Finance

• Policy Coverage
• Predetermination
• UCR
• Types of Insurance Plans
  • Regular Indemnity Plans
  • Preferred Provider Organizations (PPO / PDO / PDP)
  • Dental/Health Maintenance Organizations (Dental HMOs, DMOs) or Capitation Plans
• More Than One Insurance Policy
  • Primary and Secondary
  • Consideration & Types of Secondary Claims
  • COB
  • MOB, Carve Out, Limited Coordination, Non-Dual and Integration of Benefits
  • Dependents
  • When Does Secondary Pay

I recognize the most important goal of dental care is dental health, and I know that part of this includes paying the bill.  I also know that the emphasis of caring treatment recommendations is helping you achieve the level of health you want.

Policy Coverage

There are literally hundreds and hundreds of types of coverage depending on what your employer purchases.  PPO/PDO/PDP plans frequently provide out-of-network benefits, so be sure to check your particular coverage, because you may be able to be reimbursed even when seeing a non-participating dentist.

Policy coverage for different procedures is often difficult to discern.  I have developed a comprehensive checklist of questions for you to ask your insurance company to determine what your coverage will be.  Click here to review the checklist.

Will you get the percentage reimbursement stated? maybe.

Any reimbursement would be subject to the conditions and restrictions of your particular plan.  If you have any questions about what treatment is covered, please be sure to contact your insurance company [you will likely require specific information such as treatment codes].  The percentage of reimbursement from your insurance company is determined by their fee schedule, which is not related to local dentists' fees.  The percentage of insurance reimbursement DOES NOT mean you will receive that percentage of fee you are charged, just that percentage of what the insurance has agreed to pay in their contract with you and/or your employer (see UCR below).

Predetermination

If you have questions about what may be covered, you can request a predetermination of benefits from your insurance carrier (this may take 6-8 weeks).  An insurance predetermination requires specific treatment codes (provided by the dentist), and often accompanying documentation, such as narratives, x-rays, etc.

UCR

The most confusing element insurance companies use is what they call UCR.  UCR is referred to by insurance companies as Usual and Customary Rate.  Many times your coverage is based on a percentage of UCR.  UCR is NOT a reflection of the usual fees for dentists in your area, but rather is a maximum fee that the insurance company is contracted to pay.  The confusing part arises when an insurance policy says it will cover 100% of a particular treatment, only to find out that in fact that is not so, because it actually refers to 100% of UCR, which is not usually the dentist's fee.  Typically UCR is anywhere from 10% to 40% lower than actual fees for an area.

Types of Insurance Plans

• Regular Indemnity Insurance Plans
  These are traditional insurance plans (includes some self-insured plans) that place NO restrictions on your choice of general dentists or specialists. You never have a list of providers from which to select. Indemnity plans are usually the most flexible dental plans available. 

• Preferred Provider Organizations (PPO / PDO / PDP)
  These insurance plans are more restrictive because they provide you with a list of preferred providers (general dentists and specialists) from which to choose. Depending on the plan and insurance company, you may have a wide or narrow choice of providers. You have the flexibility of selecting another dentist or specialist from the list, at any time, for any reason. Providers on the list agree to a contracted (i.e. reduced) fee. Some PPO also allow you to go off their list and select other dentists while maintaining benefits. However, your out of pocket expenses may be slightly higher at an "off the list" dentist, where you can be responsible for the difference between your plan benefit and the dentist fee.
• Dental/Health Maintenance Organizations (Dental HMOs, DMOs) or Capitation Plans
  You are required to select one primary care provider from a list, and can only obtain treatment from that office. These plans are even more restrictive and inflexible. Dentists receive a low monthly dollar amount for each client that selects their office, they also agree to a very much reduced fee for their services and receive very reduced or NO insurance reimbursement for many procedures. Clients are still responsible for co-payments on treatment provided. You usually have to obtain a referral from your general dentist to see a specialist. You may change your primary care provider, but it involves contacting the HMO administrators who will switch you to the new provider.

More Than One Insurance Policy

For clients with coverage from more than one insurance policy, there are general rules designated by your respective insurance companies for how to manage payment with the different policies.

Primary and Secondary
In general, if there is a primary insurance and a secondary insurance, the policy that is primary is the one to which you are the subscriber.  A secondary policy is one where you are covered under someone else's policy.  These are not choices you can make, but rather determined by your insurance company.

Consideration & Types of Secondary Claims *
There are many different ways an insurance carrier considers secondary claims.

COB used to be the typical way, which means Coordination of Benefits.  Basically the two insurance carriers would coordinate the benefits between each other in order to pay 100% of the fee charged but not to exceed the charge amount, so the client or the doctor would not profit from being over compensated for the expenses.

The other types of calculating secondary insurance are MOB (maintenance of benefits), Carve Out, Limited Coordination, Non-Dual and Integration of Benefits.  All of these types usually do not pay anything secondary.  The contract language is written so that if the primary carrier paid the same or more than what the secondary carrier would have paid if they had been primary, then they (the secondary carrier) is not responsible for any payment at all. (It would be a duplication of benefits).

Integration of Benefits, the toughest form of nonduplication, means the sum of the total benefits paid by either carrier may satisfy the maximum of the secondary carrier.  For example, if the secondary carrier has a plan year maximum of $1500.00, and the client had a $3000.00 bridge or oral surgery paid at 50% by the primary plan, the secondary carrier says it has satisfied its maximum for the entire plan year even though it was the primary carrier that paid the $1500.00!  The secondary carrier hasn't paid anything, but it has satisfied its maximum.

It is so important when verifying benefits to find out exactly how the insurance company handles secondary claims.

Remember when submitting "pre-treatment estimates," all carriers estimate their benefit payment as if they are primary.

Dependents
The designation of which policy pays first for dependents again depends on the rules of your insurance company.  The typical rules for dependents of parents not separated or divorced with overlapping coverage rely on birthday of the parent, gender of the parent, or some other rule.  For divorced/separated parents, specific custody rules usually apply, unless some specific arrangement is agreed to by each party.  These designations are unique to each particular insurance.

When Does Secondary Pay
Usually, the secondary policy will not usually accept a claim until after the primary claim is paid, and then the secondary policy will often require a copy of that payment information (referred to as an EOB, explanation of benefits).