At GEMS Dental, we work hard to make sure all of our patients receive the best care possible. We work closely with you and your insurance company to make sure you are getting the best options for dental reimbursement and procedure coverage. Any questions you may have can be answered by our highly trained staff, who work hard to stay up to date on your coverage options.
Make sure to call our office if you have any concerns or questions before your first visit to our office.
It is important to provide information to our office as to your insurance policy when we have our first consultation, so we can make sure your financial options are handled quickly and carefully.
The following information is based on patient education content provided by the ADA:
Understanding Your Insurance
Dental insurance is a wonderful service that can greatly reduce the cost of your dental care, much like a “coupon” that can help keep your health under control. However, full coverage is often hard to come by in the dental world, so it is important to know what your plan covers in order to keep your dental finances in check. Benefits should be understood separately from services your dental office will provide, and it is best to consult with your dentist and your insurance to see what treatment options are best for your budget.
How Dental Plans Work
Dental plans can be provided by your employer, and the amount of coverage offered by each depends on the agency. Your employer has a set amount that is covered for their employees within their insurance plan, and it is important to check with your insurance to see what is covered before seeing your dentist to set up a treatment. The amount of coverage offered varies per insurance plan, and not all procedures may be covered. It is important to talk to your employer about the insurance benefits you receive, and discuss any potential issues with coverage.
The role of your dental office
We work hard to ensure our patients’ dental care is our top priority. It is important to know your insurance coverage to ensure you receive the best treatment while optimizing your coverage and minimizing your expense. However, in the case of a copay, you are required to cover the portion of the bill not covered by your insurance company. We do offer individualized financing plans to help you approach your dental bills in the most convenient way for you.
Insurance terms
The features of a dental plan can include, but are not limited to, the following list:
UCR (Usual, Customary and Reasonable)
The maximum amounts that are covered within your dental plan are referred to as usual, customary, and reasonable amounts, or UCR. While this may seem like a standardized rate for dental procedures, this is not necessarily true.
- The UCR are not based on the “usual” prices of dental procedures in your area.
- The insurance policy decides what is a “reasonable” rate for the UCR, and they are often not based on actual dental fees.
- Insurance companies often do not factor inflation into their UCR, leading to price issues down the road.
- Insurance companies set up their UCR independently, with no requirement to show how they arrived at this number.
If there are price discrepancies between your dental bill from our office and your UCR, that is often due to the insurance company themselves, not an overcharge by your dental office. UCRs are not necessarily reflective of your state and are often not updated to reflect current care values.
Annual Maximums
Annual Maximums are the largest amount your insurance will cover towards dental care in a given year. This is dependant on your employer and the insurance company, not our dental office, and is decided via their contract. Co-payments are required if the cost of care exceeds the annual maximums. Dental care can often fluctuate outside of the range of the annual maximums presented by insurance companies. If you believe there is a large discrepancy between the annual maximums offered by your insurance and the price of dental care, talk to your policy provider about potentially updating their policies.
Preferred Providers
Preferred providers have a contract with a certain dental plan, and as such will require you to pick from a specified list of dental providers. Preferred refers to the preferences of the insurance company itself, not anything on the part of the patient themselves. Any choice of provider that does not fall within this list may cause more steep out of pocket charges for your dental care. It is important to be aware of the limits of your dental plan before looking for a dental office both inside and outside of your plan’s list of preferred providers.
Pre-existing Conditions
Dental benefits may not cover certain preexisting conditions, such as tooth replacement for teeth extracted prior to the plan itself. However, even without coverage on these treatments, they may be prescribed by your dentist to maintain your dental health.
Coordination of Benefits (COB) or Non-duplication of Benefit
If the case of double coverage, or co-coverage, such as insurance plans from employment for both spouses, many companies wish to be aware of the level of coverage so as to coordinate bill payment. This allows your insurance to coordinate payment so both companies end up covering the same amount of treatment for their customers. The combined benefits from both plans should never exceed the actual cost of treatment, and multiple dental plans are not a guarantee of full treatment coverage. It is important to make sure your dental plan covers the procedure you are scheduled to have done, as knowledge about your coverage plan is in your hands.
Plan Limits
Some dental insurance plans may have a limit on the number of repeat treatments it will cover, such as multiple teeth cleanings per year to maintain oral health. Make sure to be aware of the coverage of your dental plan before scheduling procedures, as uncovered costs are your responsibility to cover. Be aware of your coverage plan before talking to your dentist.
Not Dentally Necessary
Many dental plans have guidelines for dentally necessary or not, and some treatments may not be considered necessary by your insurance. This has nothing to do with the decision of your dental specialist, rather it determines what treatments are reimbursed by the insurance agency itself and which are out of pocket expenses.
Treatment is determined by our professional team of dentists, and may be necessary to preserve your dental health. The plans provided by your insurance company are based on blanket acceptance or rejection of cost coverage, not because of any medical basis of the treatment itself. If you feel that you have been rejected for a dentally necessary treatment coverage by your insurance, look into your appeals services in order to get in contact with your insurance agency.
Least Expensive Alternative Treatment
The Least clause in your dental plan may dictate the kind of treatment you can receive, as it allows for your insurance company to decide which alternate, less expensive treatment it will cover. This is due to a cost reduction plan on the part of the insurance company, not on how your dental treatment can best be carried out. It is important to talk with your dentist about your most effective treatment plans, both for your oral health and for your wallet.
Explanation of Benefits (EOB)
Any written description of your coverage and copay policy from your insurance agency is called an EOB (explanation of benefits). Any out of pocket expenses should be rendered to the dental practice itself. Any issues with your insurance EOB should be brought directly to them through their contact information as to best resolve the issues.
Make your dental health the top priority
While monetary factors may influence the full extent of your dental treatment options, it is important to consider your dental health while deciding your coverage options. In many cases, while the cheapest option may be tempting when it comes to treatment, the more expensive options will likely have a more predictable outcome that will last longer, costing you less money over time.
This explanation of insurance benefits is meant to make sure you can get the best treatment options available within your price range. Our dental office is always open to helping you figure out your best dental treatment options, so give us a call if you have any questions about our policies.
