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Ask Dr. ProtzerWhat does my insurance cover?

Dental insurance can make it easier to get the dental care you need. But most plans do not cover all dental procedures.

What are Your Needs?

The amount covered by your dental insurance should not be the only deciding factor when deciding on treatment. Your treatment should be based on your needs, determined by you and your dentist.

How is my dental coverage determined?
Almost all dental plans are based on a contract between your employer and an insurance company. Your employer and the insurer agree on how much your plan pays and what procedures are covered. Some insurance companies have more limits. The more your employer is willing to pay, the better the coverage is.

We use the terms “dental plan”, “dental insurance”, and “dental benefits” interchangeably in this article. All of these terms refer to the same thing.

Submitting Claims

We will assist in submitting your insurance claim as a service to you, and in most cases accept “assignment”.

Assignment means that your insurance pays us directly and you only have to pay your portion.

You are expected to pay copayments and any cost above the annual maximum (see below). Any part of the bill not covered by your insurance is your responsibility.

Annual Maximums

The annual maximum is the largest amount a dental plan will pay during the year. This may be a calendar year (in most cases) or a fiscal year (a 12 month calendar period other than January 1st to December 31st).

Your employer decides the maximum levels of payment in its contract with the insurance company.

If the annual maximum of your plan is too low to meet your needs, ask your employer to look into plans with higher annual maximums.

Pre-Existing Conditions

A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits may not be paid for replacing a tooth that was missing before the effective date of coverage.

Co-ordination of Benefits (COB)

This applies to patients covered by more than one dental plan. The benefit payments from all insurances will not add up to more than the total charges.

Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for the entire treatment charges. There are many complicated rules. It matters who is your primary and who is your secondary insurance company. Different insurance company have different rules. And sometimes they simply don’t follow their own rules.

We will help you to maximize your benefits. However, ultimately all charges are your sole responsibility as a patient.

Plan Frequency Limitations

A dental plan may limit the number of times it will pay for a certain treatment. However, some patients need a treatment more often to maintain good oral health.

For example, a dental plan may say that they pay for teeth cleaning only twice a year even though the patient needs a cleaning four times a year. Often, they will allow more cleaning and will pay for this. Please ask us!

Make treatment decisions based on what is best for you and your health, not just what your dental plan covers.

Denial of Service by Your Dental Plan

Most insurance clerks have no dental experience. They often have a quota to meet. They may turn the claim down, claiming that they need more information. Often in spite of the fact that they indeed were provided with all the information, but did not bother to read it. Some insurance companies are better, some are worse in this regard.

If your dental plan states that a procedure is not covered, this does not mean that the procedure is not necessary. It just means that according to their own rules the procedure is not covered. Treatment decisions should be made by you after consulting with your dentist.

Bottom Line

Talk to us! We will try our very best to help you and even fight for you with your insurance company. Ultimately you are the only one to decide on the treatment, after we provided you with cost, alternatives, risks, timeline etc.

In our office we have about 100 different insurance companies that we work with on your behalf. And about 1000 different insurance coverages. We only know what you will tell us about your insurance.

Our goal is to help you take good care of your teeth. We will do everything to help you with your insurance claim.

You, as the patient, have the ultimate financial responsibility for all charges.

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