We are happy to verify, ESTIMATE your portion of treatment costs, and file your insurance claims for you. However, we DO encourage our patients to be “savvy” consumers and know their insurance plans as well! Here are some important things to know……
*Employers offer dental benefits to help employees pay for a PORTION of the cost of their dental care. The amount your plan pays is determined by the agreement negotiated by your employer with the insurer. Your plans “allowed” fees are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of the dentist’s fee or their “allowed” amount, whichever is less. (Exceeding the plan’s “allowed” fee does NOT mean that your dentist has overcharged for the procedure.)
*Information needed to submit claims on your behalf include: insurance company name, group number, who the plan holder is, their member/subscriber ID or social security number, date of birth, employer, and the effective date of coverage.
*What your annual deductible and maximum benefits are per benefit period. Keep track of what you are using - once you have used the maximum dollar amount your plan will pay toward your dental care, you are responsible for costs incurred over that amount. The deductible is the amount you must pay out of pocket before your insurance company will start paying.
*Frequency Limitations are the number of times in a benefit period a procedure will be paid For by your plan. For instance, a fluoride treatment for your child may be covered only 1 time per year, while the ADA recommendation is 2 times per year.
* Any Exclusions or Waiting Periods which the consumer should be aware of. For example, a “missing tooth clause” means that the plan will not pay for ANY procedure to replace a tooth that was missing prior to the plans effective date.
*Cost Control Measures to keep their costs down may include:
Down grading. For example, your dentist recommends a white composite filling on a molar, but your insurance will only pay for the silver amalgam filling. This is also known as “least expensive alternative treatment.” It does not mean we “coded wrong” on the claim….we code exactly what we do. It is just another way your insurance company is saving money for themselves.
Bundling. An example of bundling is when periodic (check-up) exams and limited (emergency) exams are combined in the frequency limitation.
Remember, insurance companies DO NOT base their coverage
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