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 are generally based on Usual and Customary dental services, an average of fees in your area. When a dentist signs a contract with a dental insurance company that provider agrees to match the insurance fee schedule and give their customers a reduced cost for services, this is considered an In-Network Provider or Participating Provider network (PPO). Depending on your specific plan, if you seek 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. Some dental insurance plans may have waiting period restrictions. This is a period of time before certain benefits will be covered, and is often set in place when you are a new enrollee or seek out an independent plan outside of an employer or group.
Dental insurance plans may have an annual maximum benefit limit and after that maximum benefit additional treatments 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. Orthodontics usually has a separate limit. Some plans may have an annual deductible depending on the treatment rendered. After the deductible is met, the remaining fee is then paid at its specified percentage or fee schedule.
Dental insurance companies set services or procedures into categories and refer to them with American Dental Association (ADA) codes. As an example, Preventative and Diagnostic procedures often include exams, x-rays, and basic cleanings or prophylaxis. 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. Many dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
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. Eligibility of Benefits, or EOB, statements are most often then sent with payment to both the provider of service and the plan policy holder.
Upon enrollment, be informed through the enrollee benefit packet regarding coverage and contact a dental provider and/or dental insurance company with additional questions about specific dental benefits.