental coverage, let your employer know.
The role of your dental office
Our main goal is to help you take good care of your teeth. We choose to file claims with your insurance company as a service to you. The portion of the bill not covered by your insurance company is your responsibility. Our practice offers financing plans to help pay your part of the bill.
Key terms used to describe features of a dental plan may include the following:
UCR (Usual,Customary and Reasonable)
Usual, Customary and Reasonable are the maximum amounts that will be covered by the plan. Although these terms make it sound like UCR is a standard rate for dental care, that is not the case.The terms “usual”, “customary” and “reasonable” are misleading for so many reasons:
- UCR charges often do not reflect what dentists “usually” charge in a given area.
- Insurance companies can set whatever they want for UCR charges–They are not required to match actual fees by dentists.
- An insurance company’s UCR will stay the same for many years, not taking inflation into account, for example.
- Insurance companies are not required to show how they set UCR rates. Each company has its own formula.
So if your dental bill is higher than the UCR, it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated it’s UCRs, or the data used for the UCRs is taken from areas of your state that are not similar to your community.
This is the largest dollar amount the dental plan will pay towards your treatment in a year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company. You are expected to pay co-payments as well as costs above the annual maximum. Annual maximums are not always updated to keep up with costs of dental care. If your annual maximum is too low to meet your dental needs, ask your employer to look into plans with higher annual maximums.
The plan may want you to chose dental care from a list of preferred providers (dentists who have a contract with the preferred dental benefit plan). The term “preferred” has nothing to do with the patient’s personal choice of a dentist: it refers to the insurance company’s choices. if you choose to receive dental care from outside the preferred provider group, you may have higher out-of-pocket costs. inform yourself about your plan’s method for paying both in- and out-of-network dentists.
A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though plans may not cover your conditions, treatment may still be necessary to maintain your oral health.
Coordination of Benefits (COB) or Non-duplication of Benefit
These terms apply to patients that are covered by more than one dental plan (for example, if you are insured by your employer and your spouse’s dental plan). Insurance companies often want to know if you have coverage from other companies as well, so they can coordinate benefits. For example, if your primary (main) insurance will pay half your bill, your secondary insurance will not cover the same portion of that bill.
Benefits from all companies should not add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all plans will pay for all your services. Sometimes, none of the plans will pay for the services you need. Each insurance company’s handles COB it’s own way. Please check your plans for details.
A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need treatment more often than that for best oral health. For example: a plan might pay for teeth cleanings only twice a year, even though the patient needs a cleaning four times a year. Be aware of the details in your dental plan but decide about treatment on what’s best for your health, not just what may be covered.
Not Dentally Necessary
Each dental benefit plan has it’s own guidelines on which treatment is “dentally necessary”. If a service provided by your dentist does not meet the plan’s guidelines, the charges may not be reimbursed.
However, this does not mean that the dental treatment was not necessary. Your dentist’s advice is based on our professional opinion of your clinical situation. Your plan’s guidelines are not based on your specific case. If a plan rejects a claim because the service was “not dentally necessary”, you can follow the appeals process working with your benefits manager and/or plans customer service department.
Least Expensive Alternative Treatment
If a plan has a LEAT clause, it means there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. This is one way the insurance companies keep their costs down. However, the least expensive alternative is not always the best option. You should consult with your dentist on the best option for you.
Explanation of Benefits (EOB)
An EOB is a written statement from the insurance company, telling you what they will cover and what you must pay yourself. Your portion of the bill should be paid to the dental practice. if you have questions about the EOB contact the insurance provider or we will be happy to assist you also.
Make your dental health the top priority
Although you will be tempted to decide on your dental care based on what your insurance will pay, always remember that your health is the most important thing. As with other choices in life, the cheapest option is not always the best.
We hope this has helped you understand insurance a little better. Always remember we are here to help and always have your best interest and health in mind.