UNDERSTANDING DENTAL INSURANCE


 

Insurance Situations

to be aware of

 
 

Your Explanation of Benefits or EOB is mailed to you usually a few days to a week before payment is made by your dental insurance to our office, however, sometimes they even send you the check. Most EVERYONE sits this mail aside and it stays unopened. If you do open it, please review the “amount you owe provider” or “patient pays” sections as this is typically a reflection of your cost details and what your plan may have covered. You may still owe our office and this EOB can help you determine that cost.

Medicaid/Medicare

Medicaid is state funded insurance for children, check with our Pediatric Dental Office with any Medicaid questions. Medicare does not have dental insurance, however, some supplemental policies are offered with various insurance groups. These typically do not pay on most procedures. Medicare Supplemental plans might pay a small amount toward certain procedures if there is not a wait period on the policy, we are happy to verify these benefits for you so you can estimate your cost. 

Primary/Secondary Dental Insurance

As long as your primary plan is a PPO policy we will file this for you. Depending on how the primary plan allows for coordination of benefits we may file your secondary for you as a courtesy if it is also a PPO policy. Many times patients think that because they have two dental insurances they will not have any cost, this is not the case. Primary and/or Secondary coverage may not allow for coordination of benefits which means they don’t work together. There are also situations where the Primary and/or Secondary policy has an “allowed amount” and they will not pay anything over that amount. Payment is due for anything not covered by primary and secondary coverage.

Plan Limitations

Plan limitations to look for include: waiting periods, missing tooth clause and frequencies. With waiting periods your plan may have a wait for services such as 6 months for major coverage which might include crowns or bridges. A missing tooth clause means that prior to your policies effective date if the tooth was already missing the plan will not pay to have it replaced. Some plans have frequencies such as - 1 full set of x-rays every 5 years. In which case, if you had x-rays with another provider less than 5 years ago, they would not be covered again when you come to our office and you would pay out of pocket. 

Did you know we have a  pediatric dentist  at the castle?

Did you know we have a pediatric dentist at the castle?

Keep in mind every policy is different, plans usually renew annually and your renewal may occur January 1st meaning your benefits renew that month or on the policy specific renewal month. Schools and ISD plans policy year runs from September to August.

Some policies down-code or down-grade procedures and they do not always share this information with our team so it is not always known until after the procedure has been completed and sent to the insurance. An example of this is a plan that down-codes or down-grades a porcelain crown to a lesser paid amount of a metal crown, this may result in an owed amount from you.

You are welcome to ask our team tel. 972-727-8249 for any dental codes we may file to your insurance so that you can contact the insurance directly to verify your plans specific details such as allowed amounts. For example, a tooth may need a crown and we can provide you with the code and cost, upon calling your insurance you can let them know these details and they will share with you if the cost is within or over the plan allowed amount which will better help you know your cost!