My dentist has recommended a treatment that is not covered by my dental health plan.
Does this mean the treatment really isn't necessary?
It is a common practice for dental plans to exclude treatments that are covered under a medical health plan. In addition, many plans exclude or discourage payment for sealants, pre-existing conditions, adult orthodontics, specialist referrals, and other dental services. Get a copy of your dental health plan and be aware of the exclusions and limitations in dental plan coverage. If you don’t understand any aspect of the plan’s coverage, talk with your company’s benefit administrator or call the health plan directly.
If my dentist recommends one treatment option, but my dental insurance will only pay for a different treatment option, what can I do?
Indeed, some plans will only pay for the least expensive way to treat a dental need, regardless of the treatment option selected by you and your dentist. Sometimes, the dental health insurance company will make an adjustment to the benefit allowance, but there is no guarantee or obligation that the company will do this. You -- in consultation with your dentist -- should base your treatment decision on your dental needs, and not (necessarily) on your dental health plan coverage.
My dental plan says it pays 100 percent for a certain procedure, yet the bill for the service says I owe for part of the dentist's charge. What has happened?
Dental health plans usually describe their benefits in percentages based on UCR – "Usual, Customary, and Reasonable" – fees for each dental procedure. If your dentist's fee is higher than this customary fee, your dental insurance company will pay either the UCR fee limit or a set percentage of the dentist's fee – whichever is less. Your dentist might accept the amount received from your dental health insurance company as "payment in full" or might bill you for the difference between the amount billed and the amount received from the insurance company.
The limits are the result of a contract between the plan purchaser (your company or you as an individual) and the dental health insurance company. Although these limits are called "customary," they might or might not accurately reflect the fees of dentists in your area. Additionally, there is wide fluctuation and lack of government regulation on how a plan determines its "customary" fee level.
Another possibility is that you sought dental care from a dentist who was not a "preferred provider" in your dental plan. Many health plans and dentists agree to participate in preferred provider organizations. (Contracted dentists agree to discount their fees in exchange for the possibility of seeing more patients.) Plans encourage patients to seek out these dentists by minimizing out-of-pocket expenses.) If you choose a dentist "outside of the plan," you must pay more of the cost of the service yourself.
Will my dental health plan cover my family’s dental needs?
If your employer offers more than one plan, look at the exclusions and limitations of the coverage as well as the general categories of benefits. Feel free to ask your dentist about your family's current and future dental needs before making a final decision on your dental plan.
If my dentist is not on the list of dentists provided by my employer, can I still go to him or her for treatment?
You can always go to the dentist of your choice. Whether or not your dental health insurance company will pay for treatment provided by a dentist not on the plan's list is the question. This depends on contractual agreements made between the plan purchaser (you or your employer), the dentists on the list, and the plan administrator. Under some contracts, patients are given a financial incentive to go to certain dentists but do receive some level of dental benefit, regardless of the treating dentist. Other plans do not provide any benefit coverage for treatment given by "non-participating" dentists. Call your employer’s benefits department, your dental health plan, or the third-party payer of your health plan if you have questions about your dentist, his or her participation in your dental health plan, and coverage issues.
My spouse and I each have a dental health plan. Whose program covers whom, including our children?
Your dental health plan covers you. Your spouse's plan covers him or her. You might gain additional coverage from each other's programs if they cover spouses and dependents. In no case does the benefit derived from the two coordinated programs exceed 100 percent of the dentist's charges for treatment.
The primary plan for covering your children depends on the regulations in your state. Most plans use the "birthday rule." (The spouse with a birthday occurring earlier in the calendar year is primary.) Others consider the father's plan primary. If you have two or more potential sources of coverage, check the coordination of benefits language for each plan to determine the benefits available.
Does my dentist have to send a description of my treatment plan to the third-party payer before I have any dental work done?
Dental health plans or their third-party payers often do request a "predetermination of benefits" for certain treatments. This usually means that a dental consultant will review your dentist's treatment plan and determine what benefits your plan will provide.
It is important to know that this predetermination is not a guarantee of payment. It is also important to realize that some plans might deny your normal dental benefit, or reduce the level of coverage if you do not submit a treatment plan for prior authorization.
© Copyright 1995-2009 The Cleveland Clinic Foundation. All rights reserved.
Can't find the health information you’re looking for?
Ask a Health Educator, Live!
Know someone who could use this information?...send them this link.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/10/2007...#11183
