Insurance basics

Dental insurance can be a valuable tool for managing the cost of care, but understanding how insurance companies determine reimbursement rates can be a bit of a mystery! If you’ve ever wondered how they decide what they’ll cover, this guide breaks down the different types of plans and how they calculate allowed amounts for procedures.

How Does Insurance Determine Coverage?

When an insurance plan states that it covers 80% of a filling, it actually means 80% of the allowed amount—not necessarily 80% of the full fee. How that amount is calculated depends on your specific plan.

Types of Dental Insurance Plans

• Contracted Provider: We have a set agreement with the insurance company, which determines our contracted rate for procedures. The insurance company covers a percentage of that rate. As part of our contract, we’re unable to offer discounts for seniors or prepayments, write off balances, or provide special promotions.

• UCR PPO (Usual, Customary, and Reasonable Fees): These plans reimburse based on what the insurance company determines is the “average” cost of a procedure within our zip code. Different insurance companies calculate UCR fees differently, and some employers choose higher UCR levels when purchasing upgraded plans. Our fees typically fall within the UCR limits for most major insurance providers.

• Fee Schedule PPO: For non-contracted providers, these plans use a fixed reimbursement schedule determined by the insurance company. Unlike UCR plans, they don’t consider local costs, which means reimbursement rates in Manhattan are often much lower than standard UCR levels. These plans don’t always disclose their fee schedules. For these plans, we collect in full on the day of service, and then we handle the paperwork so you can be reimbursed directly.

• HMO/DMO Plans: These plans require you to see a participating provider to receive any benefits. Dentists in these plans are paid a fixed monthly amount per assigned patient and are responsible for providing covered services at little or no cost. The assigned dentist also determines if a referral to a specialist is necessary. We are not currently in-network with any DMO plans, so care in our office would be out-of-pocket.

Other Factors That Affect Insurance Coverage

Beyond the type of plan, many other factors influence final reimbursement, including:

• Deductibles
• Downgrades
• Age limits
• Co-payments
• Annual maximums

We do our best to provide an accurate estimate based on the information given to us by your insurance company. However, it’s important to remember that this is only an estimate—final coverage decisions are made by your insurance provider.

Your dental insurance is a contract between you, your employer, and your insurance company, while our focus is on providing you with the best clinical care and patient experience possible. If your insurance pays less than expected, the remaining balance will be your responsibility.