It is important to be informed before you come in for your dental appointment. Remember that your insurance is a contract between you and your employer. Here are 10 questions that will help you figure out exactly what your insurance covers - after-all, we all hate surprises!
Commonly asked questions:
- What percentage does my plan cover for each type of service? There are 3 types of services: Basic, Major and Orthodontics. Every type of service is covered at a different percentage of the eligible amount allowed by your plan. For example, basic work may be covered at 80%, major may be covered at 50% and orthodontics at 50%.
- Does your insurance have an annual maximum? If yes, when does it start and how much is available to cover your dental work. Even if work has been pre-approved, your plan will not cover the procedure if your maximum is used up. They will only pay what is left on your maximum for that type of service. Your policy may have a separate maximum or combined maximum. Combined maximum is the total amount allowed for basic and major work combined. Orthodontic services have a separate lifetime maximum.
- What fee guide is your plan using? Your plan usually pays a percentage of the eligible amount set up in your policy. The insurance pays a percentage of the eligible amount for each dental procedure.
- Does my treatment need to be pre- authorized? A predetermination is usually required for major dental work. Your dentist can send this to your insurance. A letter will be sent, to the patient or member, from your insurance provider explaining what is covered. If your dentist will allow assignment, please forward a copy of your approval to your dentist.
- Does your insurance have age limitations for some procedures? Some plans have an age limit for orthodontic work. Also, some procedures may not be covered due to age restrictions.
- How long will my dependents be covered? Most plans cover dependents up to 18 or 21 years of age. If your child is attending post- secondary education, they may be covered up to age 24. If this is the case, you must contact your insurance company with proof of registration at least 1 month prior to your appointment. Check with your insurance provider for the details explaining the age limit specified in your policy package.
- Is there a frequency limitation for my check ups and cleanings? Most plans have a frequency limit for preventative services such as exams, x-rays and cleanings. They may allow coverage 1 in 12 months, 6 months or 9 months. Procedures such as scaling or root plaining, which is usually provided by your hygienist, may have a limit of units allowed in a rolling 12 months. If your hygienist recommends recall in 6 months, check with your insurance if you are eligible to be covered.
- Will my insurance pay the dentist or do I get reimbursed? Every policy is set up differently by your employer. Most plans do allow payment to go to your dentist. Phone ahead and ask your insurance provider if your claims can be assigned to pay the dentist.
- How does the process of claims work? Your dental office can send your claim in for you to be processed by your insurance. Most claims can be sent electronically, but sometimes the insurance company may not provide an explanation at the time of submission. In this case your dental office may ask for payment in full. All insurance companies have privacy provisions. Due to the privacy act, dental offices have only limited access to information about your policy; this makes it difficult for dentists to be certain that the insurance will pay for your dental services. Dentists are not given full detailed information about your policy.
- How does co-ordination of benefits work? If there is more than 1 insurance company, the primary insurance plan is always the patient’s insurance first, and spouse’s insurance is second. For dependent children, the primary insurance is that of the parent whose month of birth is first. Some dental offices do not co-ordinate with more than 1 insurance policy.
If you need any more help navigating the world of Dental Insurance feel free to come in, call us (780-986-6255), or email us! If you would like information about our office's specific policy towards handling dental insurance, click here!
Diane, Office Manager