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
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
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
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
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.