Dental health insurance plans vary widely. You should know how your plan is designed, since this can significantly affect the plan's coverage and out-of-pocket expenses.
Some dental insurance plans encourage you or your dentist to submit a treatment proposal to the plan administrator before receiving treatment. After review, the plan administrator may determine: the patient's eligibility; the eligibility period; services covered; the patient's required co-payment; and the maximum limitation. Some plans require predetermination for treatment exceeding a specified dollar amount. This process is also known as preauthorization, precertification, pretreatment review, or prior authorization.
To help contain costs, your dental insurance plan may limit benefits by the number of procedures and/or dollar amount in a given year. In most cases, particularly if you've been getting regular preventive care, these limitations allow for adequate coverage. By knowing in advance what and how much the plan allows, you and your dentist can plan treatment that will minimize out-of-pocket expenses while maximizing compensation offered by your benefits plan.
Many dental insurance plans provide a peer review mechanism through which disputes between third parties, patients, and dentists can be resolved, eliminating many costly court cases. Peer review is established to ensure fairness, individual case consideration, and a thorough examination of records, treatment procedures, and results. Most disputes can be resolved satisfactorily for all parties.
In reviewing and comparing dental insurance plans, consider the following when determining whether the coverage will satisfy your dental care needs:
Your dentist cannot answer specific questions about your dental insurance plan or predict what level of coverage for a particular procedure will be. Each plan and its coverage varies according to the contracts negotiated. If you have questions about coverage, contact your employer's benefits department, your dental insurance plan, or the third-party payer of your health plan.
To control costs, most dental insurance plans limit the amount of care you can receive in a given year. This is done by placing a dollar "cap" or limit on the amount of benefits you can receive, or by restricting the number or type of services that are covered. Some plans may totally exclude certain services or treatment to lower costs. Know specifically what services the plan covers and excludes.
There are, however, certain limitations and exclusions in most dental insurance plans that are designed to keep dentistry's costs from going up without penalizing the patient. All plans exclude experimental procedures and services not performed by or under the supervision of a dentist, but there may be some less obvious exclusions. Sometimes dental coverage and medical health insurance may overlap. Read and understand the conditions of your dental insurance plan. Exclusions in your dental plan may be covered by your medical insurance.
Patients and dental insurance plan purchasers should insist on regular reviews of premium levels to ensure that UCR or Table of Allowances payment schedules are equitable. This analysis can help optimize your benefit levels, ensuring that every dollar you spend is used wisely.
If you are covered under two dental benefits plans, notify the administrator or carrier of your primary plan about your dual coverage status. Insurance plan benefits coordination can help protect your rights and maximize your entitled benefits. In some cases you may be assured full coverage where plan benefits overlap, and receive a benefit from one plan where the other plan lists an exclusion.
It may be wise to choose a plan that imposes dollar or service limitations, rather than one that excludes categories of service. By doing so, you can receive the care that's best for you and actively participate with the dentist in the development of treatment plans that give the most and highest quality care.
To help stretch each dental insurance dollar, most plans provide patients and purchasers with special administrative services. Find out if your plan provides the following mechanisms to help you budget, analyze, and dispute, if necessary, the costs of dental care.
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