We can now process your Insurance claims electronically. This will enable you to be paid faster, and with less chance of being told "I didn’t receive the claim" or the Dentist never sent it out".
We have an instant confirmation of receipt and the ability to attach all photos and x-rays, to the submitted claims without delay.
Dental Insurance Lingo—Learning to Talk the Talk Will Help You Make an Informed Choic
Want to get the most from your dental benefit plan? You’ll need to learn the lingo.
Understanding your dental insurance is the key to maximizing the benefits that it offers. But like anything, you must have a basic understanding of some of the key terms associated with dental insurance; this will help you sort through the complexities of your plan and net as many of those dollars as you possibly can.
Who administrates your plan?
Third parties: These are the plan providers who provide the financial benefits for your dental insurance plan. There are three third-party types:
- Insurance companies: For-profit organizations that take on the financial risk of your benefit plan. They are the ones who will process your claim. Insurance carriers enter into a contract with either groups or individuals, and offer a variety of benefit packages.
- Dental service corporations: Not-for-profit organizations that negotiate and coordinate contracts for dental treatment, either for individuals or patient groups.
- Self-funded insurers: Employers that reimburse their employees for the dental care they receive. There are typically limitations on dollar amounts spent and treatments covered under a self-funded insurance plan.
Can you continue to see the same dentist?
If you currently have a dentist with whom you’re comfortable, you’ll want to be very careful about which insurance plan you choose.
Open panel plans allow you the freedom to choose your own dentist. They also allow any dentist to participate in their plan. These plans may also be called "freedom of choice" plans.
Closed panel plans allow you to see only dentists who are contracted to participate in the plan. There are two types of closed panel plans:
- Preferred provider organization (PPO): Under this plan, you can select from a group of dentists in your area who have agreed to provide treatment for less than their usual fee. If you choose a dentist who is not a "preferred provider," you will have to pay a greater portion of your dental bill.
- Exclusive provider organization (EPO): This is the more restrictive of the two closed-panel plans. Under this plan, you will be required to select your dentist from a limited number of dentists who have agreed to accept substantially reduced fees for their work. Participating dentists may even be salaried employees of the EPO. For this reason, many dentists do not participate in EPO plans, which greatly limits your choices. EPOs will often restrict your access to specialists and limit the amount of care you can receive each year.
How much dental care will you receive?
Each plan uses a different method to calculate your benefits and payments. Below are the most common payment schedules:
Usual, customary and reasonable (UCR): This is the payment schedule used for most traditional, fee-for-service benefit plans. The payments are usually made directly to the dentist, and are based on a fee schedule that was set decades ago (the "usual, customary and reasonable" fees). As a result, the fee schedules are quite low compared to the actual fees charged by dentists, and you wind up paying a good deal more out of pocket for the dental treatment you receive. However, with UCR plans, you are free to see any dentist you’d like.
Table or schedule of allowances: This benefit calculation method is similar to UCRs, but more restrictive. You may not be able to choose your own dentist, the level and quality of the care you receive may be lower than you’d like, and your access to specialists will be extremely limited. Under this payment schedule, a maximum dollar value is assigned to each procedure, regardless of what the actual fees for that service are in your area. If you are considering a benefit plan that uses this as their payment schedule, it’s important that you ask how often the fees are adjusted to account for inflation, because you’ll be expected to pay the difference.
Capitation (also called per capita): This fee schedule is usually associated with plans that predetermine a certain level of dental benefits that will be offered to you. If the plan administrator decides that a certain treatment is not covered, you will be responsible for paying for it. Quality of care is also compromised when this payment schedules is used, because frequently the amount paid to the dentist is actually less than the cost of providing that care. When this is the case, dentists have an incentive to under-treat; the more services they provide to you, or the more patients they see, the less money they make.
Other terms you should know
- Predetermination of costs (also called preauthorizaton: This is a treatment proposal that your dentist submits to the administrator of the benefit plan prior to the beginning of treatment. The administrator evaluates the proposal, then makes a determination of the benefits they will allow, based upon your eligibility, covered services, and the plan’s limitations. A predetermination of costs may be required by some plans when the proposed treatment exceeds a certain dollar amount. A predetermination of costs is helpful to both you and your dentist. It can help you to prioritize, plan and budget your dental treatment plan, making the best use of the benefits allotted for each year.
- Coordination of benefits: If you have dual insurance coverage (for example, you and your spouse both have family dental coverage), coordinating benefits is essential, as it will maximize the coverage you receive from each benefits plan. You should notify the administrator of your primary plan (the one provided by your employer) if you have double coverage.
- Non-duplication of benefits: Unfortunately, some plans have a clause that disallows overlap in benefits if you are covered by two dental plans.
- Annual benefits limitations: Many plans have annual caps on the dollar amount and/or the number of treatments or procedures that you may receive annually. Find out what your plan’s annual maximum is, and work with your dentist to maximize these benefits each year AND minimize your out-of-pocket expense.
- Least expensive alternative treatment (LEAT): Most dental benefit plans require that dentists follow treatment plans that are based upon providing the option that is least expensive, even if a more expensive option would better suit your individual needs. If you choose a more expensive option, you will be responsible for the difference in the cost. Unfortunately, the least expensive treatment is frequently not the one that will provide you with the best long-term results.
- Premium adjustments and re-evaluations: Both you and your employer should lobby the third party to regularly re-evaluate premium levels to be sure that the UCR or Table of Allowances payments are in line with actual fees charged by dentists in your area.
- Peer review for dispute resolution: This is a system that is in place to resolve disputes between patients, third parties, and dentists. If a case goes to peer review, individual records, treatments and results are thoroughly evaluated before a resolution is recommended. This usually resolves any disputes to the satisfaction of all parties.
How do third parties categorize the services your dentist provides?
- Diagnostic: Exams, x-rays and other services that are used to evaluate your oral health and detect malfunction or disease.
- Preventive: Services that are designed to prevent decay and disease, such as dental cleanings, fluoride treatments and the application of sealants.
- Restorative: Fillings, crowns, inlays and onlays used to restore strength and functionality to decayed or damaged teeth.
- Discretionary (or elective/cosmetic): These are treatments that the third party administrator determines to be optional