There are key terms used to describe your dental policy which may include the following:
UCR (Usual, Customary, and Reasonable)
Usual, customary and reasonable charges (UCR) are the maximum amounts that will be covered by the plan. Although these terms make it sound like a UCR charge is a kind of standard rate for dental care,
that is not the case. The terms “usual,” “customary” and “reasonable” are misleading for several reasons:
• UCR charges often do not reflect what dentists “usually” charge in a given area.
• Insurance companies can set whatever they want for UCR charges—they are not required to match actual fees charged by dentists.
• A company’s UCR amounts may stay the same for many years—they do not have to keep up with inflation.
So if your dental bill is higher than the "usual and customary rate", it does not mean your dentist has charged too much for the procedure. It could mean your insurance company has not updated its UCR's.
This is the most a dental plan will pay during the year. Your employer makes the final decision on maximum levels of payment through the contract with the insurance company. You are expected to pay copayments, as well as any costs above the annual maximum. Annual maximums are not always updated to keep up with the costs of dental care. Your annual maximum may be too low to meet your needs--you may be able to ask your employer to look into plans with higher annual maximums.
A dental plan may have a limitation or waiting period for the number of times it will pay for certain procedures. But some patients may need treatment more often than that for best oral health. For example: a plan might pay for teeth cleaning only twice a year even though the patient needs cleaning four times a year. Be aware of the details in your dental plan but decide about treatment based on what’s best for your health, not just what your insurance dictates.
Not Dentally Necessary
Insurance plans have their own guidelines for which treatment is “dentally necessary.” If a service provided by your dentist does not meet the plan’s guidelines, the charges may not be reimbursed. However, that does not mean that the dental treatment was not necessary.
Your dentist’s advice is based on his or her professional opinion of your case. Your insurance company does not know what you need. If your plan rejects a claim because a service was “not dentally necessary,” you have the right to an appeal.
Least Expensive Alternative
If a plan has a LEAT clause, it means that if there is more than one way to treat a condition, the plan will only pay for the least expensive treatment. This is how insurance companies keep their costs down. However, the least expensive alternative is not always the best option.
Explanation of Benefits (EOB)
An EOB is a written document from the insurance company, telling you what they will cover and what you must pay yourself. Your portion of the bill should be paid to the dental practice. If you have questions about the EOB, contact your insurance provider.
The plan may want you to choose dental care from a list of its preferred providers (dentists who have a contract with the dental benefit plan).
The term “preferred” has nothing to do with the patient’s personal choice of a dentist; it refers to the insurance company’s choices. If you choose to receive dental care from an out-of-network provider, you may have higher out-of-pocket costs. Inform yourself about your plan’s payout for both in- and out-of-network dentists.
A dental plan may not cover things that occured or existed before you signed up for your plan. Even though your plan may not cover certain conditions, treatment may still be necessary to maintain your oral health.
Coordination of Benefits (COB) or
Nonduplication of Benefits
This applies to patients covered by more than one dental plan, much like having two different plan policies. Insurance companies usually want to know if you have coverage from other companies as well, so they can coordinate your benefits. For example, if your primary insurance will pay half your bill, your secondary insurance will not always cover that same portion of the bill. Benefits are determined as separate entities.
Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your services. Sometimes, none of the plans will pay for the services you need. Each insurance company handles COB in its own way. Please check your plans for details.
Make your dental health the top priority. Although you may be tempted to decide on your dental care based on what insurance will pay, always remember that your health is the most important thing. As with other choices in life—such as buying medical or auto insurance, or even a home—the least expensive option is not always the best.
written by the ADA