This post mainly concerns PPO Insurances that are attached to a contracted Fee Schedule with your Dental Provider. Â Coverage is based on Percentages.
Dental Insurance is definietly purposefully tricky to confuse the average consumer. Â Their strategy is to add enough language that they eventually won’t have to cover nearly as much as you think they will cover. Â 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. Â It may be wise to carry this list to every dental appointment you attend. Â 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. Â 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. Â I also beleive your policy details can be found on your Insurance Company’s Website. Â It’s always a good idea to double check since Dentistry can get pricey; especially if you haven’t done your homework. Â 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.