Understanding Insurance
DISCLAIMER: This document is meant to provide basic information concerning dental insurance plans in general. This is by no means comprehensive and does not pertain to any one specific plan. To learn about your individual plan it is always best to contact your insurance provider directly.
If you have dental insurance, we are happy to look up your plan and provide an ESTIMATE for each procedure broken down by the insured and uninsured costs. As a courtesy our office will also file your claim for you.
If you do not have any dental insurance that is not a problem. We are happy to discuss discount plans for families with no dental insurance. Please contact our office for more information.
Terms
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Treatment Plan- The treatment plan is a schedule of procedures and appointments designed to restore the patient’s oral heath. The patient’s guardian signs the treatment plan giving our office permission to complete the treatment listed in the plan.
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As a courtesy, our office provides our best estimate of how much you will have to pay for treatment.
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Our office tries very hard to provide accurate pricing, but every insurance plan is different so our estimates are usually close but rarely exact.
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When we fail to estimate closely everyone loses. We feel that we lose the trust of our patient’s family and our patient’s family may be put in a difficult financial position. It is never our intent to provide inaccurate estimates.
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Deductible- The patient is required to pay this amount of money before the insurance company pays any amount of money. In some cases, preventative services are excluded from this payment.
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Annual Maximum- The insurance company will pay this amount of money in a given year and no more. If your bill exceeds this limit, payment is solely the responsibility of the patient.
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ADA Codes (D-Codes)- D-codes are how the dental office communicates to the patient and/or insurance company what services have been provided to the patient.
Example
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D0140 (Limited exam)- this code is completed when you visit a dental office with the intention of addressing one specific problem.
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Office Fees- Office fees are the prices the dental office charges for services (D-codes) when the patient has no insurance or if the office is not “in network” with the patient’s insurance.
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In Network- When an office is “in network,” this means the office has negotiated and agreed on lower prices for patients who have a particular insurance plan. In return for the office providing lower fees, the insurance company gives the dental office access to patients they otherwise are less likely to have the opportunity to treat. Basically, income lost because of fee reduction is made up for by treating a greater number of total patients.
White Oak pediatric Dentistry is not in network with any insurance plans.
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Co-insurance- Co-insurance determines how much of the fee the patient is responsible for paying and how much of the fee the insurance company is responsible for paying. Usually, co-insurance is divided into three categories: preventative, basic, and major. Each category is assigned a different percentage of coverage.
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Out-of-Network- When an office is “out of network,” the dental office will accept your insurance, but you will be charged “office fees” instead of “in-network” fees. Depending on the dental office’s fees and your specific plan, this may or may not significantly impact you financially.
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Insurance company may arbitrarily cap what maximum office fee they will accept from an out of network dental office. This cap number is not made public to dental offices. If an office fee for a given procedure is above the cap, the patient is responsible for the difference.
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Common complicating factors:
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Treatment provided at another office needs to be redone- If treatment was recently done at another office and needs to be replaced, insurance might not cover the cost of replacement. In most cases, a certain time period must pass before a treatment will be covered a second time. In some cases, a treatment may only be covered once per lifetime.
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Age Limits- Some procedures are only covered up to a certain age. Fluoride and sealants are two services commonly given an age restriction.
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Same Day Restrictions- Some procedures will not be covered if completed on the same day.
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Dentition Restrictions- Some procedures are only covered on permanent teeth and not primary teeth. This is often an issue when primary teeth require sealants.
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New Procedures- Newer treatment options are often not covered by insurance. This is often a problem when silver diamine fluoride is required.
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