Pricing & insurance made simple

Insurance FAQs

• Can you send a pre-approval to my insurance company?

  Certainly. This is the most accurate way to assess any out-of-pocket expenses you may incur, however it is still an estimate and subject to change at the plan’s discretion. Pre-approvals can take weeks or even months, so if the treatment is mandatory, we recommend allowing us to estimate your coverage and we can settle up after the insurance pays for your claim, rather than delay treatment that may get worse over time.

• Do plans ever change?

  Yes, plans can and do change. Even though you may have the same insurance, your employer may opt to change the level of coverage at any time, which could improve or reduce your covered benefits. It is very important that you let us know if your plan changes, or if you get a new insurance card, so that we can update our records.

• I have more than one dental insurance plan. Can I use both?

  Absolutely. However, even though you may have two dental benefit plans, there is no guarantee that both plans will pay for your services. Some secondary plans will not pay until you have exhausted the entire maximum of your primary coverage. In most cases, even if both plans pay, the payments from all insurers will not add up to more than the total charges.

• Is it normal to have to pay out-of-pocket?

  Yes. Unlike traditional insurance, dental benefits are not meant to cover all oral healthcare needs. The dental policy is simply a benefit to offset a portion of your cost of care. Your dental coverage is not based on what you need or what your dentist recommends. It is based on how much your employer pays into the plan. Our office will file claims and estimate your coverage for you, but if the insurance company declines to pay, any portion of the bill not covered by insurance is your responsibility. Luckily, our office provides some of the most flexible payment options around to help you manage any out-of-pocket expenses.

• It looks like insurance will cover 100% of a service. Is that exact?

  Sometimes yes, sometimes no. Each employer chooses a plan with a certain list of allowable fees, known as a fee schedule. As you use your insurance, we get to learn your plan’s allowable fees. If an insurance indicates they cover a dental wellness visit at 100%, but their fee schedule allows up to $170 for a dental wellness visit then they will pay a total of $170 for the visit. Many times the insurance’s allowable fees are the same as our office fees. Sometimes they aren’t. If we bill your insurance for a dental wellness visit at $227, and they allow 100% of $170, you will be responsible for the remaining $57.

• So, how do you calculate my copay?

  We consider the most current information we have for your plan. If we have very little information available, we will estimate based on similar plans and utilize the breakdown of benefits provided by your insurance company which shows a range of common procedures and the percentages that they allow for each (100% for procedure A, 80% for procedure B, 50% for procedure C covered up to the annual maximum). The benefit information your insurance provides is by no means comprehensive and does not include their allowable fees for each procedure, so the more you and others with your plan use it, the more accurately we can estimate your out-of-pocket expenses. All copayments collected are an estimate; sometimes the insurance may pay more or less than we assess. If they pay more, we will let you know, and you can request a refund check. If they pay less than we estimate, we’ll send you a statement, and you will be responsible for the charges.

• What are frequency limitations?

  A dental plan may limit the number of times it will pay for a certain treatment. But some patients may need a treatment more often to maintain good oral health. For example, one plan may cover dental wellness or gum therapy visits twice a year, while another allows four times a year. If a patient needs a dental wellness or gum care visit four times a year, but their plan only covers cleanings or gum care twice a year, the other two would be out-of-pocket. It’s important to make treatment decisions based on what’s best for your health, not just by what is covered in your plan.

• What insurances do you take?

  Most of general dentists are in-network with many Cigna PPO, Aetna PPO, United Concordia Elite, and Premera Blue Cross plans. Effective March 15th, 2024 we are no longer scheduling new patients with Delta Dental plans. We also accept most major PPO plans like MetLife and Guardian. If you have any questions about your plan, we are happy to do a complimentary benefits check for you and let you know all about your coverage.

• What is a deductible?

  The amount you pay for covered dental care before your insurance plan starts to pay. For example, if you have a $50 deductible, you’ll pay the first $50 of covered services yourself before your insurance kicks in to help. If you have a deductible, you only have to pay it one time a year per patient on the plan. Many insurance plans waive the deductible for preventative and diagnostic care like cleanings and exams, so it only applies if you need treatment like a filling.

• What is a pre-existing condition?

  A dental plan may not cover conditions that existed before you enrolled in the plan. For example, benefits will not be paid for replacing a tooth that was missing before the effective date of coverage. Even though your plan may not cover certain conditions, you may still need the treatment to keep your mouth healthy.

• What is a waiting period?

  A waiting period may be imposed if you have a new plan, for some or all dental services. This means you and your employer must pay premiums for a period of months (usually 6 to 12 months) before you can utilize your benefits.

• What is an annual maximum?

  Think of your annual maximum as an insurance bank account that renews every year. All services, unless otherwise stated, get deducted from the maximum. Once you have exhausted the bank account, any other services must be paid for out-of-pocket. Unused dollars do not roll over into the next year, unless your plan has a special rollover account. Each member on the plan has their own annual maximum account. Most plans have an annual maximum of $1,000 to $2,000 a year to offset out of pocket costs, however you are still expected to pay all copayments and deductibles that may apply.

• What is the difference between a PPO and HMO/DMO insurance?

  PPO stands for Preferred Provider Organization. HMO stands for Health Maintenance Organization. Our office works with all types of PPO insurances because these plans allow you the freedom to choose any provider you’d like to see, whether they are in or out of network. We are in-network with many PPO plans.

  We are not in-network with any HMO or DMO plans. These plans require that you choose an in-network dentist from a list of providers, and then see that specific provider for all your care. That’s because HMO/DMO dentists receive a check each month based on the number of patients assigned to him or her. HMO/DMO providers can be expected to perform services for a deeply discounted rate. On the other hand, PPO dentists only receive money from the insurance company if services are rendered.

  Usually, patients who have an HMO/DMO plan will notice their choice of dentists is quite limited because fewer offices opt to participate in this kind of plan. However, out of pocket costs are generally lower with HMO/DMO plans than PPO plans, and have fixed co-payments. Having a PPO plan allows you to access a larger number of dentists providing higher quality care, but sometimes at a greater out-of-pocket cost. Additionally, if you have a PPO plan you can see a specialist without a referral, but if you have an HMO/DMO plan you usually need to obtain a referral before seeing a specialist.

• Who decides what's covered under my plan?

  Almost all dental plans are a contract between your employer and an insurance company. Your employer and the insurer agree on the amount your plan will pay and what procedures are covered. Usually, employers choose to cover some, but not all of employees’ dental costs. Often, you may have a dental need that is not covered by your plan. If you are not satisfied with the coverage provided by your insurance, be sure to let your employer know.

• Why is my claim getting denied or only partially covered?

  Sometimes, in order to control costs, insurance companies may reduce your benefits using the following methods:

  • bundling: two different procedures were performed on the same tooth, but the insurance company combines it into one procedure
  • downcoding: the dental plan changes the procedure code to a less complex or lower cost procedure than was actually performed (for example, a white filling was performed but they changed the code to a silver filling)
  • least expensive alternative treatment: if there is more than one way to treat a condition, the plan will pay only for the least expensive treatment. For example, your dentist recommended an implant, but the plan may only cover less costly dentures.
  • delaying payment: the insurance company may not pay your claim for many months, and ask for additional information multiple times
  • not medically necessary: the insurance company may deny payment stating that they did not receive enough proof of necessity. You can appeal this process with a letter from your dentist, including supporting photos and x-rays to explain the treatment decision.