How Dental Plans Work
Your dental plan is an employee benefit provided by your employer. The insurance company portion is determined by the contract your employer has set with the insurance company. The higher the premium paid by your employer, the more generous the reimbursement.
As there are thousands of employers and plans in existence, we are unable to know the details of each plan. We do our best to update our records as patients inform us of any benefit exclusions or changes they have with their plan.
We will always diagnose and treat you based on your actual health needs without regard to the limitations imposed by your coverage. To treat you based on only your coverage would not be ethical. Our promise to you is to provide you with the finest care, at the most reasonable cost, regardless of insurance coverage.
We mainly file claims electronically. We accept most insurance plans and will directly bill your plan and wait for payment. We are usually paid within 4 weeks. If your plan specifies it will only pay the patient, you will need to pay our office at the time of the treatment and wait for reimbursement from your plan.
Any remaining balance still owing after your insurance has paid our office is your responsibility. Prompt payment is appreciated.
If our office has not received payment from your insurance plan within 60 days, the balance owing will be transferred to you, and we will expect payment from you. You may still seek reimbursement from your insurance.
Be Familiar With Your Dental Plan
It is your responsibility to be familiar with the terms and limitations and exclusions of your dental plan. You are responsible to pay any fees owing to your dentist if your plan doesn't pay. To avoid misunderstandings, we recommend that patients feel free to discuss any concerns with us.
Here is a checklist of questions you should ask in order to become sufficiently educated about your dental plan:
1. What types of dental benefits does my employer provide?
2. Are there limitations on treatment or exclusions of types of care?
3. Are my benefits following a January-December calendar year?
4. Does the plan require pre-determination of benefits? When?
5. What is the annual maximum coverage amount? Per person? Per family? Per lifetime?
6. Is there a deductible? Per person? Per family? Paid how often?
Let your plan administrator (the person at your workplace who arranges for benefits) know how your plan is or isn’t working.
Insurance companies will often only communicate with the policyholder regarding their policy benefits. This is largely due to the Privacy Act.
Typically, dental plans do not cover all procedures. There are several reasons that your reimbursement may be less than you expected. It could be that your plan has a clause to pay for a less expensive alternative procedure; or your plan has a frequency or dollar limit ("cap") for a certain procedure; or your plan does not cover the procedure as a benefit under your plan, or your plan pays out at different percentages for different procedures.
Use your benefits since you are paying the premiums!