Your dental insurance plan is a form of compensation provided by your employer. The portion of the dental treatment fee your insurance company will pay is determined by a contract between your employer and the insurance company. The higher the premium paid by your employer, the more generous the reimbursement. It is customary for dental insurance companies to pay different reimbursement percentages depending upon the procedure. There is often a yearly deductible the patient is responsible to pay and almost always a yearly maximum benefit that the dental insurance will pay out for dental service rendered per year per patient. Once this yearly maximum contractual amount has been paid the dental company will not pay any additional benefit for that calendar year.
Although it is a patient’s responsibility to know and understand the details of their dental insurance plan as a courtesy to our patients we strive to help them receive the maximum reimbursement to which they are entitled. We are happy to process our patient’s insurance claims for them and provide the insurance company with any information that will help our patients receive their maximum insurance benefit. This includes written dental histories, x-rays, and diagnostic photographs.
At Jeffrey S. Sobecks, D.D.S. we accept most dental insurance plans. Call us anytime if you have specific questions regarding your dental insurance.
General Information about Dental Insurance
Dental insurance is a type of health insurance designed to pay a portion of the costs associated with dental care. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: (1) Indemnity (or sometimes called: true dental insurance or free choice of dentist) that allows you to see any dentist you want who accepts dental insurance; (2) Preferred Provide Network dental plans (PPO); and (3) Dental Health Managed Organizations (DHMO) in which you are assigned to an in-network dentist and/or in-network dental office and use the dental benefits in that network. Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.
Indemnity Dental Insurance Plan:
This plan may be helpful when you want to stay with your dentist and he/she does not participate in a dental network. By the very nature of this plan the insurance company generally pays the dentist a percentage of your services according to the policy you purchased. In addition you will want to review the co-payment requirements, waiting periods, stated deductible, annual limitations, graduated percentage scales based on the type of procedure and/or length of time you have owned the policy prior to starting your dental work.
Dental Health Managed Organization (DHMO):
When a dentist signs a contract with a dental insurance company that provider agrees to accept an insurance fee schedule and give their customers a reduced cost for services as an In-Network Provider. Many DHMO insurance plans have little or no waiting periods, no annual maximum benefit limitations, while covering major dental work near the start of the policy period. This plan is sometimes purchased to help defray the high cost of the dental procedures. Some dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
Participating Provider Network (PPO):
Depending on your specific plan, the PPO works similar to a DHMO while using an In-Network facility. However, it allows you to use an Out-of-Network or Non-Participating Provider. Any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. As noted, some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted any additional treatments may become the patient's responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan.
Dental insurance companies divide benefits, services, or procedures into categories and refer to them with American Dental Association (ADA) 3-4 digit code. As an example, Preventative and Diagnostic procedures often include exams (ADA code 0120), x-rays (ADA code 0210), and basic cleanings or prophylaxis (ADA code 1110). Basic procedures often include fillings, periodontics, endodontics, and oral surgery. Major procedures often are crowns, dentures, and implants. Procedures such as periodontics, endodontics, and oral surgery may fall into the Major category depending on your specific plan with specific fee schedules and co-payments.
The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. Depending on the type of dental insurance policy you purchased some claims processing is handled directly by the dental office. Check with your dental insurance representative to determine the best suitable plan for you and your family.