Just like medical insurance, a dental plan may not cover conditions that existed before the patient enrolled in the plan. For example, plans may have a “missing tooth” exclusion. Benefits will not be paid for replacing a tooth that was missing prior to the effective date of coverage. This decision should be between you and your dentist. Even though your plan may not cover certain conditions, treatment may still be necessary.

A dental plan may not cover certain procedures of preventative treatments. This does not mean that these treatments are unnecessary. Patients need to be aware of the exclusions and limitations in their dental plan but should not let those factors determine their treatment decisions. Your dentist can help you decide what type of treatment is best for you.

Certain procedures may simply not be covered as often as necessary for optimal oral health. A common example might be a plan that pays for hygiene maintenance only twice a year even though the patient requires cleaning every three months. Limitations may vary depending on the contract purchased. Limitations in coverage are the result of financial commitment the plan sponsor has agreed to make and the benefits the third party payer will offer for that commitment.

The plan provides benefits for those services and materials that it considers to be dentally necessary and meet generally accepted standards of care. Based on the information your periodontal office submits, the service may not appear to meet the plan criteria and no benefit may be allowed. This does not mean that the services were not necessary. You can appeal the benefit decision by submitting relevant information. Your periodontal office can help by giving you the information requested by the insurance carrier. The claim, along with the submitted relevant information should be reviewed by the plan’s dental consultant.

To keep the premium costs down, insurance carriers will incorporate cost-control measures into the plan design. By incorporating cost control measures during the claims adjudication process, many times benefits are reduced or not paid at all. Some of the more common cost control measures are:

Bundling — This is the systematic combining of distinct dental procedures by third-party payers that result in a reduced benefit for the patient / beneficiary. A common example of bundling is when bitewing and periapical radiographs are combined and paid as a full mouth series of X-rays. The full mouth series is then subject to the plan’s limitation of allowing benefits, usually, once every five years for these X-rays.

Downcoding — This is a practice of third-party payers in which the benefit code has been changed to a less complex and / or lower cost procedure than was reported except where delineated in contract agreements.

Your dental plan may only allow benefits for the least expensive treatment for a condition. For example, your dentist may recommend a crown, but your insurance may only offer reimbursement for a large filling. As with other choices in life – such as purchasing medical or automobile insurance, or buying a home – the least expensive alternative is not always the best option.

Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan for eligible services. The plan pays an established percentage of your dentist’s fee or pays the plan sponsor’s “customary” fee limit, whichever is less. Should this charge exceed the plan’s customary fee, this does not mean your dentist has overcharged for the procedure. Why? There are no regulations as to how insurance companies determine reimbursement levels, resulting in wide fluctuations. In addition, insurance companies are not required to disclose how they determine “usual, customary and reasonable” charges.

Your plan may want you to choose your dental care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.

Direct Reimbursement is a self-funded dental plan that reimburses an individual based on a percentage of dollars spent for dental care, not on the type of treatment provided; it also allows the patient to seek treatment from the dentist of their choice. Unlike some forms of dental benefits, direct reimbursement allows patients to plan treatment with their dentists alone, with no third party interference through exclusions (except cosmetic) or plan frequency limitations on treatment. There are no predetermination requirements, no pre-existing conditions, no UCR, and typically no deductibles. In addition, there is no bundling or downcoding or least expensive alternative treatment clauses. Please contact the ADA at 800-232-1890 or dentalbenefits@ada.org for more information on Direct Reimbursement.

An EOB is a written statement to a beneficiary, from a third party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by your dental plan. In those instances where the plan makes partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the EOB. Any difference between the fee charged and the benefit paid may be due to limitations in the dental plan contract. Typical information reported on an EOB includes: 1) the treatment reported on the submitted claim by the ADA procedure code and the name of the treatment; and 2) how these benefits were determined based on the above information.