REASONS WHY TREATMENT MAY NOT BE COVERED BY YOUR INSURANCE COMPANY
Your dental insurance plan is your benefit and an agreement between the specific insurance company, your employer and you. There are many reasons treatment you receive may be only partially covered or not covered at all. We would like to outline some of those reasons so you may better understand your coverage. We do not keep track of individual patient benefits as there are approximately 1,500 individual insurance coverage's within our practice.
Reason #1 USUAL, CUSTOMARY, REASONABLE (UCR)
With most of these plans an established percentage of a dentist’s fee is paid depending on the service performed. This percentage is based on the “usual and customary” fee of dentists in the area. This is not always an accurate reflection of your particular area since most Insurance companies survey for example the entire east coast then take an average or they do not keep up with current regional data. Unfortunately, there is no regulation on how dental insurance companies determine reimbursement levels.
Reason #2 ANNUAL MAXIMUMS & DEDUCTIBLES
Your employer makes the final decision on plan maximums and deductibles through their contract with a particular insurance company. Insurance maximums over the years have not maintained pace with the rising cost of dental care, therefore some plans remain with low maximums. Deductibles are not always made clear to the plan member.
Reason #3 PREFERRED PROVIDERS
Whether or not your dentist participates in a particular dental plan (PPO) effects your benefit. If you go to a non-participating dentist, you may not be reimbursed at the same level, as a participating dentist or you may not be covered at all.
Reason #4 BENEFIT FOR ALTERNATE TREATMENT
Some plans will only cover for the least expensive course of treatment for a particular procedure. For example, your dentist may recommend a crown, as the best treatment to restore a broken tooth, yet the insurance will only reimburse for a large filling. The least expensive alternative is not always the best treatment option, however the insurance company contract will only allow that level of reimbursement.
Reason #5 PRE-EXISTING CONDITIONS
As with medical insurance most dental companies will not cover any condition that existed prior to you’re becoming a plan member. As an example, if you had a missing tooth before your insurance took affect they may not cover a bridge, partial, or implant to replace that tooth.
Reason #6 EXCLUSIONS
Certain procedures may be excluded from you benefit package or have an age limitation. Sealants are only covered on certain teeth up to a certain age even though this treatment would be a long-term preventive benefit.
Reason #7 DENIED DUE TO FREQUENCY
Most dental insurance companies allow cleaning and exam appointments either once every six months (this is the most common) or twice per plan year (normally a calendar year). It may have been recommended to you that you have cleanings three or four times per year due to a chronic periodontal condition or for other reasons in order for you to maintain good oral health. These additional services are not covered under most plans and would be your responsibility for payment.
In conclusion, the best course of treatment should be a determination between you and your dentist and should not necessarily depend on your dental coverage.
If you have any questions about your dental plan or a problem with reimbursement levels, contact your employer or the insurance company.
Please make an effort to be aware of your policy benefits, maximums and exclusions as we do not. You should be able to get this information from your employer, the insurance company or the insurance company’s website.
Revised 4/14/2011 3:26 PM