Questions about Dental Insurance By Mark Davis on December 16, 2013

Why doesn’t my insurance cover all the costs for my dental 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.

My plan says that my exams and certain other procedures are covered


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.

How does my insurance carrier come up with its allowed payments?

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.

Since the payments are negotiated, does this mean that there is always a

balance left for me to pay?

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


If I always have a balance to pay, what good is my insurance?

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!

I received an Explanation of Benefits from my insurance carrier that

says my dental bill exceeded the usual and customary, UCR. Does this

mean that Dr. Davis is charging more than he should?

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. Davis is charging

too much.

Why is Dr. Davis not on my benefit plan list?

The dentists on the list have agreed to a contract with the benefit plan.

These contracts have restrictions and requirements. Dr. Davis is not

comfortable with the restrictions.

Why doesn’t my insurance pay anything toward some procedures?

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.

My insurance plan doesn’t go into effect until next month. Can Dr.

Davis do my treatment today and send in the claim next month when

I am eligible?

State laws regulate these issues. It is insurance fraud to change the dates of

service on a claim. Dr. Davis and you can be prosecuted.

Is there anything I can do if my insurance doesn’t pay for treatment I

think should be covered?

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.

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.

Related to This

Dr. Mark Davis

Davis Dentistry

At Davis Dentistry, we care about each and every patient's oral health and overall well-being. We provide a comprehensive range of treatments with an emphasis on specialty services like:

  • Oral surgery
  • Dental implants
  • Tooth extractions
  • Periodontal therapy

Request an appointment at our Scottsdale office today. You can reach us online or by calling (480) 595-1300.

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