Dental insurance is a type of health insurance designed to pay a portion of the costs associated with dental care. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: Indemnity (or sometimes called: true dental insurance) which allows you to see any dentist you want who accepts insurance, Preferred Provide Network dental plans (PPO: briefly discussed below), and dental Health Managed Organizations (DHMO) in which you are assigned to an in-network dentist or in-network dental office and must stay within that network to receive your dental benefits.
Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. When a dentist signs a contract with a dental insurance company that provider agrees to match the insurance fee schedule and give their customers a reduced cost for services, this is considered an In-Network Provider or Participating Provider network (PPO). Depending on your specific plan, if you seek an Out-of-Network or Non-Participating Provider, any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. Some dental insurance plans may have waiting periods. This is a period of time before certain benefits will be covered. Generally set in place when you are a new enrollee or seek out an independent plan outside of an employer or group policy.
Some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted and additional treatments may become the patient's responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan. Orthodontics usually has a separate limit. Some plans may have an annual deductible depending on the type of treatment rendered. After the deductible is met, the remaining dental plan benefit is paid at its specified percentage or fee schedule.
Dental insurance companies divide benefits, services, or procedures into categories and refer to them with American Dental Association (ADA) 3-4 digit code. As an example, Preventative and Diagnostic procedures often include exams (ADA code 0120), x-rays (ADA code 0210), and basic cleanings or prophylaxis (ADA code 1110). Basic procedures often include fillings, periodontics, endodontics, and oral surgery. Major procedures often are crowns, dentures, and implants. Procedures such as periodontics, endodontics, and oral surgery may fall into the Major category depending on your specific plan with specific fee schedules and co-payments. Many dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.
The enrollment process varies but often members are assigned an identification or policy number. When dental treatment is rendered a claim for services is filed with the dental insurance company. Upon enrollment, be informed through the enrollee benefit packet regarding coverage and contact a dental provider and/or dental insurance company with additional questions about specific dental benefits. Eligibility of Benefits, or EOB, statements are most often then sent with payment to both the provider of service and the plan policy holder.
Author: Wikipedia Contributors
Publisher: Wikipedia, The Free Encyclopedia
Date of last revision: 7 September 2012