Insurance FAQs

Helpful Hint

Contact your insurance carrier by phone or email to find out what your annual maximum benefit remaining amount is, and what you can expect for reimbursement for your periodontal treatment.

Dental Insurance isn’t really insurance at all.  It is actually a money benefit typically provided by an employer to help their employees pay for routine dental treatment.

That 100% is usually what the insurance carrier allows as payment toward the procedure, not what your dentist or any other dentist in your area may actually charge.  For example, say your dentist charges $145 for an examination your carrier may allow $100 as the 100% payment for that examination, leaving $45 for you to pay.

Many carriers refer to their allowed payments as usual, customary and reasonable, UCR.  However, usual, customary and reasonable does not really mean exactly what it seems to mean.  UCR is actually a listing of payments for all covered procedures negotiated by your employer and the insurance company.  This listing is related to the cost of the premiums and where you are located in your city and state.  Your employer has likely selected an allowed payment or UCR payment that corresponds to the premium cost they desire.  UCR payments could be more accurately called negotiated payments.

Typically there is a portion of the fee that is not covered by your benefit plan.

Even a benefit plan that does not cover a large portion of the cost of needed dentistry pays something.  Any amount covered reduces what you have to pay out of pocket!

Remember that what insurance carriers call usual and customary is really just what your employer and the insurance company have negotiated as the amount that will be paid toward your treatment.  It is usually less and frequently much less than what any dentist in your area might actually charge for a dental procedure.  It does not mean that Dr. Roberts is charging too much.

The dentists on the list have agreed to a contract with the benefit plan.  These contracts have restrictions and requirements. Dr. Robert’s is not comfortable with the restrictions.

Your plan contract specifies how many of certain types of procedures it will consider annually.  It limits the number of x-rays and periodontal cleanings it will cover because these are the types of treatments that many people need to have frequently.

Sate laws regulate these issues.  It is insurance fraud to change the dates of service on a claim.  Dr. Roberts and you can be prosecuted.

Your insurance coverage is between you, your employer, and the insurance carrier.  If your insurance doesn’t pay, you are responsible for the total cost of treatment.