This post mainly concerns PPO Insurances that are attached to a contracted Fee Schedule with your Dental Provider. Coverage is based on Percentages.
Dental Insurance is definietly purposefully tricky to confuse the average consumer. Their strategy is to add enough language that they eventually won’t have to cover nearly as much as you think they will cover. And even when something is legitimately covered, it is up to the Front Desk of your Dental Provider to fight against omissions, technicalities, and hidden verbage.
Here is a small list of major stipulations that can determine if your Insurance will cover a particular procedure. It may be wise to carry this list to every dental appointment you attend. If you are unsure, ask your Dentist for a “Predetermination” or call the Insurance Company directly.
- Frequency Limitation (How often you can have a certain procedure done)
- Waiting Period (How long you need to wait until your coverage kicks in)
- Is your Provider “In The Network”? (Ask your Insurance Carrier)
- Do they pay on “Seat Date” or “Prep Date”? (Mostly for Crowns)
- Do they “Downgrade” Resin Fillings to “Amalgam” Rates?
- Do they “Downgrade” Crowns?
- Which Fee Schedule you are attached to. (Sometimes it varies)
- Can procedures be “Billed” on the same Date of Service?
- Do I have a “Calendar Year Plan” or “Anual from Start Date”?
- Do some procedures count as other procedures? (Mostly Cleanings)
- Is my procedure classified as “Preventive”, “Basic”, “Major”? (Varies)
- How much more of my Anual “Maximum” do I have remaining?
The list can most definitely be ongoing. Luckily, that is why most dental offices have a “Treatment Coordinator” to mitigate most of the liability associated with Insurance lingo and its confusing nature. I also beleive your policy details can be found on your Insurance Company’s Website. It’s always a good idea to double check since Dentistry can get pricey; especially if you haven’t done your homework. The main takeaway is that Dental Insurance and the Cost of Dentistry doesn’t need to be freightening and can be exposed at your leisure.