Insurance

We will be happy to assist you with your insurance forms. We accept all insurances that allow you to choose your dentist. Support free choice. There are many different insurance companies and hundreds of different coverage, so please check with your employer for your plan description. Cheryl is familiar with most plan policies. Remember this is your insurance and you are responsible for the dental fees. We will assist in filling out insurance forms, mail and record payments, but the account and balances not covered are your responsibility. Most insurances cover only portions of fees and in some cases they may not cover certain services. These services are the responsibility of the patient. We honor all dental plans that allow you to choose your own dentist. We have worked with 523 different dental plans. Please remember, your insurance is your insurance. We will help you obtain your benefits from your insurance company. We submit forms and record the payments, but the patient is responsible for the entire account. Please bring your insurance card with you on your first appointment and also when any change occurs. If possible, bring your dental plan benefit booklet and we may help you interpret your coverage.

Dental Insurance 101

A dental benefit plan is a contract between the carrier and the patient, or more often, the patient's employer, not the practice. There are numerous limitations and clauses on the average dental plan. The patient must need to understand that it is their employer, not the insurer or the dental practice, that sets these limitations. Understanding the limits of their benefits empowers patients to move forward with treatment, which ultimately helps patients resolve claims. Patient education is a crucial step towards ownership. Here are seven common limitations and clauses that you should be familiar with and understand.

Coverage year

Standard coverage years are calendar or fiscal. Some set the coverage year fiscally, from say, April, 2005 to March 31, 2006. More plans are calendar year, January through December, than are fiscal.

Maximums

Yearly maximum dollars vary from $500 to $2000. This is the amount the insurance carrier will pay towards your dental needs per calendar year.

Effective Date

This is the date coverage goes into effect. Knowing the effective date of coverage is important because it coincides with any waiting periods on treatment.

Waiting Periods

Knowing the waiting period for certain procedures is important so the patient can determine out-of-pocket expenses. For example, if the patient needs a crown, but there is a 12 month wait for major dentistry, the patient's out-of-pocket expenses would be 100% instead of the standard estimated 50%.

Frequency Limitations

It's good to know frequency limitations for certain procedures. The standard frequency limitations written on most contracts are preventive frequency, which commonly is covered twice a year or every six months. the two are different and it is crucial to know which one applies. If the coverage is every 12 months, always verify if it is two visits in a calendar year or within a 12-month period; it avoids confusion.

Replacement-of-major-dentistry frequency also is tricky. Standard frequency limitations on replacement of major dentistry are once every five years. A new trend is replacement of major dentistry covered once each seven or ten years.

Sometimes there are periodontal-frequency limitations. For example, scaling and root planing may a frequency limit of two to five years. Additionally, many contracts are limiting D-4910 periodontal maintenance procedures to once every 24 months. Does this mean the patient should go without treatment? Absolutely not! The dentist should always recommend the dental treatment that is in the best interest of the patient, not the dental benefit plan.

Percentage or Fee Schedule

There are two types of dental plans; one designed to pay a percentage of an allowable fee; and one designed to pay according to a fee schedule. The percentage-of-coverage plan is divided up into two categories; Preventive, restorative and major; and Type I, Type II and The III.

Non-Duplication Clauses

The standard definition of a non-duplication clause is: If a patient is covered under two plans and the primary plan pays 80% of the claim, the secondary plan will not duplicate the benefit.

Plan Administrator

Please contact your plan administrator to find out your particular plan coverage. Ask questions and be informed. You, the patient, are responsible for the dental fees you incur and are responsible for their payment. Your dental insurance may help with this responsibility. Any difference is the responsibility of the patient.

Insurance 101 information appeared in Dental Practice Report, May 2005, Lois Banta, Author.