We want to make sure that your child gets the best care possible! That’s why it’s important that you understand how to maximize your insurance plan.  Here are some tips about how we collaborate with your insurance company.

Your Dental Insurance Policy

Your dental insurance policy is a contract between you and your insurance company. Your insurance company decides how and what to do with your covered expenses, as well as which things specifically are covered.

Good questions to review with your dental insurance provider include understanding your deductible, co-insurance, exclusions and yearly maximum. Each of these will affect how you use your insurance throughout the year and prevent unwelcome surprises during a visit.

While your insurance agent can give you a thorough explanation of each of these, here is a quick summary of what each of them means on a basic level.

  • Deductible: This is the amount you must pay before your dental insurance covers services. For instance, if you have a $500 deductible it means you must pay the first $500 of a treatment before insurance will cover its portion of whatever is left. This is a yearly figure, meaning that after the deductible is met insurance will cover subsequent treatments until the total amount covered that year equals the yearly maximum (see below).
  • Co-Insurance: If you have a fee-for-service plan the insurance company agrees to pay a fixed percentage of any fees incurred for treatments. They may pay 50%, for instance, meaning you are responsible for the other 50% during your visit.
  • Exclusions: These are particular types of treatment not covered by your dental insurance plan. Each plan has specific exclusions to be aware of that, if they are treatments you need, you will know in advance that you’ll have to pay for them yourself.
  • Yearly Maximum: Often this is a maximum dollar amount that your dental insurance will cover per calendar year. If you’ve had enough procedures done that your insurance has kicked in this amount, that generally means that any further dental work you have done will no longer be covered until the next calendar year.
  • LEAT (Least Expensive Alternative Treatment: If your plan has a LEAT clause, it means that the plan will only pay for the least expensive treatment available associated with your dental needs in that instance (if there is more than one option available to treat your need.

Secondary Dental Insurance

This comes into play if you are covered by two dental plans. One of them will act as your primary plan, with the second acting as a supplemental plan. Note that this doesn’t mean you have twice the coverage.

Usually the first/primary dental insurance plan will cover you the same way it would if it were your only plan. The supplemental coverage would kick in for cases where the primary covereage doesn’t fully cover the cost of a treatment. For instance, say you are seeking a root canal treatment and your primary insurance covers 80% of that. It’s possible that your supplemental plan would further assist in paying the remaining balance.

If you have secondary dental insurance, we ask that you pay any deductibles and co-pays due on the day of appointment.

Primary insurance is determined by birth month of policy holder.  This is important and can help save you a lot of time.

Covered Expenses

Please be aware that we are only able to estimate what your insurance coverage may be, and that the actual patient portion may be more than we expect.

Each insurance is different in their coverage and fee scale.

We never know how much they will cover and you may work next to someone who has different fees than you do.  The only way that we can better estimate your coverage is with a pre-determination and we are glad to submit that for you. Please be aware that it is not always a guarantee.

Insurance Eligibility

If you are deemed ineligible for your insurance benefits at the time of service, you are responsible for payment of services.  Most insurances will give us automatic benefit package information through our eligibility system.

Smaller insurance companies will not interface with our software, so please make sure that you know your coverage when you come in our office.  Remember that your medical carrier is not always your dental carrier.

Usual, Customary, and Reasonable Fee

Each insurance company has its own fee regulations called “Usual, Customary, and Reasonable” (UCR). We don’t know how your insurance company arrives at this estimate, but it is their estimate of what our fees are supposed to be.

Each insurance company has a different UCR and we have no input into that fee.  In fact, we are not allowed to know what that fee is until after we have submitted your insurance claim or pre-determination that we send on your behalf.

Please be aware that some, perhaps all, of the services provided may be non-covered services and not considered usual, customary, and reasonable (UCR) under the terms of your insurance policy.  Our practice is committed to providing the best treatment for our patients and we charge what is the usual and customary fee for our area.  You are responsible for payment regardless of any insurance company’s arbitrary determination of usual, customary and reasonable (UCR) rates.

Failure to Pay

If your claim is denied for any reason, we expect payment from you. As a courtesy, we will file your insurance but expect you to follow up with your insurance company should a problem arise.

In case of non-payment from insurance, we will bill you. If your investigation into your insurance company’s policy leads to denied services, we will still have to bill you. Failure to pay our office may result in actions such as collections, legal actions, or the reporting of negative information to credit reporting agencies.

Exceptions to Courtesy Filing of Your Insurance

We are out of network with all dental carriers.

Blue Cross/Blue Shield and Delta Dental will not send payment to providers that are out of network.  Payment is sent directly to the policy holder (parent or guardian).  For those patients, payment is expected in full on the date of service. As a courtesy, we will file services to your insurance and the check will be mailed to the policyholder (parent or guardian).

It is the responsibility of the policy holder (parent or guardian) to provide us the Explanation of Benefits in order to file secondary if primary is Delta Dental or Blue Cross/Blue Shield.